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CLINICAL  LECTURES 

ON  THE 


PRINCIPLES  AND  PRACTICE 
OF  MEDICINE.  . 

' ( I ■ i \ 
'’''i-  i ( : ( I V Of  I i 

. -mao/. 


BY 

JOHN  HUGHES  BENNETT,  M.D.,  F.R.S.E., 

PROFESSOR  OF  THE  INSTITUTES  OF  MEDICINE, 

IND  SENIOR  PROFESSOR  OF  CLINICAL  MEDICINE  IN  THE  UNIVERSITY  OF  EDINBURGH  . 

Formerly  Lectnrer  on  the  Practice  of  Physic,  Physician  to  the  Fever  Hospital, 

Director  of  the  Poli-Clinic  at  the  Royal  Dispensary,  and  Pathologist  to  the  Royal  Infirmary,  Edin- 
burgh ; Honorary  Member  and  Emeritus  President  of  the  Royal  Medical  Society  of  Edin- 
burgh ; Member  and  Corresponding  Member  of  various  other  Scientific  and  Med- 
ical Societies  in  Edinburgh,  St.  Andrews,  Philadelphia,  New  York,  Paris, 

Brussels,  Vienna,  Berlin,  St.  Petersburg,  Jena,  Stockholm, 

Athens,  Buda-Pesth,  Copenhagen,  Amsterdam,  etc. 


FIFTH  AMERICAN, 

lEVom  tlie  E^oiarth.  TioikIoix  Edition. 

difre  Jittitbreb  anb  |l(ustraRons  mt  S^oob. 


NEW  YOKK: 

WILLIAM  WOOD  & COMPANY, 

27  GREAT  JONES  STREET. 

1874. 


PREFACE. 


tr' 


This  work  having  been  some  time  out  of  print,  a fourth  edition 
is  now  published,  every  part  of  which  has  received  numerous  ad- 
ditions, while  some  portions  of  it  are  altogether  new.  In  Sec- 
tion II.  I have  introduced  an  account  of  the  molecular  and  cell 
theories  of  organisation,  and  re-written  descriptions  of  the  gen- 
eral laws  of  nutrition  and  of  innervation  in  health  and  disease, 
of  inflammation,  and  of  tuberculosis.  In  a note  appended  to 
the  general  treatment  of  morbid  growths,  I have  inserted  a let- 
ter from  M.  Yelpeau,  in  which  that  distinguished  surgeon  has, 
from  numerous  cases  in  his  practice,  demonstrated  the  correct- 
ness of  the  opinion  I long  ago  formed,  on  pathological  grounds, 
viz.,  that  true  cancer  may  be  permanently  extirpated  with  the 
knife.  The  facts  he  has  recorded  ought  to  put  an  end  to  further 
discussion  on  the  subject. 

In  Section  III.  I have  introduced  new  considerations  on  the 
subject  of  General  Therapeutics,  and  have  referred,  under  dis- 
tinct heads,  to  the  natural  progress  of  disease ; the  knowledge 
derived  from  an  improved  diagnosis  and  pathology ; the  fallacy 
of  the  change  of  type  theory;  an  inquiry  into  our  present 
means  of  treatment ; and  the  proposition  that  physiology  and 
pathology  constitute  the  true  foundations  for  medical  practice. 
Regarding  these  subjects,  which. constitute  important  principles 
of  our  science,  I shall  be  satisfied  if  their  perusal  should  induce 
my  readers  to  refiect  on  the  uncertainty  of  our  art,  and  stimu- 


2532 ! 9 


VI 


PEEFACE. 


late  some  of  them  to  renewed  investigations  as  to  the  exact 
value  of  remedies  in  the  treatment  of  disease. 

In  Sections  lY.  Y.  and  YI.  several  new’  subjects,  and  many 
valuable  cases,  have  been  introduced,  which  it  is  hoped  will 
render  the  account  given  of  the  diseases  of  the  nervous,  diges- 
tive, and  circulatory  systems,  more  useful  to  the  medical  prac- 
titioner. 

In  Section  YII.  I have  tabulated  every  case  of  acute  Pneu- 
monia treated  by  me  in  the  Poyal  Infirmary  of  Edinburgh 
since  the  year  1848,  in  order  to  satisfy  my  medical  brethren 
that  the  restorative  (not  stimulating)  treatment  of  the  disease  is 
in  every  way  well  worthy  of  their  confidence.  The  facts 
shown  by  that  table  also  will,  I trust,  serve  to  correct  some 
prevailing  errors,  and  establish  a few  new  truths. 

In  Sections  YIII.  IX.  and  X.  are  many  additional  wood 
illustrations  and  new  cases ; some  of  the  latter,  illustrative  of 
albuminuria,  with  increased  secretion,  from  waxy  degeneration 
of  the  kidney,  are  deserving  attention.  I trust  to  be  excused 
for  having  still  further  defended  my  claim  to  the  discovery  of 
Leucocythemia.  The  subject  of  Diabetes  has  been  extended  by 
cases  taken  with  great  care,  and  a laborious  trial  of  sugar  as  a 
remedy  in  that  disease  recorded.  Certain  views  concerning  the 
diagnosis  and  etiology  of  Typhus  and  Typhoid  Fevers  have 
been  re-investigated.  A very  careful  trial  of  the  wet  sheet  in 
Scarlatina  is  detailed,  and  a singular  new  fact  in  the  history  of 
mercurial  poisoning  illustrated. 

These,  and  numerous  other  additions,  which  it  is  calculated 
have  increased  the  work  to  the  extent  of  300  pages,  I have,  by 
curtailments,  condensations,  the  employment  of  a closer  type, 
and  a slight  enlargement  of  the  page,  been  enabled  to  effect 
without  adding  to  the  bulk  of  the  volume. 

I have  again  to  express  my  obligations  to  numerous  friends 
for  assistance  rendered  to  me  in  various  w’ays,  and  especially  to 


PEEFACE. 


Vll 


Dr.  Angus  Macdonald,  House  Physician  to  the  Eoyal  Infinnary, 
for  valuable  aid  in  correcting  the  proof-sheets.  Notwithstand- 
ing the  extra  pains  bestowed  upon  it,  I am  still  deeply  sensible 
of  the  many  imperfections  with  which  this  book  is  chargeable, 
and  for  which  I once  more  solicit  the  kind  indulgence  of  my 
nuedical  brethren.  It  is  with  no  small  gratification,  however, 
that  I have  seen  the  modifications  which  I ventured  to  intro- 
duce into  the  principles  and  practice  of  medicine  gradually 
adopted  by  medical  practitioners  in  this  and  other  countries; 
and  the  good  results  which  have  everywhere  followed  may,  I 
trust,  now  be  regarded  as  satisfactory  proof  that  such  modifica- 
tions are  not  merely  temporary  changes,  but  permanent  im- 
provements in  the  practice  of  the  art. 

J.  HUGHES  BENNETT. 


Edinburgh,  A’pril^  1865. 


CONTENTS. 


List  of  Illustkations  .... 

Introduction  ..... 

The  relation  of  the  science  to  the  art  of  medicine 
Mode  of  conducting  the  clinical  course 
The  political  state  of  the  medical  profession  . 
The  social  4rtate  of  the  medical  profession 
The  present  state  of  practical  medicine 


SECTION  I. 

EXAMINATION  OF  THE  PATIENT 

Arrangement  of  symptoms,  etc.  ..... 

Inspection  of  the  dead  body  ...... 

Relative  position  of  internal  organs  ..... 

Inspection  ......... 

Inspection  of  the  general  posture  ..... 

of  the  countenance  ..... 

of  the  chest  ...... 

of  the  abdomen  ...... 

Palpation  ......... 

Increased  or  diminished  sensibility  of  parts  .... 

Altered  form,  size,  density,  and  elasticity  .... 

Alterations  of  movement  ...... 

Mensuration  ........ 

Percussion  ......... 

Of  the  different  sounds  produced  by  percussion 
Of  the  sense  of  resistance  produced  by  percussion 
General  rules  to  be  followed  in  the  practice  of  mediate  percussion 
Special  rules  to  be  followed  in  percussing  particular  organs 
in  percussing  the  lungs  . 
in  percussing  the  heart  , 
in  percussing  the  liver 
in  percussing  the  spleen 
in  percussing  the  stomach  and  intestines 
in  percussing  the  kidneys 
in  percussing  the  bladder 

Auscultation  ........ 

General  rules  to  be  followed  in  the  practice  of  auscultation  . 

Special  rules  to  be  followed  during  auscultation  of  the  pulmonary 
organs  ........ 

Of  the  sounds  produced  by  the  pulmonary  organs  in  health  and  in 
disease  ........ 

B 


pAcre 

xvii 

1 

2 

6 

13 

19 

20 

26 

26 

30 

33 

36 

36 

36 

36 

37 

43 

43 

44 

44 

46 

48 

60 

51 

61 

63 

63 

66 

67 

69 

60 

61 

62 

63 

63 

66 

66 


X 


CONTENTS. 


PAGE 


Special  rules  to  be  followed  during  auscultation  of  the  circulatory 

organs  . . .....  70 

Of  the  sounds  produced  by  the  circulatory  organs  in  health  and 

disease  .....  . . 71 

Auscultation  of  the  abdomen  ......  73 

Auscultation  of  the  large  vessels  .....  74 

Use  of  the  Microscope  .......  76 

Description  of  the  microscope  .....  77 

Mensuration  and  demonstration  .....  83 

How  to  observe  with  a microscope  .....  85 

Principal  Applications  op  the  Microscope  to  Diagnosis  ...  87 

Saliva  ........  88 

Milk  .........  89 

The  blood  ........  91 

Pus  .........  93 

Sputum  ........  94 

Vomited  matters  .......  97 

Faaces  ........  99 

Uterine  and  vaginal  discharges  . . . . .100 

Mucus  ........  102 

Dropsical  fluids  . . . . . . .103 

Urine  . . . . . . . . . 103 

Cutaneous  eruptions  and  ulcers  . . . . .107 

Use  op  Chemical  Tests  . . . . . . .110 

To  detect  albumen  in  the  urine  . . . . .110 

To  detect  bile  in  the  urine  . . . . . .110 

To  detect  bile  acids  in  the  urine  . . . . .Ill 

To  detect  leucin  and  tyrozin  in  the  urine  . . . .Ill 

To  detect  sugar  in  the  urine  . . . . . .Ill 

To  detect  chlorides  in  the  urine  . . . . ,112 


SECTION  II. 

PRINCIPLES  OF  MEDICINE  . . . 114 


Molecular  AND  Cell  Theories  OF  Organisation  . . . .115 

On  the  General  Laws  op  Nutrition  in  Health  and  Disease  . . 124 

Function  of  nutrition  . . . . . . .124 

Op  the  General  Laws  op  Innervation  in  Health  and  Disease  . . 137 

General  anatomy  and  physiology  of  the  nervous  system  . . 138 

General  pathology  of  the  nervous  system  . . . .148 

Inflammation  . . . . . . . .156 

Tuberculosis  ........  179 

Morbid  Growths  op  Texture — ^their  General  Pathology  and  Treat- 
ment .........  185 

Classification  . . . . . . . .187 

Fibrous  growths  . . . . . .188 

Fatty  growths  . . . • . . ,196 

Cystic  growths  . . . , . . .199 

Glandular  growths  ....*•  206 

Epithelial  growths  ......  210 

Vascular  growths  . . , . . .216 

Cartilaginous  growths  ......  220 

Osseous  growths  . , . . , ,226 

Cancerous  growths  ......  229 


CONTENTS.  xi 

PAGE 


General  pathology  of  morbid  growths  . . . .233 

General  treatment  of  morbid  growths  ....  242 1 

Morbid  Degenerations  of  Texture  .....  245 

, Albuminous  degeneration  ......  246 

Fatty  degeneration  .......  252 

Pigmentary  degeneration  . . . . . .262 

Mineral  degeneration  .......  269 

Concretions  .........  272 

Albuminous  concretions  . . . . . .273 

Fatty  concretions  . . . . . . .273 

Pigmentary  concretions  . . . . . .274 

Mineral  concretions  . . . . . . .275 

Urinary  concretions  .......  275 

Prostatic  concretions  . . . . . . .278 

Hairy  concretions  . . . . . . .279 

Vegetable  fibrous  concretions  .....  280 

Amyloid  and  amylaceous  concretions  .....  282 


SECTION  III. 


GENERAL  THERAPEUTICS  . 284 

The  Influence  which  the  Mind  exerts  over  the  Body  . . . 284 

The  Natural  Progress  of  Disease  .....  295 

The  Knowledge  derived  from  an  improved  Diagnosis  and  Pathology  . 297 

Fallacy  of  the  Change  of  Type  Theory  .....  299 

On  the  diminished  Employment  of  Blood-Letting  and  Antiphlogistic  Rem- 
edies in  the  Treatment  of  Acute  Inflammations  . . . 302 

Proposition  1. — That  little  reliance  can  be  placed  on  the  experience  of 
those  who,  like  Cullen  and  Gregory,  were  unacquainted  with  the 
nature  of,  and  the  mode  of  detecting,  internal  inflammations  . 303 

Proposition  2. — That  inflammation  is  the  same  now  as  it  has  ever 
been,  and  that  the  analogy  sought  to  be  established  between  it  and 
the  varying  types  of  fevers  is  fallacious  ...  * 305 

Proposition  3. — That  the  principles  on  which  blood-letting  and  anti- 
phlogistic remedies  have  hitherto  been  practised  are  opposed  to  a 
sound  pathology  .......  306 

Proposition  4. — That  an  inflammation  once  established  cannot  be  cut 
short,  and  that  the  object  of  judicious  medical  treatment  is  to  con- 
duct it  to  a favorable  termination  . . . . .313 

Proposition  5. — That  all  positive  knowledge  of  the  experience  of  the 
past,  as  well  as  the  more  exact  observation  of  the  present-  day, 
alike  establish  the  truth  of  the  preceding  principles  as  guides  for 
the  future  ........  316 

An  Inquiry  into  our  Present  Means  of  Treatment  . . . 320 

Dietetica  ........  320 

Hygienica  ........  323 

Materia  medica  . . . . . . 331 

Action  of  medicines  on  the  ultimate  elements  of  the  tissues  . . 336 

on  the  nervous  system  ....  337 

on  the  respiratory  system  . . . 339 

on  the  circulatory  system  . 339 

on  the  digestive  system  ....  341 

on  the  genito-urinary  system  . . . 342 

on  the  integumentary  system  . . . 343 


xii 


CONTENTS. 


General  theory  of  the  action  of  remedies  ....  344 

Physiology  and  Pathology  the  true  Foundations  for  Medical  ^ 

Practice  ........  347 


SECTION  IV. 

DISEASES  OF  THE  NERVOUS  SYSTEM  . . 352 

On  the  Pathology  of  Cerebral  and  Spinal  Softenings,  and  on  the 


Necessity  op  employing  the  Microscope  to  ascertain  their  Nature  . 353 

Acute  Hydrocephalus — Cases  I.  to  III.  .....  360 

Pathology  and  treatment  . . . . . .364 

Cerebral  Meningitis,  Acute — Cases  IV.  to  VI.  ....  367 

Pathology  and  treatment  ......  370 

Chronic — Cases  VII.  and  VIII.  . . . 373 

Cerebritis,  Acute — Cases  IX,  and  X.  . . . . .376 

Chronic — Cases  XI.  to  XIV.  . . . . .380 

Pathology  and  treatment  . . . . . .387 

Cerebral  Disease  from  Obstruction  op  Arteries — Cases  XV.  to  XVII.  . 390 

Pathology  ........  396 

Cerebral  Hemorrhage — Cases  XVIII.  to  XXIX.  . . . 400 

Pathology  and  treatment  . . . . . .416 

Cancer  OF  the  Brain — Case  XXX.  . . . . . .421 

Dropsy  op  the  Brain — Case  XXXI.  .....  424 

Structural  Diseases  op  the  Spinal  Cord — Cases  XXXII.  to  XL.  . . 427 

Acute  spinal  meningitis  .....  427 

Acute  myelitis  . . . . . . .428 

Paraplegia  and  chronic  myelitis — Cases  XXXIV.  to  XXXIX.  . 430 

Facial  neuralgia,  from  cancerous  disease  of  the  cranium — Case  XL.  . 441 

Functional  Disorders  of  the  Nervous  System — Case  XLI.  . . 445 

Classification  of  functional  nervous  disorders  . . . 447 

Pathology  of  functional  nervous  disorders  ....  449 

Treatment  of  functional  nervous  disorders  . . . .453 

Delirium  tremens — Cases  XLII.  to  XLV.  . . . . 455 

Poisoning  by  opium — Cases  XLVI.  and  XL VII.  . . . 458 

Poisoning  by  hemlock — Case  XL VIII.  ....  460 

Poisoning  by  lead — Case  XLIX.  .....  464 


SECTION  V. 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  . . 466 

Diseases  of  the  Mouth,  Pharynx,  and  (Esophagus — Cases  L.  to  LIV.  . 466 

Functional  Disorders  op  the  Stomach — Cases  LV.  to  LVIII.  . . 472 

General  pathology  and  treatment  of  dyspepsia  . . .475 

Vomiting  of  sarcinae — LVIII.  . . . . .479 

Organic  Diseases  of  the  Stomach  ......  481 

Chronic  ulcer  of  the  stomach — Cases  LX.  and  LXI.  ..  . . 481 

Chronic  ulcer  of  the  stomach,  with  perforation — Cases  LXII.  and 

LXIII 483 

Pathology  and  treatment  ......  488 

Cancer  of  stomach — Cases  LXIV.  and  LXV.  . . .489 

Poisoning  by  oxalic  acid — Case  LXVI.  ....  495 

sulphuric  acid — Case  LXVII.  ....  496 

corrosive  sublimate — Case  LXVIII.  . . 496 


CONTENTS. . 


xm 


Diseases  op  the  Liver  ....... 

Acute  congestion — Case  LXIX.  ..... 

Acute  jaundice — Case  LXX.  ...... 

, Abscess — Case  LXXI.  ...... 

Jaundice — Case  LXXII.  . . * r.  ’ t 'tr-trxTT  1 

Jaundice  from  cancer  compressing  the  ducts — Cases  LXXIII.  and 

LXXIV.  

Enlargement  of  the  liver — Case  LXXV.  . . . . 

Fatty  enlargement — Case  LXXVI,  ..... 

Cirrhosis — Cases  LXX VII.  and  LXX VIII.  .... 

Cancer  of  the  liver — Case  LXXIX.  ..... 

Hydatid  cyst  of  the  hver — Case  LXXX.  .... 

Diseases  of  the  Intestines  . ...... 

Diarrhoea — Cases  LXXXI.  and  LXXXII.  .... 

Constipation  . ....... 

Dysentery — Cases  LXXXIII.  and  LXXXIV.  . . . . 

Chronic  dysentery — Case  LXXXV.  ..... 

Pathology  and  treatment  of  diarrhoea  and  dysentery 
Obstruction  of  large  intestine  from  cancer — Case  LXXXVI.  . 
Strangulation  of  small  intestine  from  inguinal  hernia — Case 

LXXXVII. 

Intestinal  Worms — Cases  LXXXVIII.  to  XCI.  .... 
Peritonitis — Cases  XCII.  to  XCVI.  ..... 


PAGE 

497 

497 

498 
501 
604 

606 

510 

511 
514 
518 
622 
624 

524 

525 
626 
627 
630 
634 

535 

642 

546 


SECTIO^T  YI. 


DISEASES  OF  THE  CIRCULATORY  SYSTEM.  . 557 

Pericarditis — Cases  XCVII.  to  CII.  .....  559 

Pathology  and  treatment  . . . . . .670 

Valvular  Diseases  op  the  Heart — Cases  CUT.  to  CXV.  . . . 675 

Enlarged  foramen  ovale — Case  CXVI.  ....  692 

Pathology  of  valvular  and  organic  diseases  of  the  heart  . . 694 

Treatment  of  valvular  and  organic  diseases  of  the  heart  . . 599 

Functional  Disorders  op  the  Heart  .....  600 

Aneurism — Cases  CXVII.  to  CXXVI.  .....  601 

General  diagnosis  of  thoracic  aneurisms  ....  630 

Physical  phenomena  of  abdominal  aneurisms  . . . 630 

Pathology  and  treatment  of  aneurisms  ....  633 

Diseases  of  Veins  and  Lymphatics  .....  634 

Phlebitis  of  the  left  iliac  vein — Case  CXXVII.  . . . 634 

Angio-leucitis — Case  CXXVIII.  . ...  635 


SECTIOlSr  YII. 


DISEASES  OF  THE  RESPIRATORY  SYSTEM  . . 637 

Laryngitis — Cases  CXXTX.  to  CXXXIII.  . . . . 638 

Treatment  by  topical  applications  . . . . .639 

Diagnosis  of  laryngitis  ...  ....  647 

Pertussis — Case  CXXXFV.  ......  649 


XIV 


CONTENTS. 


Bronchitis— Cases  CXXXY.  to  CXXXVIII. 

Pathology  and  treatment 

On  injections  into  the  bronchi  in  pulmonary  diseases 
Plehritis — Cases  CXXXIX.  to  CXLVl. 

Pathology,  diagnosis  and  treatment  of  pleuritis 
Empyema — Case  CXLIV. 

Pneumonia — Cases  CXLYII.  to  CLYII.  . ! 

On  the  diagnostic  value  of  the  absence  of  chlorides  from  the 
pneumonia — Case  CLllI.  .... 

The  pathology  of  acute  pneumonia 
Treatment  of  acute  pneumonia 
Tabular  view  of  129  cases  of  acute  pneumonia 
Chronic  pneumonia  and  gangrene  of  the 
CLYII.  . . . . , ^ 

Phthisis  Pulmonalis— Cases  CLYIII.  to  CLXII. 

On  the  natural  progress  of  phthisis  pulnionalis the  tendency 

ation — the  modes  of  arrestment 
Pathology  and  general  treatment  of  i luidsis  pulmonahs 
Special  treatment  of  phthisis  pulmonaiig 
Cancer  of  the  Lung — Case  CLXIII.  . . | 

Carbonaceous  Lungs — Cases  CLXIY.  to  CLXY.  . i 
Pathology  and  treatment 


lung— Cases  C 


Page 

651 

655 

' 658 

660 

664 

671 

678 

urine  m 

686 

689 

692 

697 

LIY.  to 

713 

722 

to  ulcer- 

733 

741 

749 

754 

756 

768 

SECTION  VIII. 


DISEASES  OF  THE  GENITO-URINARY  SYSTEM  '763 

Ovarian  Dropsy — Cases  CLXYI.  to  CLXIX.  ....  '763 

Pathology  of  ovarian  dropsy  . . . . . . '775 

Treatment  of  ovarian  dropsy  . . . . . ,780 

Nephritis  and  Pyelitis — Cases  CLXX.  and  CLXXI.  . . . 782 

Desquamative  nephritis — Cases  CLXXII.  to  CLXXIY.  . . 785 

Suppurative  nephritis — Case  CLXXY.  . . . .791 

Scrofulous  nephritis — Case  CLXXYI.  . . . . 793 

Calculous  nephritis — Case  CLXXYIL  . . . . 795 

Chronic  pyelitis— Case  CLXXYIII 797 

Pathology  of  cystic  kidney  . . . . . .799 

Persistent  Albuminuria,  or  Bright’s  Disease — Cases  CLXXIX.  to 

CXCI 801 

Albuminuria  with  excessive  amount  of  urine  and  waxy  disease — Cases 

CLXXXYII.  to  CXC. .811 

Pathology  of  Bright’s  disease  ......  819 

Diagnosis  of  Bright’s  disease  ......  823 

Treatment  of  Bright’s  disease  ......  825 


SECTION  IX. 


DISEASES  OF  THE  INTEGUMENTARY  SYSTEM  . 827 

Classification  of  Skin  Diseases  ......  828 

Diagnosis  OF  Skin  Diseases  . . . . . . ,831 

Porrigo  ........  835 


CONTENTS. 


XV 


PAGE 


The  Treatment  op  Skin  Diseases  . . . . . .836 

Dermatozoa  .........  842 

Acarus  scabiei  .......  842 

Entozoon  foUiculorum  .......  846 

Dermatophyta  ........  847 

' Favus — Cases  CXCII.  to  CXCVI.  .....  847 

History  of  favus  as  a vegetable  parasite  . . . .850 

Mode  of  development  and  symptoms  of  favus  . . . .850 

Causes  .........  853 

Pathology  856 

Treatment  ........  862 


SECTION  X. 


DISEASES  OF  THE  BLOOD 

Leucoctthemia — Cases  CXCIX.  to  CCII.  • . 

Pathology  and  treatment 
Discovery  of  leucocythemia 
Chlorosis  and  Anemia — Case  CCIII. 

IcHORHJEMiA  OR  (so-called)  Py^mia — Casc  CCIY. 

Pathology  .... 

Glycoh^mia — Cases  CCV.  to  CCXIII. 

Pathology  and  treatment 
Continued  Fever  .... 

Febricula— Cases  CCXIV.  to  CCXYII. 

Kelapsing  fever — Case  CCXVIIL 

Typhoid  fever  treated  by  quinine — Cases  CCXIX.  to  CCXXI. 

Typhus  fever  treated  by  quinine — Cases  CCXXII.  to  CCXXVI 
Typhus  fever  treated  without  quinine — Cases  CCXXVII.  to 

. CCXXXII 

Diagnosis  of  continued  fevers  . 

Morbid  anatomy  of  the  Edinburgh  fever  during  the  winter  1847-8 
Pathology  and  etiology  of  continued  fever 
Typhoid  succeeded  by  typhus  fever — Case  CCXXXIII. 

Typhoid  fever— CCXXXIV 

Table  of  typhoid  and  typhus  fevers,  1862-63 — Cases  CCXXXV.  t 
CCL.  .... 

Propagation  of  fever  . 

Treatment  of  continued  fever  . 

Iniantile  Remittent  Fever — Can  it  be  separated  from  Acute  Hydro 
CEPHALUS? — Case  CCLI.  .... 

Intermittent  Fever — CCLII.  .... 

Pathology  and  treatment  .... 

Eruptive  Fevers  ...  ... 

Scarlatina — Cases  CCLIII.  and  CCLXI. 

Erysipelas — Cases  CCLXII.  and  CCLXIII. 

Variola — Cases  CCLXI V.  and  CCLXV. 

The  ectrotic  treatment  of  variola — Case  CCLXYI. 

Vaccination  ...... 

Pathology  of  variola  .... 

Diphtheria— Cases  CCLXYH.  and  CCLXYIH. 

Syphilis  and  Mercurial  Poisoning — Cases  CCLXIX.  to  CCLXXI. 

Forms  of  syphilis  ..... 

Diagnosis  of  syphilis  ..... 

Propagation  of  syphilis  .... 

Pathology  of  syphilis  ..... 


867 

867 

880 

892 

900 

902 

904 

907 

909 

918 

921 

923 

924 
927 

930 

931 
934 
937 

937 

938 

940 

942 

946 

949 

951 

952 

953 

964 

961 

962 

963 

965 

967 

968 
971 

974 

975 

976 

977 


XVI 


COKTENTS. 


Treatment  of  syphilis  ....... 

Rheumatism  and  Gout  . . . . 

General  pathology  and  treatment  ..... 

Treatment  of  acute  rheumatism  by  nitrate  of  potash — Cases  CCLXXII. 

toCCLXXV. 

Treatment  of  rheumatism  by  lemon  juice — Cases  CCLXXVI.  to 

CCLXMX. 

Diaphragmatic  rheumatism — Case  CCLXXX.  .... 
Rheumatic  iritis — Case  CCLXXXI. 


Chronic  gout — Case  CCLXXXII. 

Scorbutus — Cases  CCLXXXIII.  and  CCLXXXIY. 

Pathology  and  treatment 
Polydipsia — Cases  CCLXXXV.  and  CCLXXXVI. 
PoLYSARCiA  OR  Obesity — Case  CCLXXXVII. 
Conclusion — The  ethics  of  medicine 
Table  of  Cases  ..... 

General  Index  ..... 


PAGE 

980 

982 

982 

984 

988 

989 

990 

991 
993 
993 
995 
997 
999 

1005 

1013 


LIST  OF  ILLUSTRATIONS. 


Fig. 

1.  View  of  internal  organs  after  removal  of  the  thoracic  and  abdominal  parietes 

2.  Deep-seated  view  of  same  . . . . • . . 

3.  Remarkable  displacement  of  organs,  in  consequence  of  intestinal  obstruction 

4.  Spatulae  for  depressing  the  tongue,  one-third  the  real  size 

5.  Extreme  case  of  follicular  pharyngitis  .... 

6.  Mode  of  using  the  laryngoscope  and  tongue-depressor 

7.  View  of  the  healthy  larynx  with  the  laryngoscope 

8.  Another  view  of  the  healthy  larynx  during  ordinary  breathing 

9.  Another  view  during  deep  inspiration  .... 

10.  Complete  closure  of  the  glottis  as  in  the  act  of  swallowing  . 

11.  Transformation  of  the  right  (inferior)  false  vocal  cord 

12.  Cicatrices  and  loss  of  substance  of  the  larynx  . 

13.  Polypus  attached  to  the  right  vocal  cord  . . 

14.  Large  muriform  polypus  of  an  epithelial  character  in  the  larynx 

15.  Mode  of  inspecting  the  posterior  nares 

16.  Voltolini’s  mirror  and  shield  for  depressing  the  tongue 

17.  Septum,  posterior  orifices  of  the  nasal  fossie,  etc. 

18.  The  stethometer  of  Dr.  Quain,  half  the  real  size 

19.  Mode  of  applying  the  instrument  when  the  string  is  used 

20.  The  chest-measurer  of  Dr.  Sibson,  natural  size 
21  and  22.  Modes  of  applying  the  chest  measurer 

23.  Stetho-goniometer,  for  measuring  the  inclination  of  the  walls  of  the  thorax 

24.  The  pleximeter  ....... 

25.  The  percussion  hammer  of  Winterich  .... 

26  and  27.  Anterior  and  views  of  the  limits  and  intensity  of  dulness 

28.  View  of  percussion  in  phthisis,  atrophied  heart  and  liver,  and  abstine 

29.  View  of  percussion  in  pleurisy  ..... 

30.  View  of  percussion  in  pericarditis,  pneumonia,  and  loaded  rectum 

31.  View  of  percussion  in  hypertrophy  of  liver  and  heart 

32.  View  of  percussion  in  hypertrophied  liver  and  spleen — Enlarged  heart 

33.  View  of  percussion  in  enlarged  spleen — pushed  somewhat  upwards  . 

34.  View  of  percussion  in  dropsy  of  the  abdomen,  enlarged  heart,  and  aneurism 


Page 

34 

34 

35 
38 
38 
40 
40 
40 
40 

40 

41 
41 

41 

42 
42 

42 

43 
45 

45 

46 
46 
48 

48 

49 

54 

55 

56 

57 

58 

59 
59 
61 


35  and  36.  Anterior  and  posterior  outlines  of  the  trunk  for  marking  results  of  percussion  62 
37  to  41.  Various  kinds  of  stethoscopes 

42.  Flexible  stethoscope 

43.  Can  man’s  stethoscope 

44.  Differential  stethoscope  of  Dr.  Scott  Alison 

45.  Hydrophone  of  Dr.  Scott  Alison  . 

46-  Oberhaeuser’s  microscope  made  for  medical  men 

47.  Gruby’s  compound  pocket  microscope  . 

48.  The  same  microscope  mounted,  ready  for  use 

49.  Beale’s  clinical  microscope 

50.  Spaces  equal  to  1-lOOOth  and  l-500th  of  an  inch  magnified  250  diameters  linear 

51.  Salivary  corpuscles,  epithelial  scales,  etc.,  as  seen  in  a drop  of  saliva  . 

52.  Minute  confervoid  filaments  springing  from  an  altered  epithelial  scale 

53.  Confervoid  filaments  and  sporules,  in  exudation  on  the  mouth  and  gums 

54.  Fringe-like  epithelium,  from  the  surface  of  an  ulcer  on  the  tongue  . 

55.  Globules  of  cow’s  milk  ........ 

66.  Colostrum  of  the  human  female,  containing  milk  globules  greatly  varying  in  size 
57.  Blood-corpuscles,  drawn  from  the  extremity  of  the  finger 
68.  Blood-corpuscles  altered  in  shape  from  exosmosis 


XVlll 


LIST  OF  ILLUSTRATIONS. 


Fig.  Page 

59.  Blood-corpuscles  altered  in  form,  and  aggregated  together,  in  thickened  blood  92 

60.  The  same  united  together  in  chaplets  by  coagulated  fibrin  . , . 92 

61.  Altered  blood  corpuscles  in  the  fluid  of  an  haematocele  . . . 92 

62.  Appearance  of  blood  once  observed  in  a case  of  cholera  ...  92 

63.  Colorless  corpuscles  slightly  increased  in  number  ....  93 

64.  Appearance  of  a drop  of  blood  in  leucocythemia  ....  93 

65.  The  same,  after  the  addition  of  acetic  acid  .....  93 

66  and  67.  Pus  corpuscles  in  healthy  pus,  and  after  the  addition  of  acetic  acid  . 94 

68.  Pus  corpuscles,  surrounded  by  a delicate  cell-wall  ....  94 

69.  In  egular-shaped  pus  corpuscles,  in  scrofulous  pus  ....  94 

70.  Mass,  consisting  of  minute  molecules,  frequently  seen  in  disintegrated  tubercle  95 

71  and  72.  Masses  composed  of  molecules  and  oily  granules  varying  in  size  . 95 

73.  Mass  partly  composed  of  the  debris  of  a fibrous  structure  ...  95 

74.  Mass  composed  of  tubercle  corpuscles  ......  95 

75.  Fragments  of  phosphate  of  lime  occasionally  found  in  the  sputum  . . 95 

76.  Fragment  of  elastic  tissue  of  the  lung,  in  phthisical  sputum  ...  96 

77  and  78.  Fragments  of  areolar  and  elastic  tissue,  from  phthisical  sputum  . 96 

79.  Fibrinous  coagula  in  sputum,  exhibiting  moulds  of  the  bronchi  . . 96 

80.  Fibres,  with  corpuscles,  in  a fibrinous  coagulum  from  a bronchus  . . 96 

81.  Epithelial  cells,  embedded  in  mucus,  expectorated  from  the  fauces  . . 97 

82.  Another  portion  of  expectorated  mucus  from  the  fauces,  acted  on  by  acetic  acid  97 

83  and  84.  Cells  loaded  with  pigment  in  the  sputum  of  a collier  . . . 97 

85.  Appearance  of  starch  corpuscles  after  partial  digestion  in  the  stomach  . 98 

86.  Flake  in  the  rice-water  vomiting  of  a cholera  patient  ....  98 

87.  Structures  observed  in  certain  rice-water  vomitings  from  a cholera  patient.  98 

88.  Sarcina  ventriculi  ........  98 

89.  Portions  of  the  uredo  in  bread  partly  digested  and  disintegrated  . . 99 

90.  Structure  of  confervoid  mass  passed  from  the  bowels  ...  99 

91.  The  same  magnified  500  diameters  linear  .....  99 

92.  Rounded  masses  of  earthy  matter  ......  100 

93.  Structure  of  flakes  in  a rice-water  stool,  from  a cholera  patient  . . 100 

94.  Corpuscles  seen  in  a chronic  leucorrhoeal  discharge  ....  101 

95.  Structure  of  gelatinous  mucus  from  the  os  uteri  ....  101 

96.  The  same,  after  the  addition  of  acetic  acid  .....  101 

97  and  98.  Two  specimens  of  cancerous  juice  squeezed  from  the  uterus  . . 101 

99.  Viscid  greyish-yellow  sputa  of  pneumonia,  treated  with  dilute  acetic  acid  . 102 

100.  Spermatozoids  as  observed  in  the  fluid  of  spermatocele  . . . 103 

101.  Cells  in  fluid,  removed  from  an  ovarian  dropsy  ....  103 

102.  Lozenge-shaped  and  rhomboidal  crystals  of  uric  acid  . . . 104 

103.  Aggregated  and  flat  striated  crystals  of  uric  acid  . _ . _ . . 104 

104.  Urate  of  ammonia,  in  a granular  membranous  form,  and  in  spicular  masses  104 

105.  Triple  phosphate,  with  various  forms  of  urate  of  ammonia  . . . 104 

106.  Octahedral  and  dumb-bell  shaped  crystals  of  oxalate  of  lime  . , 105 

107.  Flat  and  rosette-like  crystals  of  cystine  .....  105 

103.  Bodies  observed  in  the  urine  of  a scarlatina  patient,  24  hours  after  being  passed  105 

109.  Cast  of  a uriniferous  tube  .......  105 

110.  Fatty  casts,  at  an  early  period  of  formation  .....  106 

111.  Fragments  of  fatty  and  waxy  casts  ......  106 

112.  Tyrozin  masses  in  urinary  sediment  of  a man  with  atrophy  of  the  liver  . 106 

113.  Leucin  in  a drop  of  the  same  urine  allowed  to  evaporate  . . . 106 

114.  Pure  tyrozin  from  the  same  urinary  sediment  ....  106 

115.  Epidermic  cells  from  crust  of  psoriasis  . .....  107 

116.  Thalli  of  the  fungus  found  in  the  ear  by  Mr.  Grove  ....  108 

117.  The  fungus  {Achorion  Schonleini)  from  a favus  crust  . . . 108 

118.  The  same  magnified  500  diameters  linear  .....  108 

119.  Epithelial  cells  from  the  surface  of  an  ulcer  of  the  lip  ...  108 

120.  The  same,  after  the  addition  of  acetic  acid  .....  lOg 

121  and  122.  Epidermic  cells  from  a softened  epithelioma  ....  lOg 

123.  Appearance  of  section  of  cancerous  ulcer  of  the  skin  ....  109 

124.  A pocket-case,  containing  a spirit-lamp,  two  stoppered  bottles,  etc.  . 112 

125  to  129.  Development  of  vibriones  ......  119 

130.  Nuclei  embedded  in  a molecular  blastema  .....  121 

131.  Young  fibre  cells  formed  by  aggregation  of  molecules  round  the  nuclei  . 121 

132.  Cancer  cells,  one  with  a double  nucleus  .....  121 

133.  Histolytic,  or  so-called  granule  cells,  breaking  down  from  fatty  degeneration  121 

134.  Remarkable  atrophy  of  the  left  side  of  the  face  ....  155 

135.  An  exact  copy  of  a portion  of  the  web  of  a frog’s  foot  inflamed  . . 157 

136.  Appearance  of  cartilage  on  each  side  of  an  incision  made  into  the  patella  . 163 

137.  Vertical  section  of  cartilage  from  the  surface  of  the  patella  . . . 163 


LIST  OF  ILLUSTRATIONS. 


XIX 


Pig. 

138, 

13y 

141 

143, 

144, 

145, 
146 

148, 

149, 

150, 

151, 

152, 

153, 

154, 

155, 

156, 

157, 

158 

159 
160. 
161. 
162. 

163. 

164. 

165. 

166. 

167. 

168. 

169. 

170. 

171. 

172. 

173. 

174. 

175. 

176. 

177. 

178. 

179. 
1«0. 
181. 
182. 

183. 

184. 

185. 

186. 

187. 

188. 

189. 

190. 

191. 

192. 

193. 

194. 

195. 

196. 

197. 

198. 
200. 
201. 
202. 
203. 
204 

207. 

208. 

209. 

210. 
211. 


and  140.  Portions  of  recent  lymph  from  the  pleura 
Portion  of  firm  pleural  adhesion  ..... 

Another  portion  of  the  same,  further  developed 
The  last,  acted  on  by  acetic  acid  . . . 

Pus  cells.  Four  cells  have  been  acted  on  by  acetic  acid 
. Pus  celts  containing  fatty  molecules,  after  adding  acetic  acid 
and  147.  Scrofulous  pus  cells  after  the  addition  of  acetic  acid  . 

Granular  exudation  and  granular  masses,  from  cerebral  softening  . 

Granular  cells  and  masses  from  cerebral  softening 
Two  vessels  coated  with  exudation  from  softening  of  the  spinal  cord 
Vertical  section  of  a granulating  sore  ..... 

Moist  gangrene,  following  compound  fracture 
Dry  gangrene  from  debility  ...... 

Three  air  vesicles  of  a pneumonic  lung  with  pus  forming  in  them  . 

Layers  of  lymph  in  pericarditis,  presenting  the  form  of  large  villi  . 

Structure  of  the  villi  in  pericarditis  ..... 

Corpuscles  from  firm  tubercular  exudation  into  the  lung 
. Corpuscles,  granules,  and  debris,  from  soft  tubercular  exudation  into  cerebellum  179 

180 
180 
180 
188 
189 
189 
189 
189 
189 

189 

190 
190 
190 
192 
192 
192 
192 
192 
192 
192 

192 

193 
193 
193 
193 
193 

193 

194 

195 

195 

196 

196 

197 

197 

198 
198 

198 

199 

200 
200 
201 
201 
201 
201 
202 
202 
202 
203 
203 


The  same,  from  tubercular  infiltration  of  a mesenteric  gland 
Section  of  a firm  miliary  tubercle  of  the  lung  .... 

Section  of  a grey  granulation  in  the  lung  .... 

Molecular  structure  of  a calcareous  pulmonary  tubercle 
Sti-uctures  in  hypertrophied  heart  ..... 

Fibrous  structure  of  the  uterus  . . . . . . 

The  same,  hypertrophied  from  great  increase  in  size  of  its  fusiform  cells 
Cell  fibres  and  fibre  cells  from  a fibro  cellular  growth  in  the  stomach 
Fusiform  cells  from  a sarcomatous  growth  in  the  kidney 
Fibro  nucleated  structure  from  a so-called  medullary  sarcoma  of  the  humerus 
Fibrous  stroma  of  a tumor  acted  on  by  acetic  acid 
Fibres  from  induration  of  the  stomach,  with  embedded  nuclei 
Fibrous  tissue,  with  free  nuclei  and  cells,  from  a white  peritoneal  patch 
The  same,  after  the  addition  of  acetic  acid  .... 

Cells  in  the  soft  part  of  a fibrous  tumor  removed  from  the  neck  by  Mr.  Syrae 
The  same,  after  the  addition  of  acetic  acid  ..... 
Fibres  in  various  stages  of  development  from  a harder  nodule  of  the  same  tumo: 
Perfect  fibrous  tissue  from  another  nodule  of  considerable  density  . 
Corpuscles  scraped  from  the  surface  of  a fibro-uucleated  growth  of  the  thigh 
The  same,  after  the  addition  of  acetic  acid 
Appearance  of  a thin  section  of  the  tumor 
Another  section,  treated  with  acetic  acid 

Soft  polypi  growing  from  the  Schneiderian  mucous  membrane 
Fibre  cells  and  fibres  from  the  pulpy  interior  of  a polypus  . 

The  same,  after  the  addition  of  acetic  acid 
Ciliated  epithelial  and  pus  cells  from  the  exterior  of  the  tumor 
The  same,  after  the  addition  of  acetic  acid 

Section  of  a dermoid  fibrous  tumor  embedded  in  the  uterine  walls 
Section  of  a dermoid  fibrous  tissue  from  the  uterus,  acted  on  by  acetic  acid 
Section  of  hard  uterine  polypus,  boiled  in  dilute  acetic  acid  and  dried 
Section  of  Neuroma  connected  with  three  nervous  trunks 
Thin  section  of  a subcutaneous  tubercle  composed  of  fibro-cartilage 
Fibrous  structure  of  a neuromatous  swelling  .... 

Lobulated  Lipoma  of  the  nose  . . ' . 

Smooth  Lipoma,  removed  from  under  the  tongue,  one-half  the  natural  size 
Two  layers  of  voluminous  fat  cells,  varying  in  size,  from  a Lipoma  . 

Fat  cells  from  the  same,  dried,  showing  crystalline  bundles  of  Margaric  acid 
Section  of  a Fibro-Lipomatous  tumor  . 

Simple  cyst  of  the  broad  ligament  of  the  uterus,  with  very  vascular  walls 
199.  Diagrams  of  compound  cystic  growths  .... 

Compound  cystic  sarcoma  of  the  mamma  .... 

Colloid  cystic  growths  in  three  lobules  of  the  thyroid  gland  . 

Delicate  oval  corpuscles  in  transparent  colloid  matter  of  the  ovary  . 

Round  and  oval  corpuscles  with  filaments  in  colloid  matter  in  the  ovary 
to  206.  Of  an  ovarian  cyst  showing  the  epithelial  cells,  etc.  . 

Cells  from  the  interior  of  a simple  cyst  .... 

Structure  of  cholesteatoma  ...... 

Encysted  tumor,  with  fatty  steatomatous  contents 
Contents  of  a large  atheromatous  cyst  ..... 

Adipose  cells,  from  a steatomatous  encysted  tumor  of  the  ovary 


XX 


LIST  OP  ILLUSTRATIONS. 


F’g.  Page 

‘J12.  Cysts  in  cystic  sarcoma  of  the  mamma,  filled  with  molecular  matter  . 203 

213.  Fibrous  tissue  from  a sarcomatous  encysted  growth  in  the  kidney  . . ^ 204 

214.  Cystic  osteoma  of  the  femur  .......  204 

215.  Cystic  osteoma  of  the  tibia  . . . . . . . 204 

216.  Cysts  in  cystic  sarcoma  of  the  mamma,  crowded  with  cells  . . . 205 

217.  Fibrous  stroma  from  another  part  of  the  same  tumor  . . . 205 

218.  Structure  of  a cystic  glandular  tumor  of  the  neck  ....  206 

219.  220,  and  221.  Structure  of  a glandular  tumor  removed  from  the  mamma  . 207 

222.  New  formed  tissue  in  a follicle  of  the  thyroid  gland  . . . ^ . 208 

223.  Cells  in  fluid  squeezed  from  a mesenteric  gland,  in  a case  of  typhoid  fever  . 209 

224.  The  same  in  another  case  .......  209 

225.  The  same  cells,  after  the  addition  of  acetic  acid  ....  209 

226.  Warts  on  the  penis  ........  211 

227.  Summit  of  a papilla  from  a wart  . . . . . . 211 

228.  Perpendicular  section  of  a papilla,  after  adding  acetic  acid  . . . 211 

229.  Transverse  section  of  the  base  of  a condyloma  ....  212 

230.  Ulcerated  epithelioma  of  the  lip  ......  212 

231.  Section  of  an  ulcerated  epithelioma  of  the  tongue  ....  213 

232.  Muscular  tissue  immediately  below  the  epitheliomatous  ulcer  . . 213 

233.  Concentric  laminae  of  condensed  epithelial  scales  ....  213 

234.  Epidermic  scales,  in  mass  and  isolated,  from  the  scrotum  . . . 214 

235.  Group  of  deep-seated  cells,  in  the  same  case  .....  214 

236.  The  same,  after  the  addition  of  acetic  acid  .....  214 

237.  Fragments  of  the  concentric  masses  figured  Fig.  212,  from  a lymphatic  gland  215 

238.  Epithelial  cells,  in  yellow  cheesy  matter,  of  the  same  gland  . . . 215 

239.  Cells  in  white  matter,  from  soft  fungoid  epithelioma  of  the  urinary  bladder  215 

240.  The  same,  after  the  addition  of  acetic  acid  .....  215 

241.  Horn  from  an  old  preparation  in  the  Edinburgh  University  Museum  . 216 

242.  True  saccular  aneurism  of  the  aorta,  nearly  filled  with  coagulated  clot  . 217 

243.  Remarkable  spontaneous  varicose  aneurism  .....  217 

244.  Aneurism  of  the  coronary  artery,  completely  filled  with  coagulated  clot  . 218 

245.  Section  of  erectile  tumor  .......  218 

246.  Varicose  cutaneous  vessels  of  the  anus  .....  218 

247  to  250.  Of  umbilical  artery  of  calf,  eight  inches  long  ....  219 

251.  Common  carotid  artery  of  an  embryo  calf,  showing  directions  of  the  fibre  cells  219 

252.  Stellate  cells  in  the  tail  of  the  tadpole,  developing  into  capillary  vessels  . 220 

253.  Capillary  vessels  in  different  stages  of  formation,  from  the  eye  of  foetal  calf  220 

254.  Branched  cells  in  lymph  exuded  on  the  peritoneum  ....  220 

255.  Vessels  in  an  early  stage  of  formation,  from  a colloid  tumor  of  the  back  . 220 

256.  Enchondroma  of  the  hand  and  fingers  ......  221 

257.  Structure  of  a firm  nodule  in  an  enchrondroma  of  the  humerus  . . 221 


258.  The  same,  after  the  addition  of  acetic  acid  .....  221 

259.  The  cartilage  cells  and  fibrous  tissue  separated,  with  numerous  molecules  . 221 

260.  Small  cartilage  with  round  granule  cells  in  SoLanoma  . . . 222 

261.  The  same  cartilage  cells,  after  the  addition  of  acetic  acid  . . . 222 

262.  Thin  section  of  a firm  portion  of  the  same  tumor  . ...  222 

263.  Fine  filaments  which  interlaced  the  cells,  these  having  been  washed  out  . 222 

264.  Thin  section  of  an  enchondroma,  with  a bony  capsule  . . . 222 

265.  Separated  cartilage  cells  from  a softened  portion  of  the  same  tumor  . 222 

266.  The  same,  rendered  more  opaque,  after  the  addition  of  acetic  acid  . . 222 

267.  Diseased  articular  cartilage  .......  223 

268.  Similar  alteration  in  costal  cartilage  of  the  dog  ....  223 

269.  270.  Two  fibrous  projections,  from  the  surface  of  a diseased  human  cartilage  223,  224 

271.  Lateral  view  of  an  exostosis  .......  224 

272.  Part  of  a section  through  one  of  the  prominences  of  the  tumor  . . 224 

273.  Section  of  a portion  of  the  tumor  ......  224 

274.  Spicular  growth  of  bone,  in  an  osteo-carcinomatous  tumor  of  the  tibia  . 226 

275.  Epulis  removed  from  the  upper  jaw  ......  226 

276.  Cells  with  many  nuclei  in  epulis  ......  226 

277.  Fibro-cartilage  between  the  separated  portions  of  a fractured  cervix  femoris  227 

278.  Spiculum  of  bone  projecting  from  the  choroid  membrane  . . . 228 

279.  Section  from  the  centre  of  the  crystalline  lens  ....  228 

280.  Loose  membranous  matter  in  the  anterior  chamber  of  the  eye  . . 228 

281.  Ossified  excrescence  on  the  arachnoid  of  the  thoracic  portion  of  spinal  cord  228 

282.  Bony  laminae  arranged  concentrically  ......  228 

283.  Section  showing  the  arrangement  of  cells  and  fibres  in  scirrhus  of  the  mamma  229 

284.  The  same,  after  the  addition  of  acetic  acid  .....  229 

285.  Isolated  cancer-cells,  from  the  same  growth  .....  229 

286.  The  same,  after  the  addition  of  acetic  acid  .....  229 


LIST  OF  ILLUSTRATIONS. 


XXI 


Fig  Page 

287.  Young  cancer-cells  from  the  lung  ......  230 

288.  The  same,  after  the  addition  of  acetic  acid  .....  230 

289.  Somewhat  older  cells  from  the  testicle  .....  230 

290.  The  same,  after  the  addition  of  acetic  acid  .....  230 

291.  Still  older  cancer-cells  from  a tumor  in  the  duodenum  . . . 231 

292.  The  same,  after  the  addition  of  acetic  acid  .....  231 

293.  Highest  development  of  cancer  cells  from  a tumor  of  the  toe  . . 231 

294.  Simple  and  compound  cancer-cells  from  the  duodenum  . . . 231 

295.  Colloid  tissue,  with  the  loculi  filled  with  molecular  matter  . . . 232 

296.  Colloid  cancer-appearance  of  the  fibrous  areolae  filled  with  cancer-cells  . 232 

297.  The  same,  after  the  addition  of  acetic  acid  .....  232 

298.  Some  of  the  cells  isolated  .......  232 

299.  Fibrous  stroma  deprived  of  the  cells  bv  pressure  and  washing  . . 230 

300.  Section  of  small  cancerous  nodule  in  the  mucous  coat  of  the  stomach  . 234 

SOI.  Cartilage  cells  from  a velvety  articular  cartilage  of  the  condyle  of  the  femur  235 

302.  Cells  from  a cancerous  tumor  of  the  brain  .....  236 

303.  Fibre  of  the  sterno-mastoid  muscle,  in  the  neighborhood  of  a cancerous  growth  240 

304.  Fasciculi  of  muscle,  forming  the  flap  in  an  amputation  of  the  thigh  . . 240 

305.  Granules,  nuclei,  and  granule  cells  in  a nerve  .....  240 

306.  Structure  of  the  soft  part  of  tumor  removed  by  Mr.  Page  of  Carlisle  . 241 

307.  308.  Structure  of  the  more  indurated  parts  .....  241 

309.  Structure  of  a fungoid  growth  of  the  leg  .....  242 

310.  The  same,  after  the  addition  of  acetic  acid  .....  242 

311.  Structureless  membrane  formed  by  heating  the  clear  fluid  of  pemphigus  . 246 

312.  Edges  of  albuminous  laminae,  in  a case  of  hydrocele  ....  247 

313.  Dense  fibrous  structure,  with  naked  nuclei  from  coats  of  the  stomach  . 248 

314.  The  same,  after  the  addition  of  acetic  acid  .....  248 

315.  Diaphanous  albuminous  bodies,  with  fatty  cancer  cells  from  the  diaphragm  248 

316.  Groups  of  blood  corpuscles  surrounded  by  an  albuminous  layer  . . 248 

317.  A similar  albuminous  layer,  round  groups  of  bird’s  blood-cells  . , 248 

318.  Substance  of  nerve  tube,  broken  across,  forming  globules  . . . 249 

319.  Cells  of  the  liver,  in  waxy  degeneration  of  that  organ  . . . 249 

320.  Section  of  the  thyroid  body,  with  its  glandular  sacs  filled  with  colloid  matter  251 

321.  Radiated  colloid  masses  from  a cyst  in  an  atrophied  kidney  . . . 251 

322.  Fatty  molecules  in  groups  .......  253 

323.  Granular  corpuscles  and  masses  from  cerebral  softening  . . . 253 

324.  Granular  corpuscles  acted  upon  by  pressure  .....  254 

325.  Early  stage  of  fatty  degeneration  of  voluntary  muscle  . . . 254 

326.  Advanced  stage  of  fatty  degeneration  in  the  muscular  fasciculi  of  the  heart  254 

327.  Another  example  of  advanced  fatty  degeneration  of  voluntary  muscle  . 254 

328.  Fatty  degeneration  of  the  psoas  magnus  muscle  of  a lad  with  morbus  coxarius  255 

329.  Other  fasciculi  of  the  same  muscle,  after  the  addition  of  ether  . . 255 

330.  Enlarged  fatty  fusiform  cells  of  the  pregnant  uterus  after  delivery  . . 256 

331.  Atheroma  of  a blood-vessel  .......  256 

332.  Fatty  granules,  oil  drops,  granule  cells,  and  cholesterine  in  atheroma  . 256 

333.  Transverse  section  through  the  coats  of  the  popliteal  artery  of  an  aged  wmman  256 

334.  Cerebral  vessels  of  an  aged  individual  who  died  of  apoplexy  . . 257 

335.  Vessels  from  softening  of  the  corpus  striatum,  coated  with  granule  masses  257 

336.  Villi  from  the  placenta  of  a six  months’ foetus  . ....  258 

337.  Fatty  granules  coating  the  blood-vessels,  within  the  placental  villi  . . 258 

338.  Groups  of  fatty  granules  scattered  through  the  substance  of  a placental  villus  258 

339.  Fatty  granules  coating  the  vessels,  and  in  the  villous  substance  . . 258 

340.  Cells  in  fatty  tracheal  cartilage  . . . . . . . 25J 

3-il.  Horizontal  section  of  the  occipital  bone  in  a case  of  syphilis  . . . 260 

342.  Thin  section  of  the  same  bone,  showing  one  of  the  ca'ncelli  . . . 266 

343.  Thin  section  of  the  outer  table  of  the  same  bone  ....  260 

344.  New  cells  formed  in  malacosteon  ......  260 

345.  Retrograde  cells,  granules,  and  granular  masses,  in  the  reticulum  of  cancer  261 

346.  Fatty  and  broken-dowm  cancer-cells  in  reticulum  of  cancer  of  the  liver  . 261 

347.  Fatty  granular  matter  from  the  softened  reticulum  of  a cancer  of  the  breast  261 

348.  Liberated  and  altered  nuclei  in  the  reticulum  of  cancer  of  the  testicle  . 261 

349.  Crystals  of  hematoidine  ........  263 

350.  Wartlike  brown  of  the  female  mamma  . . . 264 

351.  Atrophied  bronchial  cartilage,  with  deposition  of  brown  pigment  . . 264 

352.  Placental  villi,  containing  brown  pigment  from  an  aborted  foetus  . . 264 

353.  Black  pigment  masses  and  molecules  round  a tubercle  of  the  peritoneum  . 266 

354.  Transveise  section  of  a necrosed  tibia  ......  266 

355.  Black  pigment  molecules  from  the  lung  .....  266 

356.  Black  pigment  irregular  masses,  from  an  intestinal  aggregate  gland  . 266 


XXll 


LIST  OP  ILLUSTEATIONS. 


Fig. 

357. 

358. 

359. 

360. 

361. 

362. 

363. 

364. 

365. 

366. 

367. 
863. 

369. 

370. 

371. 

372. 

373. 

374. 

375. 

376. 

377. 

378. 

379. 

380. 

381. 

382. 

383. 

384. 

385. 

386. 

387. 

388. 

389. 

390. 

391. 

392. 

393. 

394. 

395. 

396. 

397. 

398. 
899. 

400. 

401. 

402. 

403. 

404. 

405. 

406. 

407. 

408. 

409. 

410. 

411. 

412. 

413. 

414. 

417. 

418. 

419. 

420. 

421. 
422 

423. 

424. 

425. 

426. 

427. 


Polygonal  cells  loaded  with  pigment,  from  the  surface  of  the  pericardium 
Cells  loaded  with  pigment,  from  a melanotic  tumor  of  the  horse 
Cells  in  a melanotic  cancer  of  the  cheek  .... 

Cells  in  the  black  sputum  of  a collier  ..... 

Calcareous  incrustation  of  the  small  vessels  of  the  brain 
Structure  of  mineral  degeneration  of  the  walls  of  an  aneurism 
Mineral  degeneration  of  the  nerve-cells  and  tubes  of  the  spinal  cord 
Mineral  masses  in  a degenerated  cancerous  tumor  of  the  omentum 
The  same,  in  a degenerated  cancerous  mass  in  the  liver 
Cancer-cells  infiltrated  with  cretaceous  molecules,  in  a mesenteric  gland 
Mineral  masses  in  a cretaceous  tubercle  of  the  lung  . 

Section  of  an  amorphous  mineral  mass  .... 

Longitudinal  section  of  an  albuminous  concretion 

Portion  of  one  of  the  concentric  lamellae  of  an  albuminous  concretion 

Transverse  section  of  the  edges  of  the  concentric  lamellae 

Section  of  the  nucleus  of  an  albuminous  concretion  . 

Longitudinal  section  of  an  albuminous  concretion  magnified  . 

Various  forms  of  biliary  concretions  ..... 

Vertical  section  of  renal  tubuli  filled  with  urate  of  ammonia. 

External  view  of  a remarkable  renal  calculus  .... 

Section  of  the  same  calculus,  with  nucleus  of  uric  acid  and  oxalate  of  lime 
Calculus  with  lithic  acid  nucleus  ..... 

Triangular  formed  calculus  of  lithic  acid  .... 

Oval  calculus  of  lithic  acid  ...... 

Oval  calculus  of  uric  acid  ...... 

The  triple  phosphate  surrounding  a mulberry  concretion  of  oxalate  of  lime 
Nodulated  mulberry  calculus  . . ... 

Phosphatic  calculus  formed  round  a fragment  of  uric  acid  calculus  . 
Phosphatic  calculus  formed  round  a piece  of  slate  pencil 
Sections  and  external  appearance  of  the  calculi  in  Mr.  Mackenzie’s  case 
Prostatic  calculi  ........ 

Mass  of  hair  found  in  the  human  stomach  . _ . 

Section  of  a remarkably  shaped  intestinal  concretion 

Section  of  an  intestinal  concretion  ..... 

Hairs  from  the  caryopsis  of  the  oat,  in  an  intestinal  concretion 
Amyloid  bodies  embedded  in  a seemingly  amorphous  matter 
The  same,  after  dilution  with  water  ..... 

The  same,  after  the  addition  of  acetic  acid  .... 

The  same,  after  the  addition  of  nitric  acid  .... 

Small  corpora  amylacea,  in  the  auditory  nerve  of  a deaf  individual  . 
Variously  shaped  and  sized  corpora  amylacea^  from  the  human  pancreas 
Longitudinal  plan  of  the  arteries  of  the  trunk  .... 

Transverse  plan  of  the  arteries  of  the  abdomen  opposite  to  the  liver 
The  same,  lower  down  ....... 

Structure  of  inflammatory  exudative  softening  of  the  spinal  cord 

Structure  of  a tubercular  exudation  in  the  cerebellum 

Structure  of  the  softened  cerebellum  ..... 

Structure  of  the  softened  cerebral  substance  .... 

Structure  of  the  softened  pons  varolii  ..... 

Amyloid  bodies  with  fragments  of  nerve  tubes,  from  the  optic  thalamus 
A blood-vessel  from  the  substance  of  the  brain  coated  with  exudation 
Another  blood-vessel  also  coated  with  exudation 
Structure  of  a chronic  grey  softening  of  the  cerebral  hemisphere 
Section  of  the  capsule  and  coagulum  of  an  old  apoplectic  clot 
Granular  corpuscles  and  masses  in  an  old  apoplectic  clot 
Peculiar  vascular  stroma  with  villi  in  cancerous  masses  of  the  brain 
Gland-like  expansions  of  stroma  in  other  portions  of  the  same  mass 
415,  416.  Lateral,  vertical,  and  front  views  of  a hydrocephalic  head  . 
Appearance  of  the  gastric  glands  in  recent  catarrh  of  the  stomach  . 
Commencing  cystic  formation  in  a gastric  follicle 
A cyst  in  the  pyloric  portion  of  the  stomach  .... 

Fatty  degeneration  of  gastric  glands  in  chronic  catarrh  of  the  stomach 
Chronic  catarrh  of  the  stomach  with  hypertrophy  of  fibrous  tissue 
Fatty  degeneration  affecting  the  upper  layer  of  gastric  follicular  epithelium 
The  gastric  and  pyloric  glands  hypertrophied  in  a cancroid  tumor 


Disintegration  of  the  hepatic  structure  following  obstruction  of  the  biliary  ducts  505 
Hepatic  cells  in  various  stages  of  fatty  degeneration  ....  512 

Structure  of  a thin  section  of  liver  in  the  last  stage  of  cirrhosis  . . 516 

Peri-lobular  fatty  or  nutmeg  liver  ......  517 


Page 

266 

266 

267 

267 

270 

270 

271 
271 
271 

271 

272 

272 

273 
273 

273 

274 
274 

274 

275 

276 
276 
276 
276 
276 

276 
27-7 

277 
277 

277 

278 

278 

279 

280 
280 
281 
282 
282 
282 
282 
283 
283 
310 
810 
310 
354 
354 

354 

355 

356 
381 
388 

388 

389 

417 

418 
423 

423 

424 
493 
493 

493 

494 
494 

494 

495 


LIST  OF  ILLUSTRATION'S. 


XXlll 


Fig. 

428. 

429. 

430. 

431. 

432. 

433. 

434. 

435. 

436. 

437. 

438. 

439. 

440. 

441. 

442. 

443. 

444. 

445. 

446. 

447. 

448. 

449. 

450. 

451. 

452. 

453. 

454. 

455. 

456. 

457. 

458. 

459. 

460. 

461. 

462. 

463. 

464. 

465. 

466. 

467. 

468. 

469. 

470. 

471. 

472. 

473. 

474. 

475. 

476. 

477. 

478. 

479. 

480. 

481. 

482. 

483. 

484. 

485. 

486. 

487. 

488. 

489. 

490. 

491. 

492. 

493. 

494. 

495. 

496. 


Pigmented  nutmeg  liver  ... 

Remarkable  carcinomatous  cyst  in  the  liver  ... 

Vascular  congestion  and  sugillation  of  the  small  intestine  in  cholera 
Granular  mass,  in  recent  exudation  on  the  intestinal  mucous  membrane  . 
An  enlarged  Payerian  sac  from  the  colon  of  a child  .... 

Flaccid  pericardium  with  small  amount  of  fluid  .... 

Distended  pericardium,  of  a pyriform  shape  ..... 

Excessive  distension  of  pericardium  ...... 

Conjoined  attachment  of  two  of  the  aortic  valves  .... 

Aortic  orifice  with  one  valve  of  a funnel-shape  .... 

Two  valves  of  the  aortic  orifice,  with  a rudimentary  one  interposed 
Congenital  malformation  of  the  aortic  valves  ..... 

Four  valves  at  the  aortic  orifice  from  the  adhesion  of  one 

Five  valves  formed  from  adhesion  and  production  of  the  septae  in  two  valves 

Button-hole  contraction  of  the  mitral  orifice  ..... 

Mi-tral  orifice,  greatly  constricted,  forming  an  oval  aperture  . 

Fibrinous  vegetations,  and  atheromatous  degeneration  of  the  aortic  valves  . 
Rough  sketch  of  innominatal  aneurism  and  adjoining  parts  . 

Diagram  of  an  aneurism  of  the  arteria  innominata  .... 

Aneurism  of  the  thoracic  aorta  and  superior  mesenteric  artery 
Appearances  in  acute  laryngitis  and  oedema  glottidis  . 

Plug  of  mucous  or  coagulated  blood  in  a bronchus 

Remains  of  pleural  abscess  ....... 

Relative  position  of  the  thoracic  and  abdominal  viscera  in  A.  Brown’s  case 

Vertical  section  of  a lung  affected  with  pleuro-pneumonia 

Two  moulds  of  coagulated  exudation  in  red  hepatisation  of  the  lung 

Fragment  of  chicken- bone  found  in  the  right  bronchus,  in  Neal’s  case 

Fluid  in  the  chronic  abscess  of  the  right  lung,  in  Neal’s  case 

Part  of  the  left  lung  with  clots  occupying  branches  of  the  pulmonary  artery 

Section  of  a lung  in  the  first  stage  of  phthisis  pulmonalis 

Section  of  a lung  in  the  second  stage  of  phthisis  pulmonalis  . 

Section  of  a lung  in  the  third  stage  of  phthisis  pulmonalis  . 

Section  of  the  summit  of  the  right  lung  in  arrested  phthisis  . 

The  section  of  the  upper  portion  of  the  lung  in  Keith’s  case  seen  from  within 
Chyle  from  the  thoracic  duct  of  a dog,  three  hours  after  eating  a meal  . 
Corpuscles  in  cancerous  juice  squeezed  from  the  thyroid  body 
The  same  after  the  addition  of  acetic  acid  ..... 

Vertical  section  through  the  wall  of  an  ovarian  cyst  .... 

Subsequent  formations  proceeding  in  the  walls  of  simple  c^sts 
Section  of  the  wall  of  an  ovarian  cyst,  with  epithelial  cells  in  situ  . 
Polygonal  epithelial  cells  from  the  same  lining  membrane 
Oval  epithelial  cells  from  the  lining  membrane  of  an  ovarian  cyst  . 

Cells  in  fluid  removed  from  an  ovarian  dropsy  .... 

Groups  of  columnar  epithelium,  etc.,  in  encephaloma  of  the  ovary  . 
Diaphanous  celloid  bodies,  naked  nuclei,  and  granule  cells  in  the  same 
The  nuclei  after  the  addition  of  acetic  acid  ..... 

Structures  occasionally  seen  in  cysts  of  the  kidney  .... 

Waxy  degeneration  of  a rnalpighiau  body,  with  a few  granule  cells  . 
Structures  in  a fatty  kidney  ....... 

Portion  of  fatty  renal  tube  ....... 

Longitudinal  section  of  a fatty  kidney  ...... 

Transverse  section  to  the  former  one  ...... 

Exudative  casts  of  renal  tubes  ....... 

Desquamative  casts,  with  blood  corpuscles,  naked  nuclei,  and  cells  . 

Fatty  casts  of  renal  tubes  with  granule  cell  ..... 

Waxy  casts  of  renal  tubes  of  various  sizes  ..... 

Dorsal  surface  of  the  female  Acarus  Scabiei  ..... 

Ventral  surface  of  the  same  ....... 

Ventral  surface  of  the  male  Acarus  ...... 

Three  follicles  of  the  skin  of  the  dog  containing  entozoa 
Cul-de-sac  of  a sebaceous  follicle,  with  entozoa  and  ova 
Hair  and  its  follicle,  with  entozoa  ...... 

Crusts  of  favus  in  different  stages  of  development  .... 

Branches  of  the  Achorion  Schosnleini,  in  an  early  stage  of  development 
Fragments  of  the  branches  more  highly  developed  .... 

A light  hair,  containing  branches  of  the  Achorion  Schosnleini 

Sporules  developing  on  the  surface  of  an  apple,  after  three  days 

The  same,  after  four  days  ....... 

The  same,  more  fully  developed  on  the  human  arm,  after  inoculation 


Page 

518 

522 

531 

532 

533 
571 

571 

572 

594 

595 
595 

595 

596 
596 
596 
596 
697 
615 
615 
623 
654 
654 
666 
674 
691 
691 
720 

720 

721 

734 

735 

736 
788 
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825 
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842 
842 
842 
845 

845 

846 
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856 
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859 


XXIV 


LIST  OP  ILLUSTRATIONS. 


Fig.  Page 

497.  Thalli,  mycelia,  and  sporidia,  of  the  Achorion  Schanleini  . . . 860 

498.  Thalli  and  sporules  from  chronic  pityriasis  of  the  scalp  . . . 865 

499.  Microsporon  Furfur,  in  pityriasis  versicolor  . . . . . 865 

500.  Portion  of  the  root  of  a hair  plucked  from  a crust  of  chronic  eczema  . 866 

501.  Portion  of  clot  from  the  vena  cava  in  leucocythemia  . . . 869 

602.  Posterior  surface  of  the  aorta  and  vena  cava  in  leucocythemia  . . 869 

603.  Appearance  of  the  cerebral  hemispheres  in  a case  of  leucocythemia  . . 870 

504.  Colorless  corpuscles,  mingled  with  a few  colored  ones  . . . 871 

605.  The  same  bodies,  mingled  with  a larger  number  of  yellow  blood  corpuscles  871 

506.  Change  produced  on  the  colorless  corpuscles  on  the  addition  of  acetic  acid  871 

507.  Cells  in  the  fluid  squeezed  from  the  lymphatic  glands  . . . 871 

508.  Blood-vessels  giving  oif  a capillary  from  the  pia  mater  . . . 871 

509.  Appearance  of  a drop  of  blood  in  leucocythemia  ....  874 

510.  The  same  after  the  addition  of  acetic  acid  .....  874 

511.  The  same  after  the  blood  has  stood  for  twenty-four  hours  . . , 875 

512.  Colorless  corpuscles  slightly  increased  in  number  ....  881 

613.  The  same  after  the  addition  of  acetic  acid  . . . . . 881 

514.  Colorless  corpuscles  increased  in  number,  and  of  small  size  . . . 882 

515.  The  same  after  the  addition  of  acetic  acid  .....  882 

516.  Colorless  blood-cells  observed  in  leucocythemia  ....  882 

517.  Development  of  the  nucleus  in  colorless  blood-cells  ....  883 

518.  Cells  of  various  sizes,  in  the  blood  of  a haddock,  frog,  and  turkey  . . 884 

519.  The  nuclei  of  the  blood-cells  of  the  haddock,  frog,  and  turkey  . . 884 

520.  Fluid  chyle,  mingled  with  water  ...*..  885 

521.  The  same,  after  the  addition  of  acetic  acid  . . . , , 885 

522.  Numerous  naked  nuclei  of  the  colorless  corpuscles  in  the  blood  . . 887 

523.  The  same  after  the  addition  of  acetic  acid  .....  887 

524.  Cells  with  single  and  multiple  nuclei  ......  890 

525.  Structure  of  a decolorised  mass  in  spleen  .....  934 

526.  The  same  after  the  addition  of  acetic  acid  .....  934 

527.  Appearance  of  exudation  and  epithelial  cells  in  the  typhoid  lung  . . 935 

528.  Another  portion  of  the  same  lung,  after  the  addition  oi  acetic  acid  . . 935 

529.  Portions  of  normal  epithelium  separated  from  the  air  vesicles  . . 935 

530.  A clinical  ward  of  the  Royal  Infirmary,  with  fever  beds,  in  1817  . . 944 

631.  Clinical  ward.  No.  XL,  1858,  with  present  arrangement  of  fever  beds  . 945 

532.  Mr.  Weir’s  scarificator  for  vaccination  .....  966 

533  and  534.  Dr.  Husband’s  tubes  charged  with  vaccine  lymph  . . ♦ 966 

535.  Skeleton  of  a dog  poisoned  by  mercury  . . . . .978 

.536.  Exostosis  of  do^s  femur  . . . . , . .979 

537.  Internal  view  of  the  same  ....  . 979 


CLINICAL  LECTURES 


INTRODUCTION. 

^1,1  '//;_//. 

Gtentlemen, — Medicine,  as  a subject  of  study,  must  be/  ^egaft’deyd  in,  a, 
two-fold  aspect,  as  a science  and  as  an  art — it  has  its  theory  / ayd^  iti 
practice;  its  principles  and  their  application.  We  can  trace  the  germs/ 
of  theory  and  practice  in  medicine  to  a very  early  period.  At  first, 
indeed,  the  art  must  necessarily  have  been  founded  upon  experience  and 
observation  alone.  Hippocrates  first  added  philosophy  and  reasoning  to 
experience,  and  introduced  those  discussions  which  led  to  the  overthrow 
of  empiricism,  and  the  final  triumph  of  dogmatism,  six  hundred  years 
later,  in  the  time  of  Galen.  Since  then,  although  the  medical  profession 
has  uniformly  conjoined  the  results  both  of  reasoning  and  experience, 
each  of  these  two  methods  has  had  its  special  supporters.  Even  at  the 
present  day  you  will  find  persons  who  complacently  call  themselves  prac- 
tical men,  and  who  sneer  at  all  modern  advances  in  pathology.  Others 
are  apt  to  attribute  too  much  importance  to  theory,  and  regard  with  feel- 
ings approaching  to  contempt  him  whom  they  denominate  a routine 
practitioner.  Hence,  unfortunately,  it  too  often  happens  that  practical 
men  are  comparatively  unacquainted  with  physiology  and  pathology; 
while  those  who  dedicate  themselves  to  the  latter  studies  are  very  scep- 
tical as  to  empirical  remedies.  On  this  subject  Cullen  made  a remark 
eighty  years  ago  which  applies  at  present : — Every  one  now-a-days 
pretends  to  neglect  theory,  and  to  stick  to  observation.  But  the  first  is 
in  talk  only,  for  every  man  has  his  theory,  good  or  bad,  which  he  occa- 
sionally employs  ; and  the  only  difference  is,  that  weak  men  who  have 
little  extent  of  ability  for,  or  who  have  had  little  experience  in  reason- 
ing, are  most  liable  to  be  attached  to  frivolous  theories  ; but  the  truly 
judicious  practitioners  and  good  observers  are  such  as  have  the  most 
extensive  views’ of  the  animal  economy,  and  know  best  the  true  account 
of  the  present  state  of  theory,  and  therefore  know  best  where  to  stop  in 
the  application  of  it.” 

If  these  observations  were  correct  when  Cullen  wrote,  they  are  far 
more  applicable  now,  when  almost  every  advance  that  has  been  made  in 
the  art  of  medicine  since  his  day  has  been  owing  to  the  result  of  scientific 
investigation.  But  in  order  to  make  this  proposition  clear,  allow  me,  in. 
the  first  place,  to  point  out  what  I conceive  to  be 
1 


2 


TNTKODUCTION. 


The  Relation  of  the  Science  to  the  Art  of  Medicine. 

If  we  regard  the  whole  field  of  human  knowledge,  and  reflect  on  the 
differences  which  exist  among  the  various  sciences,  we  must  insensibly  be 
led  to  classify  them  into  two  great  divisions,  viz.,  the  exact  and  the  in- 
exact. All  the  sciences  belonging  to  the  first  class  are  characterised  by 
the  possession  of  a primitive  fact  or  law,  which,  being  applicable  to  the 
whole  range  of  phenomena  of  which  the  science  consists,  renders  its  dif- 
ferent parts  harmonious,  and  the  deductions  of  its  cultivators  conclusive. 
Thus,  the  physical  sciences  possess  a primitive  fact  in  what  is  called  the 
law  of  gravity.  It  was  Sir  Isaac  Newton  who  demonstrated,  by  a happy 
effort  of  genius,  that  all  the  planets  in  our  system  gravitate  towards  the 
sun  by  the  same  law,  and  in  consequence  of  the  same  principle,  as  that 
by  which  bodies  on  the  earth  gravitate  towards  its  centre.  This  theory 
was  subsequently  found  applicable  to  a vast  number  of  circumstances, 
and  by  it  the  philosopher  now  explains  many  of  the  material  phenomena 
of  the  universe,  and  the  astronomer  calculates  the  movements  of  the 
heavenly  bodies.  This  law  applies  to  all  the  facts  of  which  physical 
science  is  made  up.  In  the  same  manner,  chemistry  possesses  a primi- 
tive fact  in  what  is  called  the  law  of  affinity,  discovered  later  by  Lavoi- 
sier. If  we  mix  two  salts  which  mutually  decompose  each  other,  a third 
salt  is  formed  by  the  union  in  definite  proportions  of  their  constituent 
elements.  This,  in  the  language  of  •chemists,  is  brought  about  by 
chemical  affinity.  If  we  repeat  the  experiment  a thousand  times,  the 
same  result  takes  place,  and  the  law,  which  applies  in  one  case,  is  found 
universally  applicable  to  every  phenomenon  in  chemical  science.  The 
possession  of  this  primitive  fact,  then,  communicates  the  greatest  accu- 
racy and  precision  to  the  sciences  which  possess  it,  and  on  this  account 
they  are  called  the  exact  sciences. 

But  there  are  other  sciences  which  are  altogether  destitute  of  a pri- 
mitive fact ; which  consist  of  groups  of  phenomena,  each  of  which  may 
or  may  not  be  governed  by  a particular  law.  Such  a one  is  agriculture. 
No  man,  however  skilful,  can  till  the  ground  or  cultivate  the  soil,  and 
be  certain  of  the  same  result  on  every  occasion.  Numerous  circum- 
stances, over  which  he  has  no  control,  may  destroy  his  anticipations 
and  show  the  fallacy  of  his  calculations,  and  this,  after  every  known 
condition  has  been  fulfilled,  and  every  possible  degree  of  prudence  and 
sagacity  has  been  exercised  to  ensure  success.  The  same  means,  appa- 
rently, which  operate  at  one  time  fail  to  do  so  at  another.  Such  sciences, 
then,  are  denominated  inexact  sciences,  and  it  is  to  this  class  that  medi- 
cine belongs. 

Now,  the  cultivators  of  medicine  always  have  been,  and  are  still 
endeavoring  to  render  the  science  exact ; and  hence  at  various  times 
individuals  have  brought  forward  what  they  conceived  to  be  a law  or 
primitive  fact,  and  have  tried  to  show  that  it  was  applicable  to  all  vital 
phenomena.  Some  have  placed  the  law  in  the  physical  condition  of  the 
solids,  and  others  in  the  physical  condition  of  the  fluids.  Hence  the 
terms  soUdisis  and  fluidisis.  A third  party  have  sought  it  in  the  func- 
tional conditions  of  the  body,  viz.,  an  alteration  in  the  living  force. 
Tliey  have  been  called  vitalists.  If,  for  instance,  we  could  constitute  the 


RELATION  OF  THE  SCIENCE  TO  THE  ART  OF  MEDICINE.  3 

vital  property,  excitability,  a primitive  fact,  it  would  serve  the  same  pur- 
pose in  physiology  that  gravitation  does  in  physics.  But  we  cannot  do 
this.  It  is  true  that  the  stomach  is  excited  by  the  food,  in  order  that 
digestion  may  be  produced,  and  that  the  lungs  are  excited  by  the  air 
during  the  process  of  aeration.  But  in  the  performance  of  these  func- 
ti  )ns,  excitability  plays  a secondary  part;  it  is  only  one  of  the  elemen- 
tary properties  necessary  for  their  completion,  and  is  utterly  insufficient 
10  account  for  their  production.  In  the  same  manner,  neither  the 
mechanism  of  the  solids  nor  of  the  fluids  can  explain  every  known  fact; 
so  that  it  becomes  necessary  to  take  all  three  doctrines, — solidism, 
humoralism,  and  vitaLsm, — into  consideration,  if  we  wish  to  escape 
fallacy. 

Of  late  years  it  has  been  contended  that,  as  far  as  structure  and 
development  are  concerned,  we  do  possess  a law  in  the  doctrine  of 
cyto-gcnesis,  that  is,  of  the  growth  of  those  minute  vesicles  or  cells, 
of  which  we  find  all  plants  and  animals,  at  one  period  of  their  existence, 
to  be  composed.  It  has  been  argued  that  if  a theory  of  organization 
can  be  shown  to  apply  to  all  animated  nature,  to  the  vegetable  as  well 
as  to  the  animal  kingdom  ; if  it  can  be  demonstrated  that  the  humblest 
and  minutest  tribes  of  plants  possess  the  same  original  structure  as 
is  to  be  found  in  the  most  gigantic  trees  of  the  forest ; if  it  become 
evident  that  the  same  principle  of  formation  is  discoverable  in  animals, 
whether  so  minute  that  thousands  may  be  contained  in  a drop  of 
water,  or,  on  the  other  hand,  so  enormous  as  the  elephant  or  whale ; 
nay,  more,  if  it  admit  of  demonstration  that  the  organic  diseases  to 
which  they  are  subject,  that  the  formation  of  new  growths  and  the 
reparation  of  tissues  are  explicable  by  the  same  theory  as  applies  to 
the  development  of  healthy  structure, — then,  it  is  contended,  we  are 
surely  approaching  to  something  like  a great  primitive  fact,  which  may 
ultimately  communicate  exactitude  to  physiological  science.  And  yet, 
notwithstanding  the  flood  of  light  which  has  been  thrown  upon  all 
departments  of  our  science  by  the  beautiful  generalisation  of  Schleiden 
and  Schwann,  recent  researches  have  exhibited  its  insufficiency  to  ex- 
plain all  known  phenomena  of  growth. 

Medicine,  then,  in  its  present  state,  possesses  no  primitive  fact.  But 
is  it  not  very  possible  that  it  may  do  so  at  some  future  time?  During 
the  many  ages  that  existed  before  Newton,  physical  science  was  as 
inexact  as  that  of  physiology  is  now.  Before  the  time  of  Lavoisier, 
chemistry,  like  physiology,  consisted  of  nothing  but  groups  of  pheno- 
mena. These  sciences  went  on  gradually  advancing,  however,  and 
accumulating  facts,  until  at  length  philosophers  appeared  who  united 
these  together  under  one  law.  So  medicine,  we  trust,  is  destined  to 
advance,  and  one  day  another  Newton,  another  Lavoisier,  may  arise, 
whose  genius  will  furnish  our  science  with  iU  primitive  fact,  and  stamp 
upon  it  the  character  of  precision  and  exactitude. 

Although  it  must  be  confessed  that  we  have  not  yet  arrived  at  such 
a happy  consummation,  it  cannot  be  denied  that  we  are  making  rapid 
strides  towards  it.  Notwithstanding  those  principles  which  Bacon  intro- 
duced into  the  study  of  science,  it  is  only  lately,  from  the  advance  of 
collateral  branches  of  knowledge,  that  we  have  been  enabled  to  catch 


4 


INTRODUCTION. 


glimpses  of  a correct  pliilosophy  as  applied  to  physiology.  A truly 
scientific  medicine  is  yet  to  be  created — for  all  the  processes  of  life,  both 
in  its  healthy  and  diseased  conditions,  are  really  owing  to  the  structures 
which  have  been  only  lately  made  visible  by  the  improvement  in  optical 
instruments.  W e know  also,  that  these  processes  are  connected  with  physi- 
cal and  chemical  changes,  the  importance  of  which  we  are  just  commenc- 
ing to  estimate.  But  now,  assured  of  what  is  really  necessary,  and  guided 
by  rigid  observation  and  experiment,  rather  than  by  a vague  hypothesis, 
physiology  and  pathology  are  advancing  with  such  rapidity  that  every 
year  improves  or  modifies  the  ideas  which  sprang  up  in  the  one  which 
preceded  it.  Moreover,  it  has  been  satisfactorily  shown  that  the  branch 
of  science  which  refers  to  vital  phenomena  bears  such  a relation  or 
correlation  to  various  branches  of  physical  science,  that  the  whole  is 
gradually  becoming  more  simple,  instead  of  more  complex.  Instead  of 
physiology  being  isolated  under  the  idea  that  its  laws  are  peculiar,  it  is 
every  day  becoming  more  evident  that  vegetable  and  animal  life  are  de- 
pendent on  conditions  which,  strictly  speaking,  are  elucidated  by  the 
geologist,  botanist,  zoologist,  chemist,  and  natural  philosopher.  In  short, 
the  intimate  union  of  the  natural  sciences  seems  to  be  near  at  hand. 

But  you  do  not  cultivate  these  sciences  as  barren,  however  interest- 
ing, subjects  of  medical  study.  With  you,  I apprehend,  as  with  myself, 
the  knowledge  so  acquired  constitutes  a groundwork  for  the  practice  of 
an  art.  It  is  in  this  point  of  view  I am  especially  anxious  you  should 
consider  physiology  and  pathology.  For,  gentlemen,  I trust  that,  in 
studying  these  subjects,  you  will  never  lose  sight  of  the  important  fact 
that  you  are  medical  students,  and  that,  as  such,  your  ultimate  object  is 
to  acquire  an  art;  in  other  words,  skill  in  the  employment  of  all  those 
means  which  are  directed  to  the  prolongation  of  life  and  the  cure  of 
diseases.  Now,  in  order  that  you  may  successfully  accomplish  this  great 
object,  it  is  necessary  that  you  should  appreciate  properly  the  importance 
of  theory  in  its  bearings  on  practice,  so  that,  when  you  are  called  upon 
to  treat  the  sick,  you  may  be  ready  to  take  advantage  of  all  the  knowledge 
which  you  may  have  obtained.  Hence  the  importance  of  knowing  how 
to  distinguish  between  the  nature  and  object  of  science  and  art  respec- 
tively. 

We  may  consider  science,  then,  to  be  a collection  of  theories;  art, 
a body  of  rules.  Science  says,  this  is  or  is  not ; this  is  probable  or 
improbable.  Art  says,  do  this,  avoid  that.  The  object  of  science  is  to 
discover  facts  and  determine  laws ; the  object  of  art  is  to  accomplish  an 
end,  and  determine  the  means  of  effecting  it.  Science  is  inductive,  and 
reasons ; art  is  imitative,  and  exemplifies.  Science  is  steady,  certain, 
and  progressive ; art  is  vacillating,  doubtful,  and  limited. 

Hitherto  it  has  been  imagined  that  the  chief,  if  not  the  only  method 
of  obtaining  skill  in  art  is  by  practising  it ; that  is,  obtaining  experi- 
ence. In  medicine  this  is  proverbial,  and  every  practitioner  is  more  apt 
to  boast  of  his  experience  than  of  his  scientific  knowledge.  In  the 
infancy  of  science,  indeed,  we  can  readily  understand  that  its  hasty 
generalisations  must  have  been  continually  overthrown  and  rendered 
ridiculous  tlie  moment  they  were  applied  to  practice.  Hence  the  reason 
why  art  for  many  ages  preceded  science — why  dogmatic  rules  were  more 


RELATION  OF  THE  SCIENCE  TO  THE  ART  OF  MEDICINE. 


5 


attended  to  tlian  ingenious  theories — and  why  the  accomplishment  of  an 
end,  even  when  that  end  was  limited,  was  more  regarded  than  the  dis- 
covery of  a new  fact,  or  the  determination  of  a law  capable  of  extensive 
application.  But  in  recent  times  this  state  of  things  is  gradually  be- 
coming reverseJ.  Science,  in  numberless  instances,  has  advanced  beyond 
art ; nay  more,  science  herself  has  worked  out  all  the  details,  and  made 
an  art  obedient  to  her  commands.  Thus  it  was  that  the  theory  of  achro- 
matism, worked  out  by  Euler,  led  opticians  to  make  perfect  telescopes 
and  microseopes.  Thus  it  was  that  Le  Verrier  and  Adams,  by  calcula- 
tions in  their  observatories  in  Paris  and  London,  discovered  a planet 
which  they  had  never  seen,  but  which,  when  looked  for,  according  to 
their  directions,  from  Stockholm  and  St.  Petersburg,  was  immediately 
proved  to  exist  in  fact,  as  it  had  previously  been  proved  to  exist  in 
theory.  Tims  it  was  that  the  electric  telegraph,  perfected  in  the  closet 
of  the  man  of  science,  flashed  ready-made  on  the  astonished  gaze  of  an 
admiring  world  ; and  thus  it  is  that  at  the  present  moment  we  see  the 
artizan  in  his  workshop,  the  explorer  in  the  mine,  the  agriculturist  in 
his  farm — nay,  even  the  sculptor  in  his  studio — abandoniiig  the  rules  and 
wise  saws  handed  down  to  him  from  ancient  tradition,  and  accommodat- 
ing himself  to  the  revolutions  which  science  has  dictated,  and  those  laws 
whereby  blind  experience  is  made  to  yield  to  an  enlightened  knowledge. 

We  may  therefore  receive  it  as  an  established  law,  that  the  more 
any  particular  science  is  advanced,  the  more  is  the  art  to  which  it  leads 
rendered  perfect,  and  that  true  theory  in  the  one  produces  never-failing 
rules  in  the  other.  The  art  of  navigation,  for  instance,  is  certain,  in 
so  far  as  it  is  based  on  the  science  of  astronomy,  which  admits  of  exact 
calculation.  In  like  manner,  the  only  way  of  improving  the  art  of 
medicine  is  to  advance  the  science  of  physiology ; and  all  that  has  been 
accomplished  during  the  last  fifty  years  has  been  brought  about  in  this 
manner.  In  that  short  time  have  been  discovered  the  independent  pro- 
perties of  the  nerves,  the  reflex  functions  of  the  nervous  centres,  the 
chemical  balance  of  organic  nature,  the  functions  of  cells  and  their  in- 
fluence on  nutrition  and  secretion,  the  laws  regulating  the  development 
of  the  ovum,  the  significance  of  the  sounds  produced  by  the  heart  and 
lungs,  and  numerous  other  doctrines  which  have  tended  to  improve  the 
art  of  medicine. 

But  while  the  modern  cultivator  of  medicine  loses  no  opportunity, 
and  employs  all  the  means  with  which  the  improved  state  of  science 
furnishes  him,  for  investigating  morbid  anatomy  and  the  causes  of  dis- 
eas •,  he  carefully  corrects  the  theoretical  conclusions  to  which  these 
alone  might  lead  him  by  practical  experience  and  observation.  Our 
active  and  our  speculative  powers  should  go  hand  in  hand,  so  that,  by  a 
union  of  tiieoretical  knowledge  and  practical  skill,  we  may  advance  both 
to  their  farthest  limits.  It  is  by  cultivating  medicine  in  this  spirit  that 
the  clinical  school  of  Edinburgh  has  rendered  itself  so  famous.  Those 
who  taught  the  theoretical  branches  of  medicine  from  their  chairs  in  the 
University  were  those  who  taught  the  practice  in  the  wards  of  this 
Infirmary.  They  were  thus  enabled  to  demonstrate  how,  on  the  one 
hand,  correct  observation  leads  to  just  deduction,  and  on  the  other,  how 
a knowledge  of  general  principles  causes  accuracy  and  acuteness  in 


6 


INTRODUCTIOX. 


observation.  Indeed,  it  is  impossible  to  estimate  too  highly  the  advan- 
tages which  have  resulted  from  such  a system,  which  has  been  carried  on 
uninterruptedly  by  the  Professors  of  this  University,  for  one  hundred 
and  ten  years.  This  leads  me  to  speak  of 


The  Mode  of  Conducting  the  Clinical  Course. 

Your  principal  object,  gentlemen,  in  coming  into  this  Hospital,  is, 
I presume,  to  observe  disease  for  yourselves.  Now,  to  observe  with 
advantage  two  things  are  necessary:  1st,  The  correct  appreciation  of 
actual  facts,  as  communicated  to  the  senses  of  the  practitioner  or  of  his 
patient,-  2d,  The  deduction  from  these  of  a correct  judgment  as  to  the 
nature  of  the  disease,  and  the  proper  mode  of  its  treatment.  Both  these 
processes  are  very  difficult  of  attainment,  and  some  men  have  a natural 
aptitude  for  the  one  and  some  for  the  other.  They  are  also  frequently 
confounded  together,  some  observers  considering  those  to  be  facts  which 
are  only  theories,  and  others  imagining  that  to  be  theoretical  which  is 
truly  fact.  Thus  the  assertion  that  a man  is  laboring  under  apoplexy, 
pneumonia,  pericarditis,  and  so  on,  is  only  stating  the  opinion  or  theory 
the  practitioner  holds  with  regard  to  his  case,  although  such  assertion  is 
generally  received  as  a fact.  Again,  when  it  is  said  that  porrigo  favosa 
consists  of  vegetable  fungi  growing  on  the  scalp,  the  statement,  though 
generally  received  as  mere  theory,  is  truly  a fact,  inasmuch  as  the  vege- 
tation may  actually  be  demonstrated,  and  rendered  as  visible  to  the  eye 
as  trees  growing  in  a plantation.  Indeed,  the  just  distinction  between 
theory  and  fact  is  a matter  which  has  excited  lively  discussion,  and 
hence  the  celebrated  saying  of  Cullen,  that  there  are  more  false  facts 
than  false  theories  in  medicine. 

If,  in  the  field  of  medical  observation,  we  define  a fact  to  be  any- 
thing which  is  obvious  to  the  well-cultivated  senses  of  the  observer,  we 
perhaps  approach  as  near  accuracy  as  is  possible.  Bemark,  I say  well- 
cultivated.,  because  the  senses  require  to  be  educated  before  they  can 
receive  proper  impressions.  In  this  lies  the  great  difficulty  in  teaching 
practical  medicine,  for  what  is  obvious  to  the  sight  of  an  experienced 
practitioner  is  overlooked  by  the  student ; the  sound  which  is  heard  b}^ 
the  one  is  inaudible  to  the  other ; what  the  first  feels  distinctly  is  not 
perceived  by  the  second.  Now,  this  instruction  of  the  senses  constitutes 
a kind  of  information  which  cannot  be  obtained  from  others;  you  must 
acquire  it  for  yourselves.  Of  late  years,  however,  the  detection  of  facts 
has  been  greatly  facilitated  by  the  appropriate  use  of  instruments, 
whereby  what  at  one  time  was  conjectural  is  now  rendered  certain. 
Thus,  the  existence  of  many  diseases,  which  could  formerly  be  detected 
only  by  a happy  speculation  or  by  a rare  sagacity,  is  easily  demonstrated 
by  those  who  know  how  to  employ  judiciously  chemical  tests,  micro- 
scopes, stethoscopes,  pleximeters,  specula,  etc.  To  carry  observation, 
then,  to  its  utmost  extent,  we  must  learn  how  to  avail  ourselves  of  all 
these  means  in  the  examination  of  the  signs  and  symptoms  of  disease. 

On  the  other  hand,  gentlemen,  a sound  and  correct  judgment  is 
equally  necessary,  in  order  that  the  cultivation  of  the  senses  may  lead  to 


MODE  OF  CONDUCTING  THE  CLINICAL  COURSE. 


7 


a proper  end,  and  indicate  the  direction  in  which  you  must  act  for  the 
benefit  of  the  patient.  For  this  purpose  a certain  degree  of  preliminary 
instruction  is  absolutely  essential  before  you  can  be  qualified  to  attend  an 
hospital  with  advantage.  Indeed,  I must  take  it  for  granted  that  before 
coining  here  you  are  tolerably  well  acquainted  with  anatomy  and  diemis- 
try  ; that  you  have  studied  the  institutes  of  medicine — that  is,  the  present 
state  of  histology,  physiology,  and  pathology;  and  that  you  have  a know- 
ledge of  the  materia  medica,  and  of  the  effects  of  remedies  on  the 
economy.  Thus  prepared,  you  commence  a series  of  visits  to  the  bedsides 
of  those  who  are  laboring  under  disease  ; in  other  words,  you  enter  upon 
a course  of  clinical  instruction.  What  should  we  understand  by  clinical 
instruction  ? It  is  not  attendance  on  the  lectures  only — it  is  not  merely 
learning  the  opmioiis  of  your  teacher— it  is  not  simply  deriving  know- 
ledge from  others.  It  is  acquiring  "medical  information  for  yourselves — 
it  is  the  learning  how  to  observe — it  is  that  education  of  the  senses  to 
which  I have  alluded  ; and,  in  addition,  the  formation  of  that  sound 
judgment  which  will  enable  you  to  act  for  the  benefit  of  your  patients. 
This  can  only  be  learned  by  continual  practice  and  experience ; and  it 
has  always  appeared  to  me  that  the  great  aim  of  clinical  instruction  should 
be  to  teach  the  student  to  acc^uire  that  kind  of  tact  and  readiness  to  do^ 
which  we  have  seen  constitutes  art. 

How  are  all  arts  acquired  ? A young  mechanic,  when  he  makes  a 
chair,  follows  exactly  the  same  process  as  those  who  study  what  are  called 
the  fine  arts ; that  is,  he  learns  how  to  do  what  his  master  did  before 
him.  He  imitates  his  plan  of  proceeding.  His  first  attempts  are  rude 
and  uncouth ; his  subsequent  ones  are  more  perfect,  until  at  length,  by 
continual  practice,  he  is  enabled  to  equal  or  surpass  his  instructor.  In 
painting,  sculpture,  and  music  there  are  principles  which  must  be 
attended  to,  and  which  are  learned  from  others  ; but  no  man  can  become  a 
painter,  a sculptor,  or  a musician  without  obtaining  practical  skill  as  an 
artist  in  the  way  now  alluded  to.  It  is  thus,  and  thus  only,  that  art  de- 
scends from  the  old  to  the  young.  And  so  in  medicine ; it  is  not  enough  to 
obtain  general  views  of  health  and  disease,  or  to  study  what  is  known  of 
the  nature  and  treatment  of  individual  maladies.  It  is  absolutely 
essential  to  watch  diseases  for  yourselves,  to  see  the  altered  countenance 
and  form,  to  feel  the  variations  in  the  pulse  and  temperature  of  the  sur- 
face, to  hear  the  changes  which  the  sounds  of  the  heart  and  lungs  undergo, 
to  learn  the  employment  of  stethoscopes,  microscopes,  and  other  mechani- 
cal aids  in  investigation,  and  to  adapt  those  remedies  which  are  in  use 
to  the  special  case  before  you.  It  is  only  by  a combination  of  such 
training  in  a hospital  for  the  sick,  with  the  varied  scientific  knowledge 
you  have  obtained  elsewhere,  that  you  can  hope  to  prepare  yourselves 
conscientiously  for  the  responsible  duties  of  a medical  practitioner. 

The  best  hospital  arrangements  for  clinical  teaching  are  those  which 
exist  in  Italy.  All  the  cases  admitted  are  first  placed  in  a receiving 
ward  (depositorium),  and  immediately  visited  by  the  clinical  professor  or 
his  assistant.  From  these  he  selects  daily  such  as  he  thinks  best  fitted 
for  clinical  instruction.  He  has  seldom  above  thirty  beds  himself,  a 
number  amply  sufficient  if  he  possesses  the  right  of  choice.  Thereby  he  is 
enabled  to  bring  before  his  students  examples  of  nervous,  cardiac,  pul- 


8 


INTRODUCTION. 


monary,  renal,  or  other  diseases,  multiplying  illustrative  cases  of  each  in 
his  wards  as  he  requires  them.  The  result  is,  that  when  lecturing  on 
phthisis  or  any  other  malady,  he  is  enabled  to  direct  the  attention  of  his 
pupils  to  groups  of  cases  presenting  the  various  stages  and  complications 
which  characterise  it.  He  can  thus  demonstrate  the  physical  signs  and 
symptoms  of  the  disease  in  all  its  forms;  point  out  the  numerous  varieties 
it  exhibits,  and  show  the  differences  in  treatment  which  are  necessitated 
by  varied  circumstances.  I need  not  say  that  the  proper  selection  of 
cases  for  clinical  instruction  is  a matter  of  great  importance,  because,  if 
not  sufficiently  varied,  the  student  cannot,  in  the  limited  time  at  his  dis- 
posal, take  a sufficiently  extensive  grasp  of  medical  practice.* 

In  many  schools,  especially  abroad,  there  are  separate  professorships 
of  clinical  medicine  ; whereas  in  others  clinical  teaching  is  carried  on  by 
the  professors  of  other  branches  of  medical  education.  Of  the  two  sys- 
tems I have  no  hesitation  in  preferring  the  latter.  Those  practical  phy- 
sicians who  teach  annually  the  theoretical  and  systematic  branches  of  medi- 
cine ought  to  be  those  best  qualified  for  giving  instructions  in  an  hospital, 
and  this  for  the  obvious  reason,  that  they  are  obliged  to  keep  on  a level 
with  the  advancing  knowledge  of  the  day  in  at  least  one  department  of 
science.  They  may,  it  is  true,  bring  different  kinds  of  knowledge  to  bear 
on  the  subject,  but  that  knowledge  will  be  the  best  in  its  way,  and  the 
students  will  have  the  advantage  of  observing  diseases  treated  by  each 
in  turn.  This  system  has  been  found,  on  the  whole,  to  answer  well,  al- 
though it  must  be  admitted  that  periods  of  three  mouths  are  too  short 
for  a clinical  teacher  and  his  pupils  to  work  together  in  the  course  of  a 
twelvemonth.  On  the  other  hand,  a single  professor  is  too  apt  to  pass 
into  a system  of  routine,  to  dwell  only  on  his  own  peculiar  views,  and, 
not  being  required  to  teach  any  science,  gradually  to  fall  behind,  and  then 
lose  sight  of  scientific  advancement  altogether.  Now  it  is  the  union  of 
science  and  art  which  stimulates  both  to  reach  their  highest  degree  of 
perfection.  The  physician  who  teaches  the  former  systematically  in  the 
university  is  the  man  who  will  correct  and  enlarge  his  th'eory  in  the 
wards  of  an  hospital,  and  he  who  possesses  a large  practice  and  great  ex- 
perience will  extend  his  resources  by  keeping  himself  an  couroni  with  the 
state  of  science,  as  is  necessitated  by  his  duties  in  the  university.  I be- 
lieve that  these  are  the  reasons  which  have  rendered  the  clinical  school 
of  medicine  in  Edinburgh  so  celebrated. 

As  to  the  methods  of  teaching,  they  essentially  consist  of  two  kinds. 
In  one  the  professor  gives  lectures  to  the  students  suggested  by  the 
cases  under  treatment,  to  which  are  occasionally  added,  during  his  visits 
at  the  hospital,  observations  at  the  bedside.  In  the  other  the  student 
is  encouraged  to  talk  to  the  teacher ; to  examine  the  case  tor  himself, 
form  his  own  diagnosis,  and  suggest  a treatment.  Both  systems  have 
their  advantages  and  disadvantages. 

An  experienced  teacher  pointing  out  the  difficulties  and  peculiarities 
of  particular  cases,  and  enriching  the  whole  with  the  results  of  his  own 

* The  Medical  Faculty  of  the  University,  in  surrendering  several  years  ago  the 
same  choice  as  is  still  possessed  by  the  Italian  clinical  professors,  were  guilty  of  an 
injudicious  liberality  which  has  much  weakened  the  efficiency  of  its  hospital  instruc- 
tion. 


MODE  OF  CONDUCTING  THE  CLINICAL  COURSE. 


9 


observations  made  in  a large  field  of  hospital  and  private  practice, 
cannot  but  communicate  to  bis  hearers  most  useful  information,  that  in 
after  years  should  prove  of  the  utmost  value  to  them.  Unfortunately 
the  students  who  hear  such  lectures  are  seldom  prepared  to  benefit  by 
them.  The  difficulties  of  the  experienced,  and  the  methods  by  which 
they  are  to  be  overcome,  cannot  be  entered  into  by  those  who  have  no 
experience  at  all.  Nay,  more ; the  very  facts  and  language  on  which 
descriptions  are  based  in  the  class-room  are  often  unintelligible  to  the 
student.  I remember  myself  listening  to  a most  able  lecture  on  the 
diagnosis  of  pleurisy,  the  whole  of  which  depended  on  knowing  whether 
friction  sounds  and  certain  modifications  in  the  vocal  resonance  did  or 
did  not  exist.  But  as  I had  no  clear  idea — indeed  was  profoundly 
ignorant — of  what  these  sounds  and  vocal  modifications  were,  I was  not 
much  the  better  for  the  information  communicated  to  me.  In  this 
manner  it  too  frequently  happens  that,  at  the  end  of  a series  of  clinical 
lectures,  though  the  student  has  heard  and  seen  much,  he  in  truth 
knows  very  little,  and  has  in  fact  all  his  real  practical  knowledge  to 
acquire. 

The  other  mode  of  clinical  teaching  I first  became  acquainted  with 
in  the  wards  of  M.  Bostan  in  Ibiris  in  1887,  and  subsequently  saw  it 
carried  to  a high  degree  of  perfection  in  the  great  Cliniques  of  Germany 
— especially  under  Schunlein,  Wolf,  and  Barez,  in  the  Charite  Kranken- 
haus  of  Berlin.  It  consists  in  calling  upon  a student  to  examine  the 
case  before  the  class,  in  the  presenco  of  the  teacher,  according  to  a well- 
understood  plan.  At  the  termination  of  the  examination,  he  is  asked 
to  give  his  opinion  or  diagnosis  as  to  its  nature.  Those  who  stand  round, 
and  who  have  followed  all  the  steps  of  the  examination,  are  also  invited 
to  give  their  opinion.  This  gives  an  opportunity  to  the  teacher  of 
pointing  out  the  error  of  this  view  or  the  correctness  of  that,  until  a sound 
conclusion  is  arrived  at.  Then  the  student  is  asked  to  suggest  a treat- 
ment. Again,  suggestions  on  this  point  are  solicited,  and  the  one  con- 
sidered best  is  adopted  by  the  physician  fur  such  and  such  reasons. 
Finally,  the  student  is  requested  to  prescribe,  and  taught  how  to  do  so 
correctly.  In  Germany,  the  examining  pupil  is  further  requested  to 
write  out  the  case,  and  to  keep  a record  of  it,  which  is  subsequently 
corrected  as  an  exercise  by  the  professor.  It  must  be  apparent  that  in 
this  manner  a student  will  acquire  a large  amount  of  practical  informa- 
tion. On  the  other  hand,  instruction  entirely  carried  on  in  this  manner 
deprives  the  student  of  much  that  is  valuable,  because  there  are  many 
topics  which  obviously  cannot  be  carefully  considered  at  the  bedside, 
and  others  which  a sense  of  propriety  should  prevent  being  discussed  in 
the  patient’s  presence.  In  fatal  cases,  a most  important  part  of  clinical 
instruction  consists  in  carefully  examining  the  dead  body,  and  from  the 
appearances  observed  determining  how  far  the  diagnosis  and  treatment 
have  been  correct.  This  evidently  cannot  be  carried  on  in  the  wards, 
and  is  practically  useless  to  those  who  have  not  previously  seen  the  case. 

The  system  of  instruction,  therefore,  I have  carried  out  for  the  last 
seventeen  years  in  this  infirmary  is  one  in  which  I endeavor  to  adopt 
the  excellences  and  avoid  the  defects  of  both  systems.  On  Tuesdays 
and  Fridays  I lecture  in  the  hospital  theatre,  in  which  I give  a resume 


10 


IXTRODUCTIOJS'. 


of  the  facts  of  special  cases;  dwell  on  any  difficulties  of  diagnosis  or 
treatment  that  have  presented  themselves ; refer  to  the  experience  of 
other  physicians;  discuss  pathological  doctrines;  and,  above  all,  exhibit 
the  morbid  parts  of  fatal  cases,  and  connect  the  changes  observed  in  the 
organs  after  death  with  the  phenomena  we  have  studied  in  the  living. 
On  Mondays,  Wednesdays,  and  Thursdays  I visit  with  you  all  the  cases 
in  the  wards,  and  call  upon  such  of  you  as  wish  to  examine  for  your- 
selves to  do  so,  according  to  the  plan  which  you  will  find  detailed  in  this 
little  book,  “ An  Introduction  to  the  Study  of  Clinical  Medicine.”  You 
will  then  try  and  form  your  own  diagnosis,  and  propose  a treatment. 
In  doing  this,  numerous  opportunities  will  present  themselves  which 
will  enable  me  to  give  you  practical  instruction  in  percussion,  ausculta- 
tion, the  use  of  the  microscope,  and  of  chemical  tests  at  the  bedside. 
You  also  will  gradually  learn  how  to  put  questions,  and  so  conduct  the 
inquiry  as  to  arrive  at  an  exact  result  with  as  little  fatigue  to  the  patient 
as  possible.  On  Saturdays  and  Sundays  only  the  more  urgent  cases  will 
be  visited. 

Gentlemen,  I am  happy  to  say  that  this  system  has  met  with  the 
highest  aj^proval  from  the  large  classes  I have  had  the  honor  to  instruct. 
In  1849,  the  gentlemen  then  attending  informed  me  in  this  memorial 
that,  “ Being  aware  how  every  divergence  from  the  regular  medical 
routine  is  very  generally  regarded  at  first  with  suspicion,  we  feel  it  our 
duty  to  express  the  conviction  that,  in  our  experience,  the  system  alluded 
to  has  operated  most  beneficially,  and  to  hope  that  future  students  may 
enjoy  its  advantages.”  In  1850,  a numerous  class  spontaneously  pre- 
sented me  with  this  testimonial,  in  which  they  say — “ We  do  not 
hesitate  to  inform  you  that  we  have  learned  more  of  practical  medicine 
by  your  mode  of  teaching  than  by  any  other  mode  in  use ; and  though 
objections  have  been  raised  against  it,  we  feel  certain  that  the  records  of 
these  last  few  months  will  tend  to  remove  them.  The  general  decorum 
of  the  class  at  the  bedside;  the  great  interest  exhibited  in  the  cases; 
and  last,  though  not  least,  the  never  varying  good  attendance,  all  speak 
loudly  in  its  favor,  and  will,  we  trust,  encourage  you  in  your  zealous 
exertions  to  promote  the  science  of  medicine  by  the  sound  instruction 
of  its  youthful  votaries  in  its  theory  and  practice.” 

Encouraged  by  these  marks  of  approval,  I have  continued  my  method 
of  clinical  instruction  up  to  this  time,  generally  devotiog  two  hours  to 
my  practical  teaching  in  the  wards,  and  have  never  heard  from  pupil  or 
patient  the  slightest  objection.  The  latter,  indeed,  is  uniformly  con- 
tented, being  wise  enough  to  know,  even  by  instinct,  that  a careful  and 
minute  examination  of  his  case  can  only  be  productive  of  benefit  to  him. 
Strange  to  say,  however,  objections  have  recently  been  made  from  a 
quarter  whence  I least  expected  them ; ridicule  and  misrepresentation 
have  not  been  wanting  to  give  point  to  the  attack ; and  another  system 
of  clinical  instruction  has  been  brought  forward,  which  is  considered 
preferable  to  any  other. 

The  chief  objection  is,  that  the  examination  of  a patient  before  a 
large  class  and  by  an  inexperienced  student  is  cruel  to  the  patient. 
‘‘  There  could  not,  I think,”  says  the  objector,  “ be  any  procedure  more 
shocking  than  propping  up  a poor  creature  sufiering  from  disease  of  the 


MODE  OF  CONDUCTING  THE  CLINICAL  COURSE. 


11 


lungs,  and  hammering  his  chest  for  the  recognition  of  diagnostic  sounds 
as  an  academic  exercise.”  This  passage,  which  I copy  from  the  Edin- 
burgh Evening  Courant  for  December  l3th,  1863,  may  have  a formi- 
dable appearance  to  the  public  who  read  it  in  the  newspapers,  but  will 
certainly  not  prevent  physicians  and  intelligent  students  from  practising 
percussion  in  diseases  of  the  chest.  The  reference  to  this  class  of 
diseases  also  is  singularly  unfortunate;  for  it  is  just  in  consequence  of 
the  exactitude  with  which  we  now  arrive  at  a knowledge  of  them  by  the 
“ shocking  ” process  referred  to  that  those,  formerly  so  fatal,  are  now 
almost  always  subdued.  The  “hammering”  of  every  case  of  acute 
pneumonia  in  my  wards  is  followed  by  the  rapid  recovery  of  the  patient. 
Even  phthisis — that  formerly  hopeless  disease — is  now  much  disarmed 
of  its  terror.  Besides,  in  the  system  of  teaching  I am  advocating,  the 
professor  is  always  present  to  check  any  unnecessary  trouble  or  incon- 
vience  that  might  be  given  to  the  patient ; and  in  all  acute  cases,  such 
as  of  fever  or  acute  inflammations,  no  examinations  not  absolutely  re- 
quired are  allowed. 

The  plan  of  clinical  instruction  which  has  been  proposed  as  “ prefer- 
able and  as  worthy  of  general  adoption”  is  as  follows — viz.,  “ to  bring 
the  cases  one  by  one  into  a room  where  the  students  are  comfortably 
seated,  and  if  the  patients  have  not  been  seen  previously  by  the  surgeon 
so  much  the  better.  Then  ascertain  the  seat  and  nature  of  their  com- 
plaints, and  point  out  the  distinctive  characters.  Having  done  this  so 
that  every  one  present  knows  distinctly  the  case  under  consideration,  the 
teacher,  either  in  the  presence  or  absence  of  the  patient,  according  to 
circumstances,  proceeds  to  explain  the  principles  of  treatment,  with  his 
reasons  for  choosing  the  method  preferred,  and,  lastly,  does  what  is  re- 
quisite in  the  presence  of  his  pupils.” 

Without  denying,  as  before  stated,  that  a large  amount  of  instruction 
may  thus  be  communicated,  I still  venture  to  doubt  whether  those  who 
are  taught  in  this  way  will  ever  be  enabled  to  grapple  with  the  realities 
of  practice.  I remember,  when  myself  a surgical  student  in  this  infir- 
mary, looking  at  the  brilliant  operations  of  Messrs.  Liston,  Syme,  Lizars, 
and  Fergusson.  Legs  and  arms  flew  off  with  the  rapidity  of  lightning, 
as  if  by  magic;  and  what  the  bewildered  student  mainly  occupied  him- 
self with  was  his  watch,  to  determine  in  how  many  seconds  the  opera- 
tion was  completed.  But  as  to  performing  such  an  operation  him- 
self, the  thing  was  never  thought  of  nor  inquired  into.  Further,  if  it 
be  “ shocking  ” to  examine  medical  patients  physically  in  their  own 
beds,  what  term  ought  to  be  applied  to  dragging  persons  with  fractures, 
dislocations,  wounds,  and  sores  from  their  beds,  into  a room  where  the 
students  are  comfortably  seated  ? Indeed,  it  is  easy  tp  understand  how 
those  who  receive  instruction  in  a practical  art  after  this  fashion — who 
seldom  visit  the  wards  or  follow  the  progress  of  disease  there,  and  who 
only  see  just  so  much  of  a case  as  the  teacher  places  before  them  in  the 
manner  above-mentioned — must  be  very  liable  to  present  those  appear- 
ances so  well  described  by  Dr.  Parkes,  when  subjected  to  a practical  ex- 
amination.* 

* See  report  oi  Speech  made  to  the  Medical  Council  April  80th,  1864,  in  all  the 
weekly  journals.  He  contended  that  the  medical  corporations  were  admitting  men 


12 


INTRODUCTION. 


The  only  method  of  giving  a stimulus  to  the  practical  education  of 
students  in  the  hospital  wards  is  to  institute  practical  examinations  for 
their  diplomas  or  licenses.  Those,  however,  who  are  opposed  to  practi- 
cal teaching,  and  in  favor  of  the  comfortable  looking-on  system,  are,  as 
a matter  of  course,  opposed  to  practical  examinations.  The  institu- 
tion of  the  latter  would  necessarily  cause  the  breaking  down  of  the 
former.  The  truth  is,  there  is  no  difficulty  either  in  the  one  or  the 
other.  I have  found  a large  class  no  impediment.  On  the  contrary,  it 
adds  interest  to  the  proceedings ; and  as  I have  never  yet  had  to  com- 
plain of  want  of  decorum  or  absence  of  gentlemanly  conduct  on  the 
part  of  my  students,  so  I have  no  fear  for  the  future.  The  Commis- 
sioners for  the  Universities  of  Scotland  have  enacted  that  the  examina- 
tions in  Medicine  and  Surgery  shall  be  conducted  “ in  part  by  clini- 
cal demonstrations  in  the  hospital.”  The  regulation  comes  into  opera- 
tion this  session  (1864-05),  and  will,  I trust,  be  the  means  of  inciting 
you  to  that  kind  of  study  which,  you  may  depend  upon  it,  is,  after  all, 
the  one  best  qualified  to  fit  you  for  the  responsible  duties  of  the  medi- 
cal profession. 

I am  satisfied  that  you  will  not  cultivate  practical  medicine  very 
long  iu  this  way  without  noticing  a fact,  which  is  every  year  becoming 
more  and  more  evident — viz.,  that  the  art  has  of  late  years  been  under- 
going a great  revolution.  It  is  daily  becoming  apparent  to  those  who 
observe  in  a spirit  of  sincerity  and  of  truth,  that  much  of  the  practice  of 
our  profession,  which  has  resulted  from  what  is  called  experience,  is 
altogether  incompatible  with  the  existing  state  of  our  knowledge — that 
in  consequence  it  requires  a thorough  revision — that  the  systems  and 
nosologies  of  our  forefathers,  though  useful  in  their  day,  no  longer 
apply — and  that  a new  field  of  labor  is  now  open  to  the  cultivation  of 
those  zealous  clinical  students  who  are  anxious  to  identity  themselves 
with  the  progress  of  medicine. 

It  cannot  fail  to  strike  all  those  who  have  paid  any  attention  to 
modern  medical  education,  that  whilst  physiology  and  pathology  have 
been  making  rapid  advances,  our  previous  impressions  of  the  action  of 
drugs,  and  of  various  modes  of  treatment,  have  become  altogether 
changed.  Whilst  we  were  ignorant  of  the  structure  and  functions  of  an 
organ  or  tissue,  so  long  as  we  confounded  together  causes  and  results, 
so  long  we  were  especially  apt  to  be  led  astray  by  tentative  efforts 
at  cure.  But  once  that  we  have  established  on  indisputable  data  v*4iat 
is  really  fact — what  is  the  true  law  governing  the  progress  of  a disease — 
in  how  many  instances  does  it  then  become  evident  that  the  means 
employed  for  its  removal  are  feeble  or  altogether  inert  ? This  has  now 
occurred  so  extensively — systematic  works  on  medicine  are  so  at  vari- 
ance with  books  on  physiology  and  pathology — the  practice  of  the  pro- 

who  could  not  practise  with  safety ; and  as  long  as  this  was  the  case,  so  long  must 
the  army  medical  department  examine  for  itself.  Further,  “ In  regard  to  the  general 
question  of  examination,  he  could  not  consider  the  present  system  satisfactory,  Avhen 
it  allowed  men  to  obtain  licenses  who  could  not  make  a chemical  examination  of 
water,  or  who  did  not  know  the  skeleton,  or  who  could  not  put  up  a fractured  limb 
or  pass  a catheter.” 


POLITICAL  STATE  OF  THE  MEDICAL  PKOFESSION. 


13 


fession  is  so  discordant  with  its  theory — that  many  intellectual  inquirers 
among  us  take  refuge  in  a universal  scepticism  as  to  the  action  of  drugs, 
leave  everything  to  nature,  and  merely  adopt  what  is  called  in  France 
an  expectant  treatment,  and  in  Germany  the  practice  of  “ Nihilismus.” 
Nay,  it  has  been  even  Contended  that  our  remedies,  so  far  from  doing 
good,  in  many  instances  do  positive  injury,  and  that  it  is  safer  to  trust 
to  nature  than  to  the  physician. 

The  only  method  of  escape  from  this  state  of  things,  it  appears  to 
me,  is  by  an  earnest  effort  on  the  part  of  those  who  sincerely  desire  the 
improvement  of  our  art,  to  establish  the  science  of  medicine  upon  some- 
thing like  a solid  foundation.  Let  us,  at  all  events,  endeavor  to  realise 
our  position,  and  to  separate  what  is  known  from  what  is  unknown. 
Among  the  known,  let  us  determine  what  we  have  derived  from  scientific 
generalization,  and  what  from  blind  experience ; and  in  the  vast  field  of 
the  unknown,  let  us,  if  possible,  agree  as  to  the  direction  and  manner  in 
which  we  ought  to  work,  in  order  to  explore  its  extent  and  contract  its 
boundaries. 

The  propriety  of  this  procedure  is  admitted.  Why,  then,  is  it  not 
carried  out  ? — why  cannot  we  co-operate  in  the  resolve  to  prosecute 
our  noble  profession  with  a simple  desire  to  advance  it  towards  its  true 
end — the  cure  of  disease  ? I will  answer  these  questions  by  endeavor- 
ing to  show  what  are,  as  I think,  the  circumstances  which,  at  the  outset 
of  every  honest  attempt,  discourage  our  endeavors  to  improve  medical 
practice.  They  seem  to  me  to  be  connected,  as  far  as  this  country  is 
concerned — 1st,  With  the  political;  i^d,  With  the  social;  and  3d,  With 
the  practical  status  of  our  profession.  On  each  of  these  subjects  a vol- 
ume might  be  written,  but  I shall  endeavor  to  place  their  leading  as- 
pects before  you  in  a few  words. 


The  Political  State  of  the  Medical  Profession. 

When  we  regard  all  the  other  professions  and  pursuits  of  life  in  this 
great  country,  we  find  there  are  none  of  them,  except  medicine,  whose 
cultivators  are  excluded  from  the  high  offices  of  state,  or  forbidden  to 
aspire  to  any  rank  below  that  of  royalty.  The  eminent  lawyer  or  divine 
— the  successful  admiral  or  general — the  popular  author — or  the  heads 
of  our  great  commercial  houses,  may  become  peers  of  the  realm,  are 
commonly  seen  taking  an  active  part  in  the  Legislature,  and  frequently 
receive  reward  or  distinction,  conferred  upon  them  by  a nation  grateful 
for  their  services.  It  is  a fact  well  calculated  to  excite  astonishment, 
that  a class  of  men  who  have  dedicated  themselves  to  the  well-being  of 
the  public  health  should  be  comparatively  neglected.  In  this  respect 
we  suffer  with  men  of  science  in  general,  who,  however  much  they  may 
be  respected  individually,  are  but  slightly  encouraged  by  the  state.  The 
hackneyed  phrase  of  our  legislators  with  regard  to  all  men  of  science, 
including  medical  men,  is,  in  the  words  of  Sir  Kobert  Peel,  that  “ science 
is  its  own  reward;  ” or  in  the  words  of  the  Duke  of  Argyle,  “ that  in 
the  main  it  must  depend  for  its  advancement  on  its  own  inexhaustible 
attractions,  and  on  the  delight  which  it  affords  us  to  study  the  constitu- 


14 


IXTEODUCTION. 


tion  of  tlie  world  around  us.”  But  in  every  civilised  country  except 
Great  Britain  it  has  been  thought  a matter  of  good  policy  to  encourage, 
by  marks  of  honor,  those  who,  by  their  scientific  labors,  have  contri- 
buted to  the  public  weal.  The  French  reproach  the  profession  in  this 
country  for  having  achieved  for  itself  no  adequate  honor  or  reputation. 
It  has  been  said  that  “ in  France,  during  the  last  half  century,  there  is 
no  council-board,  no  administration,  no  society,  in  which  the  medical 
profession  has  not  found  itself  represented,  whether  at  the  court  of  the 
sovereign,  or  among  the  peerage,  or  in  the  legislature.  Physicians  of  the 
Institute  take  their  place  naturally  among  the  first  of  the  land.  Their 
views,  their  discoveries,  their  cures,  their  professional  ideas  and  sugges- 
tions, must  be  listened  to,  cannot  be  neglected,  and  may  never  be  treated 
as  intrusion;  nor  had  Napoleon  fewer  physicians  and  surgeons  for 
friends,  councillors,  and  dignitaries  of  state,  than  he  had  of  any  other 
profession.  But  in  England  all  such  interests  find  themselves  either 
misrepresented,  or  not  represented  worthily ; and  the  best  of  their 
physicians  is  good  only  to  amass  money,  or  at  the  highest,  get  a 
baronetcy.” — (Examiner.)'^ 

All  this,  gentlemen,  would  be  of  little  importance,  did  it  not,  as  I 
shall  point  out  immediately,  greatly  afiPect  our  social  position,  and  through 
it  lower  the  true  objects  for  which  medicine  ought  to  be  cultivated. 

Much  of  the  evil  arises  from  the  fact,  that  the  medical  profession  in 
this  country  possesses  no  national  organization.  Unlike  the  other  pro- 
fessions, so  far  from  there  being  a bond  of  union  among  its  members 
they  are  irreconcilably  divided  by  chartered  medical  institutions.  These 
amount  to  about  thirty  in  number,  each  having  different  powers  conferred 
upon  them  by  past  sovereigns  or  governments,  and  an  interest  in  ag- 
grandising itself  at  the  expense  of  its  neighbors.  These  various  insti- 
tutions, though  they  were  all  established  professedly  to  support  the  hon- 
or and  dignity  of  medicine  and  its  cultivators,  are  so  discrepant  in  pow- 
er, and  so  conflicting  in  interest,  that  they  have  led  to  little  but  confu- 
sion and  disunion  among  the  members  of  the  profession  at  large. 

Such,  of  late  years,  have  been  the  clashing  interests,  the  conflicting 
privileges,  the  injuries  inflicted  on  the  student  and  on  medical  education, 
the  discreditable  prosecutions  in  our  courts  of  law  of  well-educated 
medical  men,  whilst  the  ignorant  pretender  is  allowed  to  escape,  and  a 
host  of  other  evils,  that  a universal  cry  has  been  raised  for  what  is  called 
medical  reform — that  is,  a re-arrangement  of  the  affairs  of  the  profession 
by  an  Act  of  the  legislature.  It  would  be  curious  to  analyse  the  different 
measures  which  have  been  proposed  for  this  purpose.  But  it  was  to  be 
anticipated  that  our  medical  corporations  would  look  after  their  own  in- 
terests— oppose  everything  that  encroached  upon  them — and  in  cases 
where  there  existed  few  or  no  privileges,  that  efforts  would  be  made  to 
obtain  them,  even  at  the  expense  of  sister  institutions. 

* As  a public  manifestation  of  this  state  of  things,  I may  refer  to  the  fact  that, 
in  1858,  I witnessed  with  pride  and  gratification  the  statue  of  Jenner  placed  in  Tra- 
falgar Scpiare,  London,  in  the  presence  of  Prince  Albert,  Lord  Lansdowne,  and  other 
distinguished  men.  But  I have  never  seen  it  since,  as,  on  my  next  visit  to  the  me- 
tropolis, it  had  been  removed  to  some  obscure  corner — fur  removed  from  monuments 
to  the  other  great  men  of  the  country. 


POLITICAL  STATE  OF  THE  MEDICAL  PROFESSION. 


15 


At  length,  however  (1858),  an  Act  passed  the  Legislature  which 
abolished  the  territorial  privileges  of  the  corporations,  and  permitted 
every  medical  man  to  practise,  according  to  his  qualification  or  qualifica- 
tions, throughout  the  kingdom.  It  empowered  a Council  to  be  formed 
of  delegates  from  the  various  universities  and  corporations — a sort  of 
medical  parliament — which  was  to  settle  the  details  of  all  vexed  ques- 
tions. It  ordered  the  preparation  and  publication  of  a Register  of 
legally  qualified  practitioners,  and  of  a national  Pharmacopoeia ; and 
provided  that  the  licentiates  and  fellows  of  a college  in  one  part  of  the 
country,  who  might  desire  to  join  another  in  a different  part  of  it,  might 
do  so  on  the  payment  of  a small  sum  (£2).  In  this  manner  the  evils 
resulting  from  local  privileges  and  jurisdiction  were  to  a great  extent 
removed.  Other  disputed  points  as  to  the  natare  of  qualifications,  what 
should  constitute  a national  and  uniform  medical  education,  instead  of 
the  vexatious  curricula  of  so  many  medical  boards,  and  a variety  of  im- 
portant but  minor  considerations,  were  to  be  determined  by  this  Medi- 
cal Council.  Since  the  Act  has  become  law,  a Register  of  qualified 
practitioners,  for  the  information  of  the  public,  and  h.aving  absolute 
authority  in  courts  of  law,  and  a national  Pharmacopoeia,  have  been 
published  ; but  as  to  the  other  points  we  have  still  to  wait  for  further 
deliberations  of  the  Council. 

While  these  efforts  to  regulate  the  medical  profession,  or  what  has 
been  called  Medical  Reform,  were  proceeding,  other  attempts  were  being 
made  to  extend  and  improve  the  advantages  of  our  national  Universities, 
or  what  has  been  called  University  Reform.  It  became  generally  felt 
that  the  system  sanctioned  by  long  usage  in  these  ancient  institutions 
required  modification  to  meet  the  altered  demands  of  the  times ; that 
the  great  end  of  all  education  was  not  to  acquire  abstract  learning  or 
science,  but  to  render  knowledge  useful  in  life  ; and  that  the  value  of 
that  education  ought  to  be  tested  by  its  fitness  to  prepare  men  for  the 
various  professions  and  administrative  offices  of  the  country.  It  was 
maintained  that  a university  education,  therefore,  should  make  not 
merely  a learned  man,  but  also  a practical  man,  and  that  academical  de- 
grees should  not  be  regarded  only  as  marks  of  honor — to  be  crowned, 
as  in  the  Olympian  games,  with  chaplets  of  barren  leaves — but  should  be 
considered  as  proofs  of  proficiency,  and  rewarded  with  branches  on  which, 
like  those  from  the  garden  of  the  Hesperides,  we  might  look  for  golden 
fruit.  In  short,  the  spirit  of  our  time,  and  the  most  obvious  good 
policy,  pointed  to  the  support  and  extension  of  the  Universities  as  the 
true  source  of  professional  knowledge  for  the  youth  of  our  country.  It 
is  there  that  intimacies  are  formed  between  men  of  different  classes  and 
professions;  it  is  there  that  the  narrow  tone  of  mind,  fostered  by  mere 
professional  schools,  is  counteracted ; it  is  there  that  the  associated 
students  learn  the  value  of  general  information  and  enlarged  ideas  when 
brought  to  bear  upon  distinct  pursuits ; and  it  is  there  that  the  preju- 
dices of  caste  and  of  corporate  exclusiveness  are  merged  in  the  catholic 
desire  to  render  education  as  general  as  possible  for  the  good  of  the 
country  at  large.  Great  changes,  in  consequence,  have  been  gradually 
made  in  the  government  and  regulations  of  the  English  and  Irish 
Universities.  A new  University  was  established  in  London,  a second  in 


IG 


INTRODUCTION. 


Durham,  and  another  with  three  colleges  in  different  cities  of  Ireland, 
each  having  a complete  medical  faculty.  And,  lastly,  the  Scottish  Unh 
versities  have  been  made  the  subject  of  an  Act  of  Parliament,  whereby, 
as  you  are  aware,  this  University  obtained  a new  constitution,  which  is 
now  in  full  operation,  and  which  gives  students,  graduates,  and  profes- 
sors a share  in  its  government. 

It  would  be  evidently  premature  to  speak  of  w'hat  is  likely  to  be 
the  result  of  all  this  legislation  with  regard  to  the  welfare  of  the  medi- 
cal profession.  But  already  events  have  taken  place  with  which,  as  ma- 
terially influencing  your  future  position,  you  should  be  acquainted. 

The  Medical  Act  provides  that  two  or  more  corporations  may  unite 
for  the  purpose  of  constituting  one  examining  board,  and  thereby  securing 
at  once  an  efficient  examination  in  two  or  more  of  their  especial  depart- 
ments— the  successful  candidate  receiving  the  licenses  of  the  different 
corporations  who  so  unite.  This  plan,  if  conscientiously  carried  out, 
cannot  but  be  of  the  greatest  service,  and,  without  depriving  these  bodies 
of  their  privileges,  abolishes  one  of  the  great  evils  to  which  I have  pre- 
viously alluded.  Thus  in  England,  a union  of  the  Colleges  of 
Physicians  and  Surgeons  would  enable  those  distinguished  bodies  to 
appoint  able  physicians  and  surgeons  in  every  way  qualified  to  carry  out 
the  important  duties  of  examiners,  and  what  seem  to  be  the  purposes  of 
the  Act.  Such  would  appear  to  be  the  reason  why  the  English  Poor- 
law  and  Army  Medical  Boards  insisted  that  their  medical  officers,  who 
are  required  to  practice  both  medicine  and  surgery,  should  possess  what 
is  called  the  double  qualification.  In  other  words,  they  demand  to  be 
satisfied  that  such  candidates  have  been  carefully  examined  in  medicine 
by  physicians,  and  in  surgery  by  surgeons,  which  is  obviously  the  only 
way  of  ensuring  that  the  examination  has  been  a hona  fide  one. 

But  in  Scotland,  the  fellows  of  the  E-oyal  Colleges  of  Physicians  and 
Surgeons  are,  with  few  exceptions,  parties  who  practise  both  branches  of 
the  art,  and  are  what  is  called  in  the  profession  general  practitioners. 
There  is,  in  truth,  little  distinction  between  the  one  college  and  the 
Other ; so  that,  in  forming  a joint  board,  unless  the  few  physicians  on 
the  one  side,  and  the  few  surgeons  on  the  other,  constituted  that  board, 
there  would  be  no  guarantee  of  a thorough  medical  and  surgical  exami- 
nation, as  would  occur  in  the  case  I have  supposed  of  the  London 
Colleges.  Instead  of  different  elements  being  united  to  make  a perfect 
whole,  similar  elements  are  brought  together  from  the  two  institutions, 
neither  medicine  nor  surgery  being  properly  represented  at  all  as  dis- 
tinct professions.  Such  a plan  does  not  fulM  the  object  of  the  Medical 
Act,  nor  meet  the  requirements  of  the  Poor-law  and  Army  Medical 
Boards. 

While  these  powers  were  given  by  the  Medical  Act  to  the  numerous 
corporations,  the  ancient  large  privileges  granted  to  the  Universities 
were  confirmed.  The  Universities  can  now  grant  the  degrees  of  Doctor, 
Bachelor,  or  Licentiate  of  Medicine,  and  Master  of  Surgery ; and  their 
graduates,  on  presenting  their  diplomas,  are  enrolled  in  the  G-eneral 
Register  of  Medical  Practitioners,  and  are  empowered  to  practise  both  in 
medicine  and  surgery,  as  has  been  the  practice  immemorially  among  the 
great  Continental  Universities.  There  can  be  no  doubt  that  the  adoption 


POLITICAL  STATE  OF  THE  MEDICAL  PROFESSION. 


17 


of  this  course  generally  would  be  of  great  advantage  to  the  public  and 
to  the  profession  at  large.  It  would  not  only  elevate  the  status  of  sur- 
geons, by  conferring  upon  them  academical  rank,  but  would  constitute 
another  means  of  getting  rid  of  those  corporate  distinctions  which  have 
created  so  much  jealousy  among  medical  men. 

The  necessity  of  extending  the  preliminary  studies  has  met  with  the 
concurrence  of  all  parties.  The  conviction  has  gained  ground,  that 
he  who  wishes  to  understand  the  phenomena  of  the  animal  economy 
must  approach  them  by  the  way  of  a logical  and  physical,  as  well 
as  by  that  of  a classical  education.  In  future,  therefore,  no  one 
can  enter  upon  the  study  of  medicine  until  his  knowledge  in  lite- 
rature and  arts  has  been  more  satisfactorily  tested  than  it  was  former- 
ly. The  regulations  on  this  head,  it  is  hoped,  will  tend  to  enlarge  the 
attainments  of  medical  students,  and  produce  a favorable  reaction  on 
medicine  itself. 

I must  not  overlook  the  circumstance,  that  it  has  already  become 
necessary  to  repeal  an  important  clause  in  the  Medical  Act,  in  conse- 
quence of  an  occurrence  which  was  not  anticipated.  This  consisted  in 
the  Royal  College  of  Physicians  of  Edinburgh  selling  its  licenses  to  the 
surgeons,  apothecaries,  and  druggists  of  England,  without  examinaticn,. 
for  the  sum  of  £10  ; while  many  of  the  purchasers,  to  the  astonishment 
of  the  profession,  assumed  in  consequence  the  university  title  of  Doctor 
of  Medicine,  which  the  College  in  question  had  taken  no  steps  to  prevent. 
I shall  not  venture  to  state  any  opinion  of  my  own  as  to  this  unfortunate 
transaction,  but  give  you  that  of  an  eminent  physician,  himself  a Fellow 
of  the  College  he  complains  of,  and  who  spoke  as  follows  when  President 
of  the  British  Medical  Association  : “ It  is  to  be  hoped,’’  he  says,  “ that 

the  self-respect  of  our  profession  will  deter  its  members  from  supporting 
this  sale  of  medical  indulgences,  and  so,  by  rendering  the  English  traffic 
less  lucrative  than  was  anticipated,  lead  its  promoters  to  remember  the 
purpose  for  which  their  College  was  established.  A distinction  in 
letters,  whether  in  medicine,  law,  or  divinity,  which  may  be  obtained  by 
merely  paying  down  a few  pounds,  is  worth  precisely  what  it  costs ; it 
proves  pecuniary  ability,  nothing  more.  The  initials  of  physician  by 
purchase  would  correctly  intimate  the  estimation  in  which  the  possessor 
of  such  a distinction  will  be  held  by  every  one  but  himself.  There  is 
a want  of  more  of  acknowledged  authority  in  our  profession,  and  not  of 
less.  And  although  colleges  may  have  but  little  power  to  create  this, 
they  are  not,  as  in  this  instance,  without  the  power  to  lessen  that  which 
exists.  I feel  personally,”  continues  Dr.  Radcliffe  Hall,  “ that  faith  is 
not  kept  with  those  who  formerly  considered  it  creditable  to  be  connec- 
ted with  the  Edinburgh  College  of  Physicians;  and  that,  in  bare  jus- 
tice, every  Fellow  ought  to  have  a vote  in  deciding  whether  or  not  so 
radical  a degradation  of  his  College  should  take  place.  Surely  there  is 
great  defect  in  the  constitution  of  the  Medical  Council  of  Great  Britain 
if  it  cannot  interfere  to  prevent  so  grave  an  abuse  of  vested  authority 
as  this.”* 


^Address  to  the  South-Western  Branch  of  the  British  Medical  Association.  Brit, 
Med.  Jour.^  July  9,  1859. 


18 


INTRODUCTION. 


Gentlemen,  the  Medical  Council  did  interfere,  and  insisted  on  a med- 
ical examination ; but  how  far  this  was  rendered  stringent  we  will  not 
inquire.  No  less  than  356  candidates  passed  this  so-called  ex- 
amination between  the  29th  March  and  20th  April  of  1860 ; and 
during  twelve  months,  nearly  1000  persons  altogether  obtained  the 
license. 

The  result  has  been,  that  the  London  College  of  Physicians,  having 
first  remonstrated  in  vain,  properly  refused  to  admit  this  flood  of 
licentiates  to  its  own  body  on  the  conditions  provided  by  the  Act;  and 
the  clause  which  enabled  a medical  man  on  changing  his  residence  to 
join  a sister  college  at  a nominal  charge,  has  been  repealed  in  a short 
bill,  which,  under  the  circumstances,  all  parties  admit  to  be  necessary. 
Thus,  not  only  has  the  status  of  physic  and  physicians  been  lowered  in 
^Scotland  by  the  institution  expressly  founded  to  elevate  both,  but 
all  fellows  and  licentiates  of  every  college  in  the  kingdom  have,  by 
dts  conduct,  been  excluded  from  an  important  reciprocal  privilege,  which 
had  been  long  struggled  for,  and  which  was  actually  conferred  upon  them 
by  the  Legislature. 

As  young  graduates,  you  will  naturally  feel  indignant  that  the  title 
of  Doctor  should  be  usurped  by  parties  who  have  no  claim  to  it.  Such, 
however,  is  the  difficulty  of  legislating  on  this  matter,  and  so  indiscrimi- 
nate the  manner  in  which  the  highest  medical  title  is  given  by  the  public, 
that  I have  no  other  advice  to  offer  you  than  this, — viz  , that  on  all  proper 
occasions  you  should  at  least  do  yourselves  the  justice  of  pointing  out 
the  distinction  (not  apparently  understood  in  England  and  abroad)  be- 
tween the  College  of  Physicians  and  the  LLiiversity  of  this  city.  I sin- 
cerely trust  that  the  Loyal  College  before  long  may  see  it  to  be  consist- 
ent with  its  honor  to  repudiate  an  act  which  has  been  so  universally  con- 
demned by  the  profession  at  large. 

Such  then,  is  the  actual  political  condition  of  the  profession  into 
which  you  are  about  to  enter.  Let  us  hope  that,  as  the  Medical  and 
Scotch  Universities  Acts  are  brought  into  operation,  the  cause  of  medical 
education,  and  the  improvement  of  the  schools,  will  advance.  Among 
these,  that  of  Edinburgh  has  hitherto  occupied  a pioud  position;  and 
great  indeed  will  be  the  responsibility  of  those  who,  with  the  pow'er  of 
supporting  and  increasing  her  influence,  are  induced  to  cripple  her  re- 
sources and  impede  her  usefulness  in  the  vain  hope  of  reconciling  inter- 
ests and  satisfying  institutions  which  are  essentially  antagonistic.  What 
W'e  require  is  a legislation  which,  instead  of  maintaining  a system  of 
rival  institutions  and  opposing  schools,  perpetuatir  g disunion  and  re- 
tarding the  cause  of  scientific  progress  among  us,  will  draw  these  dis- 
cordant elements  together,  for  the  purpose  of  co-operation  and  mutual 
support.  Nor  is  this  impracticable,  as  such  a constitution  exists  in  most 
Continental  nations,  and  has  been  found  to  work  admirably.  To  this 
end  the  various  universities  and  corporations,  instead  of  independent  and 
•contradictory  action,  should  be  empowered  to  carry  out  one  system  of 
education  and  privilege  in  the  three  divisions  of  the  kingdom,  subordi- 
nate to  a uniform  direction.  Instead  of  numerous  schools  acting  as 
rivals  to  and  injuring  one  another,  a machinery  ought  to  be  devised  by 
which  the  talent  now  diffused  and  wasted  should  be  concentrated  under 


THE  SOCIAL  STATE  OF  THE  MEDICAL  PROFESSIOJ5". 


19 


a wise  administration,  so  as  to  strengthen  instead  of  weaken  our  national 
Universities.  In  this  manner  the  strongest  stimulus  would  be  given  to 
successful  exertion,  while  ability  and  scientific  merit  might  hope  to 
meet  sometliing  like  adequate  reward. 

Gentlemen,  believing  that  the  interests  of  medicine  as  a science,  its 
dignity  as  a profession,  and  its  usefulness  to  the  community,  are  inti- 
m itely  associated  with  the  manner  in  which  public  bodies  carry  out  the 
spirit  of  their  foundation  statutes  and  charters,  you  will  not,  I trust,  re- 
gard my  having  directed  your  attention  to  this  important  subject  as  un- 
necessary or  inopportune.  To  explain  fully  the  numerous  intricacies  of 
this  perplexed  matter  time  would  not  permit.  I shall  be  satisfied  if,  on 
reflection,  my  remarks  shall  have  led  you  to  see  the  incongruity  in  a 
science  like  medicine,  which  is  one  and  indivisible,  of  its  cultivators 
being  constantly  opposed  to  one  another  on  account  of  corporate  distinc- 
tions and  animosities.  I would  earnestly  urge  you  to  labor  in  the 
cause  of  union — which,  proverbially,  is  strength — as  the  only  method  of 
placing  the  profession  of  medicine  in  a dignified  position  with  regard  to 
the  State  on  the  one  hand,  and  the  public  on  the  other,  and  thus 
furthering  the  beneficent  object  for  which  it  is  cultivated. 


The  Social  State  of  the  Medical  Profession. 

The  evils  resulting  from  the  political  condition  of  the  medical  pro- 
fession have  led  to  still  greater  ones  in  its  social  state.  In  consequence 
of  the  complete  absence  of  public  positions,  with  emoluments  sufficient 
to  satisfy  the  reasonable  desire  and  ambition  of  scientific  men — as  the 
most  skilful  physician,  or  most  successful  discoverer,  does  not,  in  conse- 
quence, receive  any  dignity  or  honor  from  the  State — and  as  the  offices 
of  our  medical  corporations  as  they  are  at  present  managed  are  utterly 
incapable  of  supplying  the  deficiency — it  follows  that  the  only  prize 
open  to  the  aspiring  and  ambitious  is  the  wealth  to  be  derived  from  an 
enormous  practice. 

If,  indeed,  there  were  any  necessary  relation  between  the  popularity 
of  a physician  and  his  real  professional  merit,  we  might  recognise  this 
as,  so  far,  a reward  and  encouragement.  But  it  is  notorious  that  this  is 
not  the  case,  and  that  in  many  instances  large  practices  are  acquired  by 
the  most  unblushing  charlatanism.  St.  John  Long  was  supposed  to  have 
received  about  twelve  thousand  pounds  a year  for  pretending  to  cure 
consumption  by  rubbing  an  escharotic  liniment  into  the  chest,  and 
when  at  length  he  was  tried  for  the  manslaughter  of  Miss  Cashin, 
evidence  in  his  favor  was  given  by  half  the  aristocracy  of  the  metropo- 
lis. In  all  ages,  indeed,  the  successful  pretender  has  succeeded  in  col- 
lecting more  gold  than  could  be  accomplished  by  honorable  members  of 
the  profession ; formerly,  however,  the  imposture  was  manifest,  and  car- 
ried its  own  shame  with  it.  But  the  bane  of  the  profession  at  this  mo- 
ment is  the  existence  of  a class  of  medical  practioners  who,  in  arduous 
competition  with  their  fellows,  and  pressed,  perhaps,  by  the  necessity,  if 
not  the  desire,  of  making  money,  have  come  to  the  conclusion,  that 
what  they  really  know  and  can  perform  professionally  is  of  much  less 


20 


INTEODUCTION. 


consequence  than  what  the  public  gives  them  credit  for.  The  ultimate 
influence  of  this  state  of  things  on  their  own  morals,  and  on  the  welfare 
of  the  profession,  must  be  obvious. 

But  let  us  suppose  that  a really  able  man,  after  years  of  toil  and 
anxiety,  at  length  reaches  the  full  career  of  a metropolitan  practice.  Is 
this,  after  all,  a suitable  reward  for  his  labors?  Is  this  position  really 
a desirable  one,  with  regard  to  its  results  either  on  his  own  mind  or  on 
the  honor  and  higher  interests  of  his  profession  ? On  this  head  I pre- 
fer reading  the  statement  of  another.  “ Many  years’  attention  to  all 
subjects  affecting  the  profession  of  physic,”  says  an  anonymous  writer, 
“ has  led  us  to  the  conclusion  that  large  practices,  the  only  prizes  which 
the  profession  offers  at  present  to  its  members,  are  in  many  ways  its 
bane.  By  them  the  high  scientific  tone  of  the  profession  is  depressed; 
its  independence  sunk  ; a low  standard  of  effort  is  fostered ; the  indi- 
vidual who  succeeds  is  rendered  worthless ; the  public  cheated  ; false 
practice  authorised ; quackery  promoted ; and  sterling  merit  often  de- 
prived of  its  just  reward.”* 

The  same  writer  goes  on  to  observe  that  occasionally  also,  this  ex- 
cessive practice  leads  to  such  a love  of  money,  or  desire  to  be  thought 
important,  distinguished,  or  influential,  that  in  order  to  obtain  it,  the 
proper  etiquette  of  the  profession  is  abandoned,  and  every  feeling  of 
gentlemanly  propriety  and  honor  is  first  blunted,  then  destroyed.  The 
great  position  a person  of  this  kind  fancies  he  has  attained  leads  him 
to  overlook  the  interests  and  just  claims  of  his  fellow-practitioners, 
and  to  tempt  away  their  patients,  who,  after  all,  among  the  crowd  of 
those  he  attends,  are  often  sadly  neglected.  By  watching  the  progress, 
and  mingling  in  the  society  of  certain  men  of  this  class,  the  professional 
mind  is  in  danger  of  being  rendered  unsound,  and  actuated  more  by  a 
desire  of  attaining  what  is  conventionally  received  as  “ success  in  life” — 
which  simply  means  the  obtaining  of  a large  income — than  by  the  higher 
incentive  of  public  usefulness. 


The  Present  State  of  Practical  Medicine. 

If  the  political  state  of  the  medical  profession  leads  to  the  deteriora- 
tion of  the  social  one,  so  does  the  latter  lead  to  the  greatest  confusion 
in,  and  distrust  of,  the  power  of  cure.  What,  indeed,  is  to  be  expected 
of  men  whose  highest  aim  and  boast  are  to  have  a large  practice  ? Are 
the  statements  of  their  wonderful  cures,  of  their  practical  knowledge, 
and  the  success  of  remedies  in  their  hands,  and  so  on,  to  be  trusted 
statements  which,  for  the  most  part,  so  far  from  promoting,  tend  only  to 
retard  and  obstruct  the  advancement  of  the  medical  art  ? On  the  other 
hand,  those  of  this  class  who  act  conscientiously  (and  many  such,  to  the 
honor  of  medicine,  exist)  are  too  busy  in  the  active  duties  of  their  call- 
ing, and  have  too  little  time  to  follow  the  rapid  progress  of  the  science. 
Hence,  what  they  have  acquired  by  long  experience  is  seldom  seen  by 


* Azygos  on  Medical  Reform,  London,  1853.  The  author  of  this  pamphlet  will 
see  that  I have  adopted  some  of  his  arguments  and  a little  of  his  phraseology. 


PRESENT  STATE  OF  PRACTICAL  MEDICINE. 


21 


them  to  harmonise  (though  truth  in  practice  always  must  in  the  end  har- 
monise) with  truth  in  theory. 

Although  twenty-four  years  have  elapsed  since  the  cell  doctrine  of 
growth  has  been  admitted  into  physiology  and  pathology,  medical  men 
have  not  yet  realised  to  themselves  its  vast  importance  in  a practical 
point  of  view.  The  morbid  processes  of  inflammation,  of  tuberculiza- 
tion, and  of  various  morbid  growths,  are  now  for  the  most  part  elucidated 
by  this  theory.  But  a cell  pathology  is  no  more  universally  applicable 
to  the  phenouiena  of  disease  than  is  humoralism  or  solidism.  Indeed, 
we  may  more  correctly  speak  of  a molecular  pathology,  for  a molecule, 
and  not  a cell,  is  the  first  and  last  form  of  organisation.  What,  however, 
it  is  important  to  remember  here  is,  that  if  there  be  a molecular  or  a cell 
physiology  and  pathology,  so  there  is  a molecular  and  a cell  therapeutics. 
For  it  is  evident  that  those  diseases  which  depend  on  an  increase  or  di- 
minution of  molecules  and  cells  can  only  be  reached  scientifically  through 
a knowledge  of  those  laws  which  govern  their  evolution  and  disinte- 
gration. 

Thus,  growth  (that  is,  the  multiplication  of  cells)  is  favored  by  in- 
creased warmth,  by  room  for  expansion,  and  by  moisture  ; and  it  is 
checked  by  cold,  by  pressure,  and  by  dryness.  If,  then,  an  exudation  be 
poured  out  and  coagulated  near  the  surf^ace,  as  it  can  only  disappear  by 
its  passing  through  the  stages  of  cell  growth,  we  favor  suppuration — that 
is,  the  growth  of  pus-cells — by  warm  poultices  or  fomentations,  and  re- 
tard it  by  cold  and  pressure. 

Pneumonia  consists  of  an  exudation  into  the  vesicles  and  tissues  of 
the  lung,  which  coagulates  and  excludes  the  air.  It  is  very  doubtful 
whether  a large  bleeding  from  the  arm  can  operate  upon  the  stagnant 
blood  in  the  inflamed  part,  or  the  congested  capillaries  in  its  neighbor- 
hood; that  it  can  directly  affect  the  coagulated  exudation  is  impossible. 
But  by  lowering  the  strength  and  vital  power  of  the  individual,  venesec- 
tion is  directly  opposed  to  the  necessary  vital  changes  which  the  exuda- 
tion must  undergo  in  order  to  be  removed  by  cell  growth  and  disintegra- 
tion. Hence  it  is,  in  my  opinion,  that  the  mortality  from  pneumonia  has 
diminished  since  large  bleedings  have  been  abandoned,  and  not  because, 
as  has  been  suggested  by  an  eminent  authority,  inflammations,  like  fevers, 
have  changed  their  types  since  the  days  of  Cullen  and  Gregory. 

The  absorption  of  a pleuritic  effusion  depends  on  the  formation  of 
new  blood-vessels  in  the  coagulated  exudation  which  is  adherent  to  the 
pleurae.  These  in  their  turn  are  the  results  of  cell  formation.  Such 
formation  so  far  from  being  encouraged,  can  only  be  retarded  or  pre- 
vented by  large  bleedings  and  antiphlogistics. 

The  growth  of  tumors  may  be  encouraged  or  retarded  by  the  same 
means  which  influence  all  other  kinds  of  cell  development.  But  if  they 
assume  a parasitic  character,  as  in  cancerous  growths — that  is,  if  the  cells 
possess  a power  of  multiplication  in  themselves — then  the  only  chance  of 
cure  is  in  their  complete  destruction  or  extirpation.  But  the  surgeon 
who  trusts  to  his  naked  sight,  forgets  that  germs  are  infiltrated  among 
the  surrounding  tissues,  and  are  so  minute  that  he  cannot  see  them ; yet 
he  employs  no  microscope  to  discover  them.  He  cuts  out  a tumor,  but 
only  cuts  through  the  disease.  Need  we  wonder,  therefore,  that  cancer 


22 


INTRODUCTION. 


should  frequently  return,  or  rather  continue  to  grow,  when  in  fact  it  had 
never  been  removed  ? 

Our  improved  knowledge  with  regard  to  parasites,  both  animal  and 
vegetable,  illustrates  the  flood  of  light  which  the  cultivation  of  natural 
science  has  thrown  upon  diseases,  the  pathology  of  which  was  formerly 
unknown.  It  has  now  been  shown  that  an  animal  may  live  as  a cystic 
worm  in  one  animal — say  a mouse,  and  as  a tapeworm  in  another — 
say  a cat ; and  that  to  prevent  the  appearance  of  the  last  parasite,  we 
must  not  allow  the  former  one  to  enter  the  digestive  organs  as  food. 
In  like  manner,  the  demonstration  that  favus,  pityriasis,  diphtheria, 
pyrosis,  and  other  disorders  are  connected  with  the  growth  of  vege- 
table organisms,  has  completely  revolutionised  the  treatment  of  those 
affections. 

The  beneficial  changes  which  have  taken  place  in  our  treatment  of 
apoplexy,  syphilis,  small  pox,  phthisis,  Bright’s  disease,  and  many  other 
diseases,  might  in  like  manner  be  shown  either  io  have  originated  from 
or  to  be  capable  of  being  satisfactorily  explained  by  an  advanced  know- 
ledge of  physiology. 

Again,  notwithstanding  the  universality  with  which  the  stethoscope 
and  auscultation  are  now  received  as  necessary  means  of  diagnosis,  how 
few  of  our  medical  men,  comparatively,  are  really  skilful  in  detecting  by 
them  the  morbid  changes  going  on  in  the  heart  and  lungs.  The  stetho- 
scope, indeed,  was  as  much  sneered  at  when  it  was  first  introduced  as 
was  the  microscope.  Physicians  existed  who  taught  that  a piece  of  stick 
was  not  likely  to  make  us  discern  what  was  going  on  in  the  lungs, 
and  who  cautioned  students  against  losing  their  time  in  learning 
auscultation,  just  as  some  now  do  in  reference  to  histology.  But  the 
philosophic  practitioner  must  see  the  necessity  of  using  every  means 
in  his  power  for  detecting  disease,  whether  stethoscopical,  microscopical, 
or  chemical. 

I cannot  too  strongly  advise  you  not  to  be  influenced  by  the  opinion 
of  those  who,  educated  before  these  means  of  research  came  into  general 
use,  speak  of  them  as  worthless,  especially  in  the  investigation  and  diag- 
nosis of  disease.  It  is  because  they  are  ignorant  of  their  value  that  they 
hold  them  out  as  of  little  benefit.  I need  scarcely  remark  that  this  kind 
of  reasoning  is  altogether  unsound,  and  is  directly  opposed  to  the  intro- 
duction of  all  improvement  in  either  science  or  art.  What  should 
we  think  of  a modern  astronomer  who  sneered  at  telescopes,  and  boasted 
that  it  was  enough  for  him  to  examine  the  heavens  with  his  naked  eye  ? 
or  how  should  we  like  to  trust  ourselves  at  sea  with  the  navigator  who, 
as  in  ancient  times,  steered  by  the  sun  and  stars,  and  who  abused  sextants 
and  other  instruments  by  which  alone  exact  calculations  can  be  made  of 
his  course  ? Such,  however,  is  precisely  what  those  medical  men  do  who 
underrate  stethoscopes  and  microscopes,  betraying  an  unacquaintance 
with  the  present  state  of  their  own  art. 

At  all  events,  in  this  Clinic,  you  will  find  that  we  seize  eagerly  on 
every  means  that  science  places  in  our  hands  for  detecting  the  true 
nature  of  disease;  that  percussion,  auscultation,  histology,  and  chemistry 
are  all  pressed  into  our  service ; that,  whilst  we  spare  no  pains  to  make 
ourselves  masters  of  observation,  cultivate  our  senses  to  the  utmost,  study 


PRESENT  STATE  OF  PRACTICAL  MEDICINE. 


23 


symptoms,  and  thus  endeavor  to  unite  the  knowledge  of  the  present  day 
with  the  experience  of  the  past  ; we  never  forget  that  the  Medical  Art 
is  founded  on  science,  the  only  guarantee  of  its  elevated  and  ennobling 
character,  and  the  only  secure  means  for  its  future  advancement. 

What,  then,  is  required,  in  the  present  condition  of  medicine,  is  an 
attempt  to  bring  our  advanced  knowledge  of  physiology  and  pathology 
to  bear  upon  the  treatment  of  disease,  and  by  renewed  observation,  with 
all  the  aids  which  modern  diagnosis  gives  us,  to  reinvestigate  the  action 
of  our  more  important  remedies.  In  so  doing,  we  should  not  neglect 
past  experience,  but  endeavor  to  make  the  truths  it  has  taught  us  har- 
monise with  scientific  laws. 

So  far  from  believing  in  the  propriety  of  a pure  expectant  system 
or  a “ Nihilismus,”  I am  convinced  that  experience  has  furnished  us 
with  some  most  precious  results.  No  one  can  doubt,  for  instance,  that 
quinine  cures  ague,  and  that  lemon-juice  cures  scurvy.  Why  they  do 
so  we  are  ignorant ; and  hence  those  remedies  are  given  empirically — 
that  is,  as  a result  of  blind  experience.  It  has  also  been  distinctly 
shown  that  sulphur  ointment  cures  scabies.  But  here,  I think,  false 
reasoning  has  stepped  in,  and  declared  sulphur  to  be  as  much  a specific 
for  scabies  as  quinine  is  for  ague.  But  scabies  depends  upon  the  presence 
of  insects  which  lay  their  eggs  in  the  skin ; and  the  greasy  matter  of 
the  ointment  is  brought,  by  means  of  friction,  into  contact  with,  and 
asphyxiates  them,  just  as  well  without  as  with  sulphur.  But  to  dis- 
cover these  insects,  and  to  determine  their  habits,  patient  and  long-con- 
tinued scientific  research  was  necessary,  and  practice  now  reaps  the  bene- 
fit of  it. 

It  is  true  that  the  contradictory  opinions  concerning  medical  doctrine 
and  practice  have,  in  all  times,  excited  the  ridicule  of  the  weak-minded, 
and  still  constitute  the  ground  on  which  Medicine  is  attacked  by  the 
ignorant  and  superficial.  Yet  the  differences  which  exist  no  more  prove 
that  there  is  no  foundation  for  Medicine  as  a science,  than  the  varieties 
of  religious  sects  show  that  there  is  no  truth  in  religion,  or  than  the 
opposing  dicisions  of  our  courts  of  law  prove  jurisprudence  to  be  a 
farce.  All  these  contradictions  depend  upon  imperfect  attempts  at  cor- 
rect theory ; and  this  latter  once  rendered  perfect,  it  will  be  seen  that 
both  health  and  disease  are  governed  by  laws  as  determinate  as  the 
motion  of  the  planets  and  the  currents  of  the  ocean. 

But  notwithstanding  the  discouragements  which  knowledge  has  re- 
ceived and  will  ever  suffer  from  the  indolent  or  narrow-minded,  at 
no  period  has  the  tendency  to  cultivate  scientific  medicine  been  more 
strongly  manifested  than  it  is  at  this  moment.  Everywhere  in  Europe 
do  we  observe  a noble  effort  to  enlarge  the  foundations  on  which  its 
practice  is  based.  Everywhere  we  see  Natural  Philosophy  advancing; 
enthusiastic  chemists  pushing  forward  organic  analyses ; anatomists 
unwearied  in  their  researches  concerning  development  and  the  structure 
of  tissues;  physiologists  experimenting  and  concentrating  all  the  re- 
sources of  modern  science  in  order  to  elucidate  organic  laws  ; and  patho- 
logists busy  in  connecting  the  symptoms  observed  in  the  living,  with 
alterations  in  the  minutest  tissues  and  atoms  of  the  dead.  At  this  time 
Medicine  is  undergoing  a great  revolution,  and  to  you  gentlemen,  to  the 


24 


INTRODUCTION. 


rising  goneration,  do  we  look  as  to  the  agents  who  will  accomplish  it. 
Amidst  the  wreck  of  ancient  systems,  and  the  approaching  downfall  of 
empirical  practice,  you  will,  I trust,  adhere  to  that  plan  of  medical 
education  which  is  based  on  Anatomy  and  Physiology.  If  you  resolve 
to  follow  in  the  legitimate  path  of  improvement  to  which  all  reason  and 
experience  invite  you,  be  assured  that  the  toil  of  mastering  what  is  no»w 
known  of  correct  generalization  will  not  be  in  vain.  Everything  pro- 
mises that  before  long  a law  of  true  harmony  will  be  formed  out  of  the 
discordant  materials  which  surround  us  ; and  if  we^  your  predecessors, 
have  failed,  to  you^  I trust,  will  belong  the  honor  of  building  up  a 
system  of  Medicine  which,  from  its  consistency,  simplicity,  and  truth, 
may,  at  the  same  time,  attract  the  confidence  of  the  public,  and  command 
the  respect  of  the  scientific  world. 


SECTION  I 


EXAMINATION  OF  THE  PATIENT. 

It  is  absolutely  necessary  that  an  examination  of  patients  at  the  bed-side 
should  be  conducted  with  order,  and  according  to  a well-understood  plan. 

I have  observed  that  some  students,  on  being  called  upon,  in  their  turn, 
to  interrogate  a case,  feel  great  embarrassment,  and  are  unable  to  proceed. 
Others  put  their  questions,  as  it  were,  at  random  without  any  apparent 
object,  and  wander  from  one  system  of  the  economy  to  another,  vainly 
searching  for  a precise  diagnosis,  and  a rational  indication  of  cure.  But 
continual  practice,  and  the  adoption  of  a certain  method,  will  remove  all 
difficulty.  No  doubt,  questioning  a patient,  to  arrive  at  a knowledge  of 
his  condition,  requires  as  much  skill  in  the  medical  practitioner,  as  ex- 
amining a witness  does  in  counsel  at  the  bar.  They  make  it  an  especial 
study,  and  you  must  do  so  likewise.  You  should  remember  that,  in 
proportion  as  this  duty  is  performed  well  or  ill,  is  the  probability  of  your 
opinion  of  the  case  being  correct  or  incorrect ; and  not  only  will  the  re- 
putation you  hold  among  your  colleagues  greatly  depend  on  your  ability 
in  this  matter,  but  the  public  also  will  promptly  give  its  confidence  to 
him  whose  interrogations  reveal  sagacity  and  talent. 

The  method  of  examination  difters  greatly  among  practitioners,  and 
must  necessarily  vary  in  particular  cases.  Men  of  experience  gradually 
form  a certain  plan  of  their  own,  which  enables  them  to  arrive  at  their 
object  more  rapidly  and  securely  than  that  adopted,  with  perhaps  an 
equally  good  result,  by  others.  In  a clinical  class,  however,  and  in  order 
that  every  one  present  may  follow  and  understand  what  is  going  forward, 
the  method  adopted  must  be  uniform.  I hold  it  to  be  a matter  of  great 
importance,  that  every  one  standing  round  the  bed  should  take  an  equal 
interest  in  what  is  proceeding,  and  this  he  cannot  do  unless  he  is  fully 
aware  of  the  manner  and  object  of  the  examination.  The  plan  which 
appears  to  me  the  best,  and  which  we  shall  follow,  is  the  one  I learnt 
when  myself  a clinical  student  in  the  wards  of  Professor  Rostan  of  Paris. 
Its  object  is  to  arrive,  as  quickly  as  possible,  at  a knowledge  of  the  ex- 
isting condition  of  the  patient,  in  a way  that  will  insure  the  examiner 
that  no  important  organ  has  been  overlooked  or  has  escaped  notice. 

For  this  purpose,  we  search  out,  in  the  first  instance,  the  organ 
principally  affected,  and  ascertain  the  duration  of  the  disease,  by  asking 
two  questions,  “ Where  do  you  feel  pain  ? ” and,  “ How  long  have  you 
been  ill  ? ” Let  us  suppose  that  the  patient  feels  pain  in  the  cardiac  region^ 


26 


EXAMIN'ATION  OF  THE  PATIENT. 


we  immediately  proceed  to  examine  the  heart  functionally  and  physically, 
and  then  the  circulatory  system  generally.  We  next  proceed  to  those 
organs  which  usually  bear  the  nearest  relation  to  the  one  principally 
affected — say,  the  respiratory  organs — and  we  then  examine  the  lungs 
functionally  and  physically.  We  subsequently  interrogate  the  nervous, 
digestive,  geuito-urinary,  and  integumentary  systems.  It  is  a matter  of 
little  importance  in  what  order  these  are  examined — the  chief  point  is, 
not  to  neglect  any  of  them.  Lastly  we  inquire  into  the  past  history  of 
the  case,  and  thus  we  arrive  at  all  the  information  necessary  for  the  for- 
mation of  a diagnosis. 

The  following  is  the  arrangement  of  symptoms  and  circumstances 
demanding  attention  under  each  of  the  seven  heads  into  which  the  ex- 
amination is  divided ; — 

I.  Circulatory  System — Heart. — Uneasiness  or  pain;  its  action 
and  rhythm ; situation  where  the  apex  beats ; extent  of  dulness  deter- 
mined by  percussion ; its  impulse  ; murmurs — if  abnormal,  their  character, 
and  the  position  and  direction  in  which  they  are  heard  loudest.  Arterial 
pulse — Number  of  beats  in  a minute;  large  or  small,  strong  or  feeble, 
hard  or  soft,  equal  or  unequal,  regular  or  irregular,  intermittent,  con- 
fused, imperceptible,  etc.  If  an  aneurismal  swelling  exist,  its  situation, 
pulsations,  symptoms,  extent,  and  sounds,  must  be  carefully  examined. 
Venous  pulse — If  perceptible,  observe  position,  force,  etc. 

II.  Respiratory  System. — Hares. — Discharges;  sneezing.  Larynx 

and  Trachea — Voice,  natural  or  altered  in  quality,  hoarse,  difficulty  of 
speech,  aphonia,  etc. ; if  affected,  observe  condition  of  epiglottis,  tonsils, 
and  pharynx,  by  means  of  a spatula.  Lungs — State  of  respiration ; 

easy  or  difficult,  quick  or  slow,  equal  or  unequal,  labored,  painful, 
spasmodic,  dyspnoea,  etc. ; odor  of  breath.  Expectoration,  trifling  or 
profuse,  easy  or  difficult ; its  character,  thin  or  inspissated,  frothy, 
mucous,  purulent  or  muco-purulent,  rusty,  bloody  ; microscopical  exami- 
nation. Haemoptysis,  color,  appearance,  and  amount  of  blood  discharged. 
Cough,  rare  or  frequent,  short  or  long,  painful  or  not,  moist  or  dry. 
External  form  of  the  chest,  unusually  rounded  or  flattened,  symmetrical 
or  not,  etc.  Movements — regular,  equal,  their  amount,  etc.  Resonance, 
as  determined  by  percussion,  increased  or  diminished,  dulness,  cracked- 
pot  sound,  etc.  Sounds  determined  by  auscultation,  if  abnormal,  their 
character  and  position. 

III.  Nervous  System. — Brain  — Intelligence — augmented,  per- 
verted, or  diminished  ; cephalalgia  ; hallucinations  ; delirium,  stupidity, 
monomania,  idiocy ; sleep,  dreams,  vertigo,  stupor,  coma.  Spinal  cord 
and  nerves — Pain  in  back  ; general  sensibility,  increased,  diminished,  or 
absent;  special  sensibility — sight,  hearing,  smell,  taste,  touch,  their 
increase,  perversion,  or  diminution  ; spinal  irritation,  as  determined  by 
percussion ; motion,  natural  or  perverted,  fatigue,  pain  on  movement, 
gait;  trembling,  convulsions,  contractions,  rigidity,  paralysis. 

IV.  Digestive  System. — Mouth — Lips,  teeth,  and  gums;  taste  in  the 
mouth,  saliva.  Tongue — Mode  of  protrusion,  color,  furred,  coated,  fissured, 


EXAMINATION  OF  THE  PATIENT. 


27 


condition  of  papilloo,  moist  or  dry.  Fauces^  ionsils^  pharynx^  and  oRsopha- 
gus — Deglutition — if  impeded,  examine  the  pharynx  with  a spatula  ; the 
cervical  glands,  neck,  etc.  ; regurgitation.  — Appetite,  thirst, 

epigastric  uneasiness  or  pain,  swelling,  nausea,  vomiting,  character  of 
matters  vomited,  flatulence,  eructations.  Abdomen— measurement  and 
palpation ; pain,  distension  or  collapse,  borborygmi,  tumors,  constipation, 
diarrhoea,  character  of  dejections,  haemorrhoids.  Liver — Size,  as  determin- 
ed by  percussion,  pain,  jaundice,  results  of  palpation,  etc.  Spleen — Size, 
as  determined  by  percussion.  If  enlarged,  examine  blood  microscopically. 

V.  Genito-Urinary  System. — Uterus — Condition  of  menstrual  dis- 
charge, amenorrhoea,  dysmenorrhoea,  menorrhagia,  leucorrhoea,  etc.  If 
there  be  long-continued  pain,  or  much  leucorrhoeal  discharge,  examine  os 
and  cervix  uteri  with  the  finger,  and,  if  necessary,  with  the  speculum ; 
uterine  or  ovarian  tumors ; pain  in  back  ; difficulty  in  walking,  or  in 
defoecation ; functions  of  mammae.  Kidney — Lumbar  pain  ; micturition ; 
quantity  and  quality  of  urine,  color,  specific  gravity ; tube  casts  and 
precipitates,  as  determined  by  the  microscope,  and  by  chemical  tests;  ac- 
tion of  heat;  nitric  acid,  etc.;  action  on  test  papers  ; stricture;  discharges 
from  urethra;  spermatorrhoea;  etc.  (See  use  of  Chemical  Tests.) 

VI.  Integumentary  System. — General  posture;  external  surface; 
color  ; expression  of  countenance  ; hue  of  lips  ; obesity  ; emaciation  ; 
rough  or  smooth ; dry  or  moist ; perspiration ; marks  or  cicatrices ; 
eruptions  (see  diagnosis  of  skin  diseases)  ; temperature  ; morbid  growths 
or  swelling;  anasarca;  oedema;  emphysema,  etc. 

VII.  Antecedent  History. — Age;  parentage;  constitution;  here- 
ditary disposition;  trade  or  profession;  place  of  residence;  mode  of 
living  as  regards  food  and  drink;  habits;  epidemics  and  endemics; 
contagion  and  infection ; exposure  to  heat,  cold,  or  moisture  ; kind  of 
lodging,  drainage,  water,  smells,  etc. ; irregularities  in  diet ; excesses  of 
any  kind;  fatigue  ; commencement  and  progress  of  the  disease;  date  of 
rigor  or  seizure  ; mode  of  invasion  ; previous  treatment ; in  female  cases 
whether  married  or  single — have  had  children  and  miscarriages — pre- 
vious diseases,  etc. 

Such  are  the  principal  points  to  which  your  attention  should  be 
directed  during  the  examination  of  a case.  A little  practice  will  soon 
impress  them  on  your  memory,  and  in  this  manner  habit  will  insure  you 
that  no  very  important  circumstance  has  been  overlooked.  At  first,  in- 
deed, it  may  appear  to  you  that  such  a minute  examination  is  unneces- 
sary ; but  we  shall  have  abundant  opportunities  of  proving  that,  whilst 
a little  extra  trouble  never  does  harm,  ignorance  of  a fact  frequently 
leads  to  error.  It  is  surprising,  also,  how  rapidly  one  thoroughly  con- 
versant with  the  plan,  is  able  to  examine  a patient  so  as  to  satisfy  him- 
self that  all  the  organs  and  functions  have  been  carefully  interrogated. 
Remember  that  the  importance  of  particular  s3^mptoms  is  not  known  to 
the  patient,  and  that,  consequently,  it  is  not  in  his  power  voluntarily  to 
inform  you  of  the  necessary  particulars.  It  is  always  your  duty  to  dis- 
cover them. 


28 


EXAMINATION  OF  THE  PATIENT. 


In  carrying  out  the  examination,  the  following  hints  may  be  attended  to ; 

1.  It  should  never  be  forgotten  that  you  are  examining  a fellow- 
creature  who  possesses  the  same  sensitiveness  to  pain,  and  the  same 
feelings  that  you  do,  and  that  everything  that  can  increase  the  one  and 
wound  the  other  should  be  most  carefully  avoided.  Prudence,  kindness, 
and  delicacy,  are  especially  enjoined  upon  those  who  treat  the  sick,  and 
no  levity  ought  to  be  tolerated  among  those  who  are  determining  the 
value  and  duration  of  life. 

2.  The  questions  should  be  precise,  simple,  and  readily  compre- 
hended. When  an  individual  has  a limited  intelligence,  or  is  accus- 
tomed to  a particular  dialect,  you  will  not  arrive  at  your  object  by 
becoming  impatient,  or  talking  in  a loud  voice,  but  by  putting  your 
interrogations  in  a clear  manner,  and  in  language  proportioned  to  the 
intelligence  of  the  individual. 

3.  It  is  often  necessary,  after  asking  the  first  question,  “ Where  do 
you  feel  pain  ? ” to  tell  the  patient  to  put  his  or  her  hand  on  the  part.  An 
Irish  peasant  applies  the  term  “ heart  ” to  an  indefinite  region,  extending 
over  great  part  of  the  chest  and  abdomen ; and  a woman,  in  speaking  of 
pain  in  the  stomach,  often  means  the  lower  part  of  the  abdomen. 

4.  When  pain  is  referred  to  any  circumscribed  part  of  the  surface, 
the  place  should  always  be  examined  by  palpation,  and,  if  possible,  seen. 
Eostan  relates  very  instructive  cases  where  the  omission  of  one  or  the 
other  of  these  rules  has  led  to  curious  errors  in  diagnosis. 

5.  Although  the  question,  “ How  long  have  you  been  ill  ? ” is 
sufiiciently  plain,  it  is  often  difficult  to  determine  the  period  of  com- 
mencement of  many  diseases.  In  acute  inflammatory  or  febrile  disorders, 
we  generally  count  from  the  first  rigor.  In  chronic  affections,  a length- 
ened cross-examination  is  frequently  necessary  to  arrive  at  the  truth. 

6.  A state  of  fever  may  be  said  to  exist  when  we  find  the  pulse 
accelerated,  the  skin  hot,  the  tongue  furred,  unusual  thirst,  and  headache. 
These  symptoms  are  commonly  preceded  by  a period  of  indisposition, 
varying  in  duration,  and  ushered  in  by  a rigor  or  sensation  of  cold. 
Such  a febrile  state  may  be  idiopathic,  when  the  case  is  called  one  of 
fever,  or  symptomatic  of  some  local  disease,  when  the  nature  of  the  case 
is  determined  by  the  organ  affected  and  lesion  present. 

7.  During  the  physical  examination  of  a case,  the  temperature  of  the 
apartment  should  be  considered,  and  the  doors  and  windows  shut,  so 
that  the  patient  be  guarded  against  cold.  For  the  same  reason  exposure 
of  the  surface  should  not  be  continued  longer  than  is  necessary.  Silence 
must  be  maintained  not  only  amongst  those  who  surround  the  bed,  but 
generally  throughout  the  ward.  When  the  patient  is  weak  the  physical 
examination  should  be  shortened,  or  altogether  suspended. 

8.  In  endeavoring  to  ascertain  the  cause  of  the  disease,  great  tact 
and  skill  in  examination  are  necessary.  We  must  guard  ourselves 
against  the  preconceived  views  of  the  patient  on  the  one  hand,  and  be 
alive  to  the  possibility  of  imposition  on  the  other.  Sometimes,  with  all 
our  endeavors,  no  appreciable  cause  can  be  discovered ; and  at  others 
we  find  a variety  of  circumstances,  any  one  of  which  would  be  sufficient 
to  occasion  the  malady. 

9.  In  forming  our  diagnosis — that  is,  in  framing  a theory  deduced 


EXAMINATION  OF  THE  PATIENT. 


29 


from  tbe  facts  elicited  by  examination — we  should  be  guided  by  all  the 
circumstances  of  the  case,  and  be  very  careful  that  these  are  fully  known 
before  we  hazard  an  opinion.  Even  then  it  is  not  always  possible  to 
come  to  a satisfactory  conclusion,  and  in  such  cases  the  diagnosis  should 
be  deferred  until  further  observation  has  thrown  new  light  upon  the 
nature  of  the  disease. 

10.  In  recording  a case,  it  is,  for  the  most  part,  only  necessary  to 
put  down,  under  each  head,  the  symptoms  or  signs  present.  If  any 
system  be  quite  healthy,  it  should  be  said  that  it  is  normal.  In  many 
cases,  however,  it  is  necessary  to  state  what  are  called  negative  symptoms. 
This  demands  great  tact,  and  exhibits  a high  degree  of  medical  informa- 
tion. For  instance,  an  attack  of  epilepsy  generally  commences  with  a 
cry  or  scream ; but  sometimes  there  is  none — when  this  should  be 
stated.  Again,  no  expectoration  is  a rare  negative  symptom  in  pneu- 
monia. Symptoms  which  are  usually  present  in  the  disease,  but  are 
absent  in  the  particular  case,  constitute  negative  symptoms. 

11.  All  mention  of  size  should  be  according  to  its  exact  measurement 
in  feet  and  inches.  Situation  is  often  referred  to  certain  regions,  into 
which  the  surface  has  been  arbitrarily  divided,  such  as  subscapular, 
cardiac,  epigastric,  etc.,  but  it  is  always  better  to  refer  at  once  to  anato- 
mical parts,  such  as  the  clavicle,  particular  rib,  nipple,  umbilicus,  angle 
of  scapula,  and  so  on.  Extent  should  also  be  determined  by  proximity 
to  well-known  fixed  points.  All  vague  statements,  such  as  large,  great, 
small,  little,  etc.,  should  be  carefully  avoided.  It  is  useless  to  speak  of  the 
pulse  or  of  the  respiration  as  being  quick  or  slow,  whereas  by  saying  that 
the  first  is  60  or  120,  and  the  second  12  or  40  in  the  minute,  a correct 
statement  is  given  at  once.  In  recording  cases,  dates  and  references 
should  always  be  stated  in  the  day  of  the  month,  or  still  better,  of  the 
disease,  and  not  in  the  day  of  the  week.  The  authority  formgny  statements 
should  be  given  ; such  as,  the  patient,  the  nurse,  or  the  friends,  say,  etc. 

12.  In  conversing  on,  or  discussing,  the  circumstances  of  the  case  at 
the  bed-side,  we  should  always  use  technical  language.  Thus  instead  of 
saying  a man  has  a cavern  at  the  top  of  the  lung,  we  should  speak  of  a 
vomica  under  the  clavicle ; instead  of  saying  a man  has  a diseased 
heart  we  should  speak  of  cardiac  hypertrophy,  or  of  insufiiciency  of  the 
mitral  or  aortic  valves,  etc.  In  a witness-box,  before  a jury,  it  is  right 
to  use  the  common  familiar  names  of  things,  and  instead  of  cranium  to 
say  skull,  instead  of  axilla  to  say  arm-pit,  instead  of  abdomen  to  say 
belly,  etc.  There,  the  object  is  to  instruct  the  uneducated  ; here,  the 
educated  in  medicine,  while,  at  the  same  time,  we  avoid  alarming  or 
causing  anxiety  to  the  patient. 

13.  In  prescribing  for  the  patient,  many  circumstances  should  be 
taken  into  consideration,  such  as,  the  probable  time  of  your  next  visit, 
the  form  in  which  medicine  is  most  easily  taken  by  the  patient,  his 
means,  etc.  The  prescription  should  be  written  in  Latin,  and  the 
quantities  denoted  by  the  usual  pharmaceutical  signs,  but  the  directions 
for  administration  should  be  written  in  English. 

Having  formed  a diagnosis,  and  prescribed  for  the  patient,  the 
further  examination  should  be  conducted  at  intervals,  varying,  as  regards 
time,  according  to  the  gravity  of  the  case.  In  addition  to  the  changes 


30 


EXAMIiJ^ATION  OF  THE  PATIENT. 


which  may  occur  in  the  signs  and  symptoms  previously  noticed,  the 
effect  of  remedies  should  be  carefully  inquired  into,  and  care  taken  to 
ascertain  whether  the  medicine  and  diet  ordered  have  been  administered. 
If  the  case  prove  fatal  the  symptoms  ushering  in  death,  and  the  manner 
in  which  it  occurs,  should  be  especially  observed.  Whenever  a record 
of  the  case  is  to  be  kept,  I cannot  too  strongly  impress  upon  you  the 
importance  of  noting  these  down  in  a book  at  the  time,  rather  than 
trusting  to  the  memory.*  For  a long  series  of  years  the  reports  of 
cases,  dictated  aloud  by  the  professor,  and  written  down  at  the  bed-side 
by  the  clerk,  has  formed  a leading  feature  of  the  Edinburgh  system  of 
clinical  instruction,  and  constitutes  the  only  trustworthy  method  of 
drawing  up  cases  with  accuracy. 

When  a patient  dies,  the  examination  is  not  completed.  The  time 
has  now  arrived  when  an  inspection  of  the  dead  body  confirms  or  nulli- 
fies the  diagnosis  of  the  observer.  You  should  consider  this  as  a most 
important  part  of  the  clinical  course.  It  is  invariably  regarded  with 
the  greatest  interest  by  those  who  practise  their  profession  with  skill. 
It  is  only  in  this  manner  that  any  errors  they  may  have  committed  can 
be  corrected ; that  the  value  of  physical  diagnosis  can  be  demonstrated 
and  properly  appreciated,  and  the  true  nature  or  pathology  of  diseases, 
and  the  mode  of  treating  them  rationally,  can  ever  be  discovered. 

But  here,  again,  method  and  order  are  as  necessary  in  the  examina- 
tion of  the  dead  as  of  the  living,  and  it  is  of  equal  importance  that  no 
viscus  be  overlooked.  The  three  great  cavities  should  always  be  inves- 
tigated. Nothing  is  more  injurious  to  the  scientific  progress  of  medicine 
than  the  habit  of  inspecting  only  one  of  them,  to  satisfy  the  curiosity 
of  the  practitioner  or  to  determine  his  doubts  on  this  or  that  point. 
Many  medical  m.n  direct  their  attention  to  a certain  class  of  diseases, 
and  are  apt  to  attribute  too  much  importance  to  a particular  lesion. 
It  has  frequently  happened  to  me,  when  pathologist  to  the  Boyal 
Infirmary,  to  observe,  that  after  the  physician  has  examined  this  or  that 
organ,  to  which  he  has  attributed  the  death  of  his  patient,  and  left  the 
theatre,  that  after  examination,  according  to  the  routine  I always  practised, 
has  revealed  important  lesions  that  were  never  suspected.  Thus  a person 
supposed  to  die  of  Bright’s  disease  of  the  kidney,  may  have  a pneumonia 
that  was  latent  and  overlooked.  Large  caverns  and  tubercular  deposits 
in  the  lungs  may  satisfy  the  physician,  and  he  may  leave  the  body  when 
intense  peritonitis  may  be  subsequently  found,  arising  from  intestinal 
perforation.  A man  has  hypertrophy,  with  valvular  disease  of  the  heart; 
he  dies  suddenly,  and  everything  is  referred  to  the  cardiac  lesion.  On 
opening  the  head,  an  apoplectic  extravasation  or  yellow  softening  may  be 
discovered.  I cannot  too  strongly,  therefore,  impress  upon  you  the  ne- 
cessity of  always  making  a thorough  post-mortem  examination,  and  for 
this  purpose  you  should,  if  possible,  obtain  permission  to  inspect  the 
body  and  not  any  particular  cavity. 

The  object  of  a post-mortem  examination  is  threefold  : — 1st,  The 

* I have  arranged  a note-book  for  taking  cases,  according  to  the  system  of  exami- 
nation here  recommended,  which  may  be  procured  of  Mr.  Thin,  medical  book-seller, 
close  to  the  Infirmary. 


EXA.MINATION  OF  THE  PATIENT. 


31 


cause  of  deatli ; 2d,  An  appreciation  of  the  signs  and  symptoms;  3d,  The 
nature  of  the  disease.  These  inquiries  are  very  distinct,  but  practitioners 
generally  have  only  in  view  the  two  first.  It  frequently  happens  that, 
on  the  discovery  of  a lesion  that  seems  to  explain  the  fatal  termination, 
they  feel  satisfied,  and  there  is  an  end  to  the  investigation.  In  medico- 
legal cases,  this  is  the  only  object  But  even  here  it  is  necessary  to 
examine  all  the  organs,  to  avoid  a possibility  of  error,  for  how  can  any 
conscientious  man  form  an  opinion,  that  an  abdominal  disease  has  been 
fatal,  if  he  be  not  satisfied  by  inspection  that  the  chest  and  brain  are 
healthy  ? Again,  it  often  occurs  that  a particular  sign  or  symptom  is 
unusual  or  mysterious,  and  this,  if  explained  by  the  examination,  is 
sufficient  for  the  practitioner.  But  it  must  be  obvious,  that  this  throws 
no  light  upon  the  nature  of  the  disease,  or  its  mode  of  cure.  To  do  this, 
morbid  changes  must  be  sought  for,  not  in  that  advanced  stage  where 
they  cause  death,  or  occasion  prominent  symptoms,  but  at  the  very 
earliest  period  that  can  be  detected.  Hence  we  must  call  in  the  micro- 
scope to  our  assistance,  and  with  its  aid  follow  the  lesion  into  the  ultimate 
tissue  of  organs;  we  must  observe  the  circumstances  which  produced  it, 
as  well  as  the  symptoms  and  physical  signs  to  which  it  gives  rise ; the 
secondary  disorders,  and  the  order  of  their  sequence ; their  duration  and 
mode  of  termination.  This  is  the  kind  of  extended  investigation  which 
can  alone  be  serviceable  to  the  advancement  of  medicine,  and  such,  I 
trust,  will  be  the  object  you  will  have  in  view  in  examining  dead  bodies. 
At  all  events,  such  are  the  views  that  I shall  constantly  endeavor  to 
place  before  you  during  this  course  of  clinical  instruction. 

The  following  is  an  arrangement  of  the  organs,  textures,  etc.,  which 
demand  your  attention  : — • 

I.  External  Appearances. — Number  of  hours  after  death.  General 
aspect  and  condition  of  the  body;  peculiarities  of  person;  marks  on  the 
surface ; sugillation ; amount  of  decomposition.  In  cases  of  suspected 
death  by  violence,  great  minuteness  in  the  external  examination  is  neces- 
sary. In  unrecognised  bodies  the  probable  age,  the  color  of  the  hair,  and 
any  peculiarity  connected  with  the  teeth,  should  be  especially  noticed. 

II.  Head. — Scalp;  calvaria;  meninges;  sinuses;  choroid  plexus; 
brain,  its  form  and  weight;  cerebellum,  its  weight;  cortical  and  medul- 
lary substance  of  brain ; ventricles,  exact  quantity  of  fluid  in  each,  which 
should  be  removed  with  a pipette — its  character;  medulla  oblongata; 
nerves,  and  arteries  at  the  base  of  the  brain  ; base  of  cranium  ; sinuses. 

III.  Spinal  Column. — Integuments  over  spine  ; vertebrae ; men- 
inges; cord;  nerves. 

IV.  Neck. — Thyroid  gland;  larynx  and  its  appendages ; trachma; 
tongue;  tonsils;  fauces;  pharynx;  oesophagus;  large  blood-vessels; 
nervous  trunks ; cervical  vertebrae. 

V.  Chest. — Thymus  gland  ; position  of  thoracic  viscera ; lining 
membrane  of  bronchi;  bronchial  glands;  pleurae;  contents  of  pleural 
cavity;  parenchyma  of  lungs;  do  diseased  portions  sink  in  water? 
large  thoracic  veins;  pericardium,  its  contents;  general  aspect  and  posi- 
tion of  the  heart;  its  weight;  amount  and  condition  of  blood  in  its 
various  cavities ; right  auricle ; coronary  veins ; auricular  septum ; right 


32 


EXAMINATION  OF  THE  PATIENT. 


ventricle;  size  of  its  cavity;  thickness  and  degree  of  firmness  of  its 
walls ; endocardium ; tricuspid  valve ; pulmonary  artery,  its  calibre  ; 
pulmonary  veins ; left  auricle ; mitral  valve ; left  ventricle ; thickness 
and  condition  of  its  muscular  tissue;  size  of  its  cavity;  sigmoid  valves; 
coronary  arteries ; aortic  opening  and  arch ; thoracic  aorta,  its  structure 
and  calibre. 

VI.  Abdomen. — Peritoneum  and  peritoneal  cavity;  omentum; 
position  of  abdominal  viscera  ; omenta  ; stomach  ; duodenum ; small 
and  large  intestines ; liver,  its  weight,  form,  and  structure — its  artery 
veins,  and  ducts;  gall  bladder  and  its  contents;  portal  system; 
pancreas  and  its  duct ; mesenteric  and  other  absorbent  glands ; spleen, 
its  weight,  size,  and  structure ; supra-renal  capsules ; kidneys,  weight  of 
each;  secreting  and  excreting  portions ; pelvis;  ureters;  bladder;  with 
the  prostate  and  urethra  in  the  male ; in  the  female,  uterus,  ovaries, 
Fallopian  tubes,  vagina;  abdominal  aorta  and  vena  cava;  large 
abdominal  arteries  and  veins ; ganglia  of  the  sympathetic  system. 

VII.  Blood. — Appearance  in  the  cavities  of  the  heart,  in  aorta,  vena 
cava,  vena  portae,  etc. ; congulated  and  fluid  portions — adhesion  or  not 
of  the  former. 

VIII.  Microscopic  Examination  of  all  the  morbid  structures  and 
fluids,  the  blood,  etc.  etc. 

In  carrying  out  the  post-mortem  examination,  the  following  hints 
may  be  attended  to  : 

1.  As  I have  already  said,  the  head,  chest,  and  abdomen  should 
always  be  examined,  but  the  spinal  cord  and  neck  need  not  be  disturbed 
unless  the  symptoms  indicate  some  lesion  there.  In  special  cases,  par- 
ticularly judicial  ones,  however,  every  part  should  be  carefully  inspected, 
and  in  them  it  may  be  further  necessary  to  investigate  a variety  of  cir- 
cumstances connected  with  the  external  or  surgical  lesion,  such  as  frac- 
tures, wounds,  and  burns;  injury  to  the  large  vessels;  alterations  of  the 
organs  of  sense ; signs  of  maturity  and  viability  in  new-born  children, 
etc.  etc. 

2.  Great  care  should  be  taken  never  to  disfigure  the  body.  Incisions 
through  the  skin,  therefore,  should  be  made  in  such  directions  that  when 
the  edges  are  afterwards  sewn  together,  the  necessary  dissections  below 
may  not  be  visible.  Neither  should  the  body  be  exposed  more  than  is 
needful,  and  delicacy  demands  that  the  genitals  should  always  be  kept 
covered.  The  wishes  and  feelings  of  friends  and  relations  should  invari- 
ably be  held  in  consideration. 

3.  Before  removing  the  stomach,  or  any  portion  of  the  intestines,  a 
ligature  should  be  placed  above  and  below  the  tube,  which  should  after- 
wards be  opened  with  the  greatest  care,  and  the  character  of  the  contents, 
whether  gaseous,  fluid,  mucous,  bloody,  faecal,  or  containing  foreign 
substances,  observed  before  washing  and  inspecting  the  mucous  surface. 
This  rule  should  be  especially  followed  in  all  medico-legal  investigations, 
in  which,  from  neglect  of  it,  the  ends  of  justice  have  been  frequently 
defeated. 

4.  You  should  seize  every  opportunity  of  opening  dead  bodies  with 
your  own  hands,  and  acquiring  dexterity  in  exposing  the  cavities,  taking 


EXAMINATION  OF  THE  PATIENT. 


33 


out  the  viscera,  etc.  Nothing  is  more  painful  than  to  see  the  brain  cut 
into  or  contused,  in  removing  the  calvarium ; or  the  large  vessels  at  the 
root  of  the  neck  wounded  in  disarticulating  the  sternum,  so  that  the 
surrounding  parts  are  deluged  with  blood ; or  the  cardiac  valves  cut 
through,  instead  of  being  simply  exposed ; or  awkward  incisions  made 
into  the  intestines,  whereby  faeces  escape ; slipping  of  ligatures,  etc.  etc. 
Coolness,  method,  knowledge  of  anatomy,  and  skilfulness  in  dissection, 
are  as  necessary  when  operating  on  the  dead  as  on  the  living  body. 

5.  In  examinations  made  at  private  houses,  it  is  not  always  necessary 
to  remove  the  viscera.  The  heart,  lungs,  liver,  kidneys,  etc.,  may  be 
readily  examined  in  situ.  But  in  this  Infirmary,  where  every  facility 
exists,  the  viscera  are  invariably  taken  out,  and  after  describing  the  morbid 
alterations  they  present,  I shall  always  pass  them  round,  so  that  every 
one  present  may  examine  them. 

6.  It  is  a good  rule  never  to  omit  the  examination  of  a morbid 
texture  or  product  microscopically,  until  experience  has  made  you 
perfectly  familiar  with  its  minute  structure. 

7.  Notes  of  the  examination  should  always  be  made  at  the  time. 
The  methodical  report  may  be  drawn  up  afterwards.  If  organs  are- 
healthy,  this  should  be  distinctly  stated,  so  that  hereafter  all  doubt  as  to 
their  having  been  carefully  examined  may  be  removed.  Here  negative 
appearances  are  often  of  as  much  consequence  as  negative  symptoms. 

8.  In  describing  morbid  appearances,  we  should  be  careful  to  state 
the  physical  properties  of  an  organ  or  texture,  such  as  the  size,  form, 
weight,  density,  color,  odor,  position,  etc. ; and  avoid  all  theoretical 
language,  such  as  its  being  inflamed,  tubercular,  cancerous,  gangrenous, 
and  the  like,  as  well  as  such  indefinite  description  as  small  and  large, 
narrow  and  wide,  increased  or  diminished,  etc.  etc. ; size  should  always 
be  stated  in  feet  and  inches,  and  the  amount  of  fluid  in  quarts,  pints, 
or  ounces. 

9.  The  amount  of  care  and  time  bestowed  on  the  examination  of  an 
individual  body  will  vary  according  to  circumstances.  In  some  cases  it 
may  require  continued  investigation,  involving  microscopical  and  chemical 
research  for  several  days.  I have  never  heard  of  a student  regretting  the 
employment  of  too  much  care  in  post-mortem  investigation,  although  the 
occurrence  of  omissions  from  carelessness  and  unacquaintance  with  morbid 
anatomy  are  unfortunately  too  often  exhibited  by  medical  men  in  courts 
of  justice,  to  the  detriment  of  our  profession  in  the  eyes  of  the  public, 
and  not  unfrequently  to  the  perversion  or  suppression  of  justice.'^ 

For  the  correct  examination  of  the  patient  in  the  manner  described, 
it  will  be  found  necessary  to  possess  an  accurate  knowledge  of  the  relative 
position  of  the  various  internal  organs.  This  subject  is  not  placed  so 
carefully  before  the  student  as  it  deserves — a circumstance  which  may 
probably  be  attributed  to  the  fact,  that  anatomy  is  for  the  most  part 
taught  by  surgeons.  But  now  that  physical  diagnosis  constitutes  so 
necessary  a part  of  medical  education,  topographical,  as  distinguished  from 

*For  an  excellent  guide  to  the  examination  of  the  dead  body,  I would  recommend 
the  practitioner  and  student  to  a work  entitled,  “ What  to  Observe,”  published 
under  the  authority  of  the  London  Medical  Society  of  Observation. 

3 


34 


EXAMINATION  OF  THE  PATIENT. 


surgical  anatomy,  is  every  day  felt  to  be  more  necessary.  I would 
earnestly  therefore  recommend  the  student  of  Clinical  Medicine  to  study 
the  excellent  work  of  Dr.  Sibson  on  Medical  Anatomy,  in  which  this  sub- 
ject is  admirably  treated  and  illustrated.  From  his  work  I have  borrowed 
the  two  accompanying  figures,  which  exhibit  at  a glance  the  posifioii  of  the 


Fig.  1.  Fig.  2. 


internal  organs  in  a healthy  adult  male  after  death.  They  also  indicate 
the  general  relation  of  the  viscera  to  the  fixed  parts  of  the  trunk  and 
thoracic  walls,  the  study  of  which  is  far  more  useful  than  learning  the 
contents  of  various  artificial  regions  marked  out  by  lines  on  the  surface 
of  the  body. 

In  studying  all  such  relations  of  the  viscera  after  death,  it  should  be 
remembered  that  the  organs  do  not  occupy  exactly  the  same  position  in 
the  living  body.  “ Expiration  is  the  last  act  of  life,  and  this  last  expira- 
tion is  usually  more  extensive  and  forced  than  the  expiration  of  tranquil 
life.  In  the  dead  body,  the  lungs  shrink  up  within  the  position  that 
they  usually  occupy  during  life;  at  the  same  time  the  heart  and  its 
vessels  retract,  an  1 the  abdominal  organs  follow  the  diaphragm  somewhat 
upwards.” — [Sibson.) 

The  remarkable  changes  which  occasionally  occur  in  the  natural 
position  of  the  internal  viscera  may  be  judged  of  from  a ease  which 
occurred  to  Professor  Easton  of  Glasgow,  in  a pregnant  female,  aged 
twenty-seven.  The  enlargement  of  the  uterus,  co-operating  with  a 
gradually  increasing  tendency  to  accumulation  of  faeces  in  the  lower  end 

Fig.  1.  Superficial  view  of  internal  organs  after  removal  of  the  thoracic  and  abdo- 
minal parietes.  Fig.  2.  Deep  view. — (Sibson.) 


EXAMINATION  OF  THE  PATIENT. 


35 


of  the  colon,  at  length  produced  enormous  distension  of  the  sigmoid 
flexure,  the  ascending  portion  of  which  measured  thirteen,  and  the ' 
descending  twenty-five  inches  in  circumference.  The  spleen  and  dia- 
phragm were  forced  high  up 
to  the  left  side,  compressing 
tlie  lung  and  displacing  all 
the  neighboring  organs,  so 
that,  on  elevating  the  ster- 
num and  removing  the  ribs 
after  death,  the  appearances 
represented  Fig.  3 were  ex- 
hibited.'* In  the  case  of  Allan 
Brown,  recorded  under  the 
head  of  Pleuritis,  in  a sub- 
sequent part  of  this  work, 
another  singular  transposi- 
tion of  viscera  occurred.  As 
the  result  of  empyema  of  the 
left  thoracic  cavity ,the  heart 
was  forced  over  to  the  right 
side.  From  drinking  effer- 
vescing lemonade  shortly 
before  death,  the  stomach 
was  distended  with  gas,  and 
caused  to  twist  round  par-  F:g.  3. 

tially  on  itself  at  the  cardia,  so  that  nothing  could  escape.  The  distend- 
ed stomach  was  found  to  occupy  nearly  the  whole  of  the  abdomen,  and 
air  was  forced  between  its  coats,  causing  emphysema  of  the  organ. 

Besides  the  method  of  general  examination  previously  detailed,  it  is 
further  essential  to  employ  various  special  modes  of  investigation.  These 
are  inspection,  palpation,  mensuration,  percussion,  auscultation,  the  use  of 
the  microscope  and  of  chemical  tests.  To  them  we  are  indebted  for  that 
precision  and  certainty  which  characterise  the  results  of  physical  science. 
Up  to  a comparatively  recent  period  medical  men  formed  their  diagnosis 
and  prognosis  of  internal  diseases  from  an  observation  of  functional 
symptoms.  But  as  these — being  often  only  the  sensations  of  the  patient 
— may  vary  from  hour  to  hour  according  to  accidental  circumstances,  while 
the  pathological  lesions  which  occasion  them  remaiu  the  same,  they  are 
most  uncertain.  Formerly  it  was  imagined  that  every  morbid  organic 
change  gave  rise  to  a certain  train  of  symptoms,  and  that  a knowledge  of 
these  was  all-sufficient  to  determine  the  structural  malady.  But  this  idea 
is  negatived  by  clinical  observation,  which  teaches  us  that  many  different 
lesions  have  the  same  symptoms ; and  that,  occasionally,  most  important 
and  even  fatal  organic  diseases  have  no  symptoms  at  all.  Cases  of  fatty 
heart,  and  atheromatous  degeneration  of  the  cerebral  blood-vessels,  often 
give  rise  to  no  symptoms  whatever  until  death  suddenly  supervenes  by 
* Monthly  Journal  of  Medical  Science,  Dec.  1850,  p.  494. 


Fig.  3.  Remarkable  displacement  of  organs,  in  consequence  of  intestinal  obstruc- 
tion. a.  Caput  coli ; 6,  ascending  portion  of  sigmoid  flexure ; c,  descending  portion ; 
i/,  gravid  uterus  turned  a little  (ffwn. — {Easto7i.) 


36 


EXAMINATION  OF  THE  PATIENT 


syncope  or  coma.  Hence,  whenever  physical  exploration  is  applicable,  it 
should  be  had  recourse  to,  in  addition  to  an  investigation  of  the  symptoms. 
It  is  in  a great  measure  owing  to  our  superior  knowledge  in  thi&  respect 
that  medicine  has  made  such  great  advancement  during  the  present 
century. 

INSPECTION. 

Inspection  of  a part  or  of  the  whole  surface  of  the  body  in  various 
positions  is  often  of  the  utmost  importance.  The  latter  is  necessary  in 
the  examination  of  army  recruits,  but  can  seldom  be  carried  out  rigorously 
in  hospital,  and  still  less  in  private  practice.  Delicacy  forbids  it  in  females. 
The  part  affected,  however,  ought  always  to  be  seen,  a neglect  of  which 
rule  has  led  to  numerous  errors.  The  various  eruptions  which  appear 
on  the  surface  of  the  body  are  spoken  of  in  another  place.  Here  I shall 
only  shortly  allude  to  the  inspection  of  the  general  posture,  of  the  counte- 
nance, of  the  thorax,  of  the  abdomen,  of  the  pharynx,  of  the  larynx,  and 
of  the  posterior  nares. 

Inspeciion  cf  ilie  general  posture  of  the  patient  in  repose  and  in 
motion  is  often  highly  diagnostic.  Thus  the  position  and  attitude 
assumed  by  the  body  in  cases  of  fever,  in  acute  inflammations,  in  hemi- 
plegia or  paraplegia,  in  hydrothorax  and  asthma,  in  colic  or  spasmodic 
diseases,  and  even  in  various  forms  of  insanity,  are  very  characteristic. 
The  description  of  these,  however,  belongs  to  the  consideration  of  indi- 
vidual diseases.  As  a general  rule,  the  supine  position  denotes  muscular 
debility — quick  and  forcible  changes  of  position  indicate  excitement  of 
the  nei-vous  system  or  spasm — whilst  fixed  and  restrained  movements 
are  dependent  on  paralysis  or  inflammatory  pain. 

Inspection  of  the  countenance  is  a matter  of  such  importance  as  to  be 
instinctively  practised,  with  a view  of  determining  the  amount  of  pain, 
disturbance  of  the  feelings,  or  general  mental  and  bodily  condition  of 
the  patient.  A thorough  knowledge  of  the  indications  so  presented  to 
the  physician  is  only  to  be  attained  by  long  experience  in  the  observa- 
tion of  disease.  The  cuticular  surface  may  be  so  altered  as  to  give  a 
peculiar  appearance  to  the  complexion,  especially  in  chronic  diseases  of 
the  digestive  system.  The  changes  in  the  blood-vessels  and  blood 
occasion  pallor  or  flushing ; the  sallow  and  yellow  hue  observed  in  some 
disorders ; the  state  of  tumidity  or  shrinking,  of  heat  or  coldness,  and 
of  dryness  or  moisture.  Alterations  in  the  subcutaneous  and  muscular 
tissues  produce  emaciation,  or  oedema,  languor,  and  various  kinds  of 
convulsion  or  paralysis.  The  individual  features  also  require  to  be 
studied,  especially  the  eye  and  mouth.  Pain,  if  in  the  head,  causes  the 
brow  to  corrugate ; if  in  the  chest,  the  nostrils  to  be  drawn  upwards ; if 
in  the  abdomen,  the  lips  to  be  raised  and  stretched  over  the  gums  and 
teeth.  These  changes  are  more  readily  observed  in  children,  in  whom 
they  are  not  under  the  control  of  the  will. 

Inspection  of  the  Chest. — This  refers  to  the  form  and  configuration 
of  the  entire  thorax,  or  its  various  parts,  and  to  a careful  comparison  of 
the  two  sides  when  at  rest  and  when  in  motion.  It  is  often  difiicult, 
in  cases  where  changes  are  not  well  marked,  to  determine  them  by  mere 


BY  INSPECTION. 


37 


inspection.  To  do  so,  a good  light  and  proper  position,  both  of  the 
observer  and  of  the  patient,  are  necessary.  The  observer  should,  if 
possible,  be  directly  in  front  of  the  patient,  and  whenever  the  case 
admits  of  it,  the  latter  should  be  in  the  sitting  posture.  The  chest  may 
be  so  altered  in  disease  as  to  be  irregular  or  unsym metrical,  from  dis- 
tortions, congenital  or  acquired,  in  the  bones  of  the  vertebral  column  or 
of  the  thoracic  wall?.  Various  portions  of  it  may  be  expanded  or  bulge 
out,  as  in  cases  of  empyema  or  thoracic  tumors ; or  it  may  be  retracted 
and  depressed,  as  occurs  in  chronic  phthisis.  A case  presented  itself  to 
the  late  Dr.  Spittal  at  the  Royal  Dispensary  of  this  city,  where  the  re- 
traction was  so  great  on  one  side  that  the  student  in  charge  of  it  had 
placed  compresses  on  the  sound  side,  in  the  belief  that  the  healthy  prom- 
inence there  was  indicative  of  a tumor.  The  motions  of  the  chest 
bear  reference  to  inspiration  and  expiration,*  which  pass  imperceptibly 
into  one  another,  and  can  be  made  more  rapid  or  prolonged  voluntarily. 
A forced  inspiration  gives  rise  to  more  thoracic  movement  in  the  female 
than  in  the  male,  in  whom  it  is  more  abdominal.  In  disease  these 
motions  are  altered  in  various  ways — 1st,  By  general  excess  or  diminu- 
tion, as  in  cases  of  spasmodic  asthma  or  laryngeal  obstruction.  2d,  By 
partial  immobility,  as  in  pleurisy ; or  by  augmented  expansion,  as  in  the 
side  not  affected  in  a pneumonia  or  pleurisy.  3d,  By  increased  rapidity, 
as  in  pericarditis ; or  unusual  slowness,  as  in  coma. 

Inspection  of  the  Abdomen.  — The  abdomen  in  health  is  slightly  convex, 
and  marked  by  elevations  and  depressions,  corresponding  to  the  muscles  in 
its  walls,  the  umbilicus,  and  prominences  of  the  viscera  below.  It  varies 
according  to  age  and  sex — in  youth  being  smoother  and  flatter  than  in  the 
adult,  and  in  females  being  broader  inferiorly  than  in  males,  from  the  greater 
width  of  the  pelvis.  In  disease  it  may  be,  1st,  enlarged  generally  and  sym- 
metrically, as  in  dropsies,  or  partially,  and  irregularly,  from  ovarian,  hepat- 
ic, splenic,  and  other  tumors ; 2d,  it  may  be  retracted — generally,  from  ex- 
treme emaciation,  or  partially,  from  local  intestinal  obstruction.  The  su- 
perficial abdominal  veins  are  sometimes  greatly  enlarged,  and  at  others  dis- 
tinct pulsations  are  visible,  dependent  on  deep-seated  cardiac  or  arterial 
disease.  The  abdomen,  like  the  chest,  is  in  constant  movement  in  connec- 
tion with  the  act  of  respiration,  being  more  prominent  during  inspiration. 


* “ During  inspiration,  the  clavicles,  first  ribs,  and  through  them  the  sternum, 
and  all  the  annexed  ribs,  are  raised  ; the  upper  ribs  converge,  the  lower  diverge  ; the 
upper  cartilages  form  a right  angle  with  the  sternum,  and  the  lower  cartilages  of 
opposite  sides,  from  the  seventh  downwards,  move  further  asunder,  so  as  to  widen 
the  abdominal  space  between  them,  just  below  the  ziphoid  cartilage;  the  effect  being 
to  raise,  widen,  and  deepen  the  whole  chest,  to  shorten  the  neck,  and  apparently  to 
lengthen  the  abdomen.  During  expiration,  the  position  of  the  ribs  and  cartilages  is 
reversed  ; the  sternum  and  ribs  descend  ; the  upper  ribs  diverge,  the  lower  converge ; 
the  upper  cartilages  form  a more  obtuse  angle  with  the  sternum,  and  the  lower  carti- 
lages of  opposite  sides  approximate,  so  as  to  narrow  the  abdominal  space  between  them, 
just  below  the  ziphoid  ; the  effect  being  to  lower,  narrow,  and  flatten  the  whole  chest, 
to  lengthen  the  neck,  and  apparently  to  shorten  the  abdomen.  It  is  to  be  observed, 
that  during  inspiration,  while  the  ribs  and  sternum  are  moving  upwards,  the  lungs 
and  heart,  and  the  abdominal  organs,  are  moving  downwards,  and  that,  consequently, 
viewed  in  relation  to  the  ribs,  the  descent  of  the  internal  organs  appears  to  be  greater 
than  it  really  is.” — {Sihson.') 


38 


EXAMINATION  OF  THE  PATIENT 


and  flattened  during  expiration.  These  respiratory  movements  of  the  ah' 
domen  bear  a certain  relation  to  those  of  the  chest,  being  often  increased 
when  the  latter  are  arrested,  and  vice  versa.  Thus,  in  pleurisy,  the  re- 
spiratory movements  are  mostly  abdominal,  whereas  in  peritonitis,  they  are 
altogether  thoracic.  The  variations  observable  in  the  disturbed  rela- 
tions of  the  respiratory  movements  in  the  thorax  and  abdomen  are  often 
highly  instructive,  especially  in  cases  of  dyspnoea  from  hydrothorax, 
spasmodic  asthma,  anaemia,  ascites,  abdominal  tumors,  etc. 

Inspection  of  the  Pharynx. — For  this  purpose  a broad  spatula  firmly 
mounted  in  a handle  at  right  angles  is  necessary  to  depress  the  tongue. 
Such  spatulas  are  now  easily  procurable  of  diflerent  forms  in  all  surgical- 
instrument  makers’  shops,  the  most  convenient  being  those  here  figured, 


(Fig.  4).  The  greatest  difference  exists  in  various  persons  as  to  the  freedom 
with  which  they  can  bear  pressure  on  the  dorsum  of  the  tongue.  In  some 
that  organ  can  be  readly  depressed,  and  the  top  of  the  epiglottis  brought 
into  view  without  causing  any  inconvenience.  In  others  this  cannot  be 
done  without  exciting  cough,  or  sensations  of  suffocation  or  sickness.  In 
a few,  the  parts  are  so  sensitive  that  the  slightest  touch  induces  spasms. 
These  latter  cases  are  rare,  and  reiterated  efforts  in  the  vast  majority  of 
instances,  by  educating  the  parts  as  it  were  to  submit  to  interference,  en- 
able the  practitioner,  after  a shorter  or  longer  time,  easily  to  bring  into 
view  the  tonsils,  pillars  of  the  fauces,  uvula,  back  of  the  pharynx,  and 
upper  edge  of  the  epiglottis.  In  this  manner  enlargement  or  ulcerations 
ot  the  tonsils  or  uvula  can  be  readily  seen,  as  well  as  the  various  morbid 
ulcerations  of  the  mucous  membrane.  Among  these,  follicular  pharyngitis 

Fig,  4.  Spatulse  for  depressing  the  tongue — one-third  the  real  size. 

Fig.  '.  Extreme  case  of  follicular  pharyngitis,  shown  by  the  tongue-depressor. — 
{After  Horace  Green.) 


Fig.  4. 


Fig,  5. 


BY  INSPECTION. 


39 


is  the  most  common,  red  circular  swellings,  in  the  form  of  split  peas, 
being  scattered  more  or  less  thickly  over  the  surface.  Occasionally  these 
are  aggregated  together,  as  in  the  extreme  case  now  figured  (Fig.  5). 

Inspection  of  the  Larynx  — The  idea  of  illuminating  and  rendering  the 
larynx  visible  bj’^  means  of  a reflector  has  been  more  or  less  attempted  by 
Liston,  Warden,*  Avery,  Garcia,  and  others,  but  abandoned  as  impractica- 
ble in  medicine,  until  successfully  revived  in  recent  times  (1858-59)  by 
Professor  Czermak,  of  Pesth.  For  the  examination  of  the  larynx  he 
employs,  1st,  a perforated  mirror,  by  means  of  which  a powerful  light  is 
thrown  from  a lamp  into  the  back  of  the  mouth,  and  through  which  the 
operator  gazes  in  the  direct  axis  of  the  illuminating  rays.  This  mirror 
may  be  attached  to  a bent  stalk,  the  end  of  which  can  be  held  firmly  by 
the  teeth,  but  is  far  more  conveniently  attached  to  the  framework  of  a 
pair  of  spectacles,  or  to  a band  passing  around  the  head.  2d,  A laryngeal 
- mirror  of  glass  or  steel,  varying  in  size,  attached  to  a stem  at  one  of  its 
corners,  which  having  been  previously  warmed  to  prevent  condensation 
of  the  breath  upon  it,  is  placed  against  the  uvula,  and  reflects  the 
image  of  the  rima  glottidis  to  the  eye  of  the  observer. 

The  following  directions  are  given  by  Czermak  : — “ The  person  ex- 
amined places  his  hands  upon  his  knees,  the  upper  part  of  the  body  is 
advanced  forwards,  the  neck  bent  onward,  the  nape  slightly  inclined 
backwards,  the  mouth  widely  open,  the  tongue  flattened  and  held  a little 
without.  The  observer  is  seated  in  front  of  the  person  to  be  examined; 
he  places  in  his  mouth  the  handle  which  supports  the  illuminating  mirror, 
and  looks  through  the  central  opening  ; the  laryngeal  mirror,  introduced 
into  the  back  part  of  the  mouth  with  the  right  hand  is  illuminated  by  the 
light  which  is  projected  from  the  illuminating  mirror  ; the  left  hand  can 
be  placed  upon  the  shoulder  of  the  person  examined,  and  steadies  the  chin 
and  the  nape,  or  holds  a tongue- depressor,  which  he  can  often  trust  to  the 
patient  himself.  In  the  first  place,  the  illumination  of  the  back  part  of 
the  mouth  and  the  mutual  position  are  regulated ; then  the  laryngoscope 
is  heated,  and  its  temperature  regulated  by  the  touch.  After  these  pre- 
liminaries are  gone  through,  we  request  the  patient  to  open  the  mouth 
wide,  and  alternately  to  inspire  deeply  and  to  pronounce  the  sound  ah  ; 
during  this  we  endeavor  to  place  the  back  of  the  laryngoscope  against  the 
uvula  and  the  velum  palati,  to  sustain  these  parts  a little,  and  to  give  the 
mirror  a convenient  inclination ; at  times  it  is  impossible  to  avoid  touching 
the  posterior  wall  of  the  pharynx  ; the  examination  is  directed  by  the 
image  we  thus  obtain.  In  this  way  we  commence  each  laryngoscopic  ex- 
amination. Practice  and  reflection  will  bring  each  observer  to  compre- 
hend the  modifications  to  which  he  ought  to  submit  this  proceeding,  ac- 
cording to  the  special  circumstance  ; whether,  for  instance,  he  is  in  some 
degree  to  advance  or  to  withdraw  the  laryngoscope,  to  bend  it,  to  lower 
or  to  elevate  it,  to  change  the  position  and  attitude  of  the  individual  un- 
dergoing examination,  raise  his  chair,  etc.” 

The  method  which  I have  found  most  convenient  for  examining  the 
larynx  with  these  instruments  is  seen  in  the  accompanying  diagram.  When 

* Dr.  Warden  of  Edinburgh  distinctly  showed  the  larynx  in  1845  by  means  of  a 
spatula  and  a reflecting  prism  invented  for  the  purpose. — Edinburgh  Monthly  Journal 
of  Medical  Science,  1845,  p.  552. 


40 


EXAMINATION  OF  THE  PATIENT 


direct  sunlight  cannot  be  obtained — which  is  always  the  best  method  of 
illumination — a brilliant  gas  jet,  the  glare  of  which  is  screened  from  the 
eyes  of  the  operator  by  a shade,  answers  very  well  This  should  be  placed 
near  the  ear  of  the  patient,  on  the  side  opposite  to  the  eye  employed  of  the 
observer,  in  order  to  diminish,  as  much  as  possible,  the  inclination  of  the 


reflector  forwards.  A brilliant  light  is  absolutely  essential,  and  is  readily 
obtained  by  a globe  of  glass,  six  inches  in  diameter,  filled  with  water, 
as  recommended  by  Dr.  Walker.*  Instead  of  the  tongue-depressor,  the 
tongue  may  be  drawn  forward  and  held  by  its  tip  with  the  hand  and  a 
towel,  and  if  the  patient  can  do  this  himself  the  examination  is  facilitated. 

The  appearances  of  the  larynx  when  closed  moderately  and  fully  dilated, 


Fi^,  9.  Fig.  10. 

as  shown  in  himself  or  in  others,  are  represented  by  Czermak  in  a state  of 
* The  Laryngoscope,  1864,  p.  13. 

Fig.  6.  Mode  of  using  the  laryngoscope  and  tongue-depressor.  The  light  is  ob- 
tained from  a movable  gas  jet,  the  glare  of  which  is  screened  from  the  observer  by  a 
shade  mounted  on  a stand. 


BY  INSPECTION. 


41 


health,  in  the  accompanying  figures.  When  widely  dilated,  and  the  neck 
straightened,  the  cartilaginous  rings  of  the  trachea  and  bifurcation  of  the 
bronchi  have  been  made  visible.  These  appearances  are  greatly  modified 
in  disease,  when  oedema,  ulcerations,  cicatrices,  morbid  growths,  or  irreg- 
ularities in  the  form  of  the  glottis  and  mucous  membrane,  are  readily 
detected,  of  which  several  interesting  cases  have  already  been  published. 


Fig.  11. 


Fig.  12. 


Fig.  13. 


Fig  14. 


As  the  use  of  the  laryngoscope  extends  these  will  of  course  become  more 
numerous.  The  rendering  ulcers  and  morbid  growths  visible  by  the 
laryngoscope,  not  only  establishes  an  exact  diagnosis,  but  permits  of  the 
direct  application  of  means  for  their  cure  or  removal. 


Fig.  Y.  View  of  the  healthy  larynx  with  the  laryngoscope,  when  the  vocal  cords 
are  closed  as  in  sounding  high  notes. — {Czermak.) 

Fig.  8.  Another  view  of  the  healthy  larynx  during  ordinary  breathing. — ( Czermak^ 

Fig.  9.  Another  view  during  deep  inspiration,  with  the  trachea  straight,  showing 
the  glottis  widely  dilated,  and  through  it  the  rings  of  the  trachea  and  bifurcation  of 
the  bronchi. — {Czermak.) 

In  the  three  last  figures  the  numbers  indicate  the  following  parts : — 1,  Base  of  the 
tongue ; 2,  Posterior  wall  of  the  pharynx  • 3,  Entrance  of  the  oesophagus,  the  line  of 
demarcation  between  the  wall  of  the  pharynx  and  the  posterior  surface  of  the  larynx ; 
4,  Epiglottis  ■ 5,  Arytenoid  cartilages  ; 6,  Cushion  of  the  epiglottis  ; 7,  Aryteno- 
epiglottic  ligament ; 8,  Tubercle  corresponding  to  the  cartilage  of  Wrisberg ; 9,  Tuber- 
cles of  the  cartilages  of  Santorini ; 10,  Tubercle  which  sometimes  exists  between  the 
two  preceding ; 11,  Process  of  the  arytenoid  cartilages ; 12,  Inferior  vocal  cords  ; 13, 
Superior  vocal  cords ; 14,  Ventricles  of  Morgan!;  15,  Anterior  wall  of  the  trachea; 
16,  Posterior  wall  of  the  trachea ; 17,  Right  bronchus  ; 18,  Left  bronchus. 

Fig.  10.  Complete  closure  of  the  glottis  as  in  the  act  of  swallowing. — {Czermak.) 

Fig.  11.  Transformation  of  the  right  (inferior)  false  vocal  cord  into  a hard,  rough, 
and  ulcerated  mass. — ( Czermak.) 

Fig.  12.  Cicatrices  and  loss  of  substance  of  the  larynx. — {Czermak.) 

Fig.  13.  Polypus  attached  to  the  right  vocal  cord,  the  real  cause  of  a supposed 
nervous  aphonia. — ( Czermak.) 

Fig.  14.  Large  muriform  polypus  of  an  epithelial  character. — {Czermak.) 


42 


EXAMINATION  OF  THE  PATIENT 


Inspection  of  the  Posterior  Nares. — If  instead  of  directing  the  mirror 
downwards,  it  be  carried  behind  the  uvula  and  directed  upwards,  a pos- 
terior view  of  the  nares  may  be  seen  with  the  openings  of  the  Eustachian 
canals.  The  laryngoscope  then  becomes  a rhinoscope.  In  this  case  it 
may  be  necessary  to  draw  the  uvula  forwards  by  a small  blunt  hook  or 
bent  spatula  (Fig.  15,  K).  Here,  as  in  the  case  of  the  larynx,  morbid 
alterations,  polypi,  etc.,  can  be  seen  and  distinguished  from  a healthy  state 


of  the  parts.  Dr.  Voltolini  of  Breslau  has  also  pointed  out  the  great 
advantage  of  this  mode  of  exploration  in  the  diagnosis  and  treatment  of 
diseases  of  the  ear.  He  recommends,  instead  of  a spatula  for  depressing 
the  tongue,  a shield  of  gutta  percha,  a portion  of  which  is  raised  up  to 

Fig.  15.  1 — 6,  section  of  the  six  upper  cervical  vertebrae;  o,  a section  of  the 
basilar  process  of  the  occipital  bone ; a section  of  the  body  of  the  sphenoid  bone 
and  sinus ; y,  a section  of  the  crista  galli  of  the  ethmoid  bone ; /,  a section  of  the 
frontal  bone  and  sinus ; w,  os  nasi  of  the  left  side ; m,  the  palate  process  of  the 
superior  maxillary  bone  separating  the  mouth  from  the  nasal  fossae  ; v,  the  posterior 
or  pharyngeal  edge  of  the  vomer  ; d,  the  opening  of  the  Eustachian  tube  ; pu\  a sec- 
tion of  the  soft  palate  and  uvula,  indicating  the  normal  position  of  these  parts ; 
the  soft  palate  and  uvula  drawn  forwards  and  upwards  by  the  hook  {K) ; ph,  the 
pharynx  ; the  tongue ; a section  of  the  inferior  maxillary  bone ; A,  a section 
of  the  hyoid  bone ; c,  X,  a section  of  the  epiglottis  and  larynx ; tr^  the  trachea. 
The  external  wall  of  the  left  nasal  fossa  is  indicated  by  dotted  lines ; a,  6,  c,  the  tur- 
binated bones ; x,  x\  two  different  positions  of  the  rhinoscopic  mirror ; jcy,  x'y\  two 
different  directions  of  the  light  and  sight. — {Czermak.) 

Fig.  16.  Mirror  and  shield  for  depressing  the  tongue,  useful  in  the  examination 
of  the  posterior  nares  and  orifices  of  the  Eustachian  tubes ; half  the  real  size. — 
( Voltolini.) 


BY  PALPATION. 


43 


admit  the  passage  under  it  of  the  handle  of  the  mirror  strengthened  for 
that  purpose.  In  this  manner  the  mirror  can  he  directed  upwards  and 
the  tongue  depressed  with  one  hand,"^  a matter  of  great  importance,  as 
the  other  hand  must  be  employed  in 
pulling  forward  the  uvula.  Even  when 
the  patient  depresses  his  own  tongue, 
which  is  seldom  done  by  him  efficiently, 
it  will  be  found  difficult,  unless  the  hand 
which  manipulates  the  rhinoscope  be  kept 
low,  as  in  depressing  the  tongue,  to  pre- 
vent its  interfering  with  the  rays  of  light 
The  application  of  these  instruments 
management  of  the  light,  and  overcoming  the  irritability  of  the  parts 
concerned,  often  require  the  exercise  of  patience  and  perseverance  in 
the  practitioner.  In  this  also,  as  in  every  other  method  of  physical 
exploration,  practice  and  dexterity  of  manipulation  are  required.  Perse- 
verance and  skill  in  their  employment,  however,  cannot  fail,  in  appropri- 
ate cases,  to  improve  our  means  of  arriving  at  an  exact  diagnosis,  and 
thereby  of  extending  the  domain  of  medical  science. f 


PA.LPATION. 

Palpation  also  is  a necessary  mode  of  examination,  and  is  sometimes 
practised  by  simply  applying  the  tips  of  the  fingers,  at  others  by  placing 
the  hand  on  the  part  affected,  and  not  unfrequently  by  employing  both 
hands,  and  pressing  with  them  alternately.  This  latter  method  is  most 
applicable  in  endeavoring  to  judge  of  tumors,  especially  when  large  or 
deep  seated,  and  situated  in  the  abdomen.  The  position  of  the  patient 
during  palpation  must  be  varied  according  to  the  part  examined.  The 
horizontal  posture  is  best  to  judge  of  deep-seated  pulsations  and  vibra- 
tions, but  sometimes  the  erect  posture,  or  even  leaning  forward,  becomes 
necessary,  as  when  the  heart  is  being  examined.  When  feeling  the 
abdominal  organs  through  the  integuments,  these  last  should  be  relaxed 
by  causing  some  one  to  flex  the  inferior  extremities  on  the  abdomen, 
and  push  the  head  and  neck  forwards.  In  this  manner  palpation  affords 
information — 1st,  As  to  the  increased  or  diminished  sensibility  of  various 
parts ; 2d,  Of  their  altered  form,  size,  density,  and  elasticity ; and,  3d, 
Of  the  different  kinds  of  movement  to  which  they  may  be  subjected. 

1.  When  pain  is  experienced  in  any  part,  it  is  generally  increased 
by  pressure  and  movement,  if  inflammatory,  Wt  relieved  if  neuralgic. 
Not  unfrequently  pressure  causes  pain  or  tenderness  where  otherwise 

* Virchow’s  Archiv.,  Band.  21,  s.  45. 

f For  full  details  and  numerous  interesting  cases,  see  Czennak  on  the  Lar>'ngo- 
scope  in  the  “Selected  Monographs”  of  the  New  Sydenham  Society  for  1861,  Also 
the  works  of  Drs.  Gibb  and  Walker. 


Fig.  17.  Septum,  posterior  orifices  of  the  nasal  fossae,  turbinated  bones,  and  orifices 
of  the  Eustachian  tubes.  The  posterior  arched  surface  of  the  velum  covers  the  inferior 
part  of  the  nasal  cavity. — {Czermak.) 


44 


EXAMINATION  OF  THE  PATIENT 


neither  are  experienced.  Thus  deep  pressure  in  the  right  iliac  region 
causes  pain  in  typhoid  fever,  which,  however,  must  be  judged  of  from 
the  expression  of  the  countenance,  rather  than  the  statement  of  the 
patient.  Again,  over  the  vertebral  column  pressure  or  percussion  may 
induce  pain  that  is  otherwise  not  felt.  In  paralytic  cases  the  diminution 
of  sensibility  can  only  be  ascertained  by  feeling  or  pinching  the  part, 
and  the  limitation  of  anaesthesia  is  best  arrived  at  by  pricking  the  sur- 
face with  some  pointed  hard  substance. 

2.  Alterations  in  external  form  and  size  may  be  judged  of  by  inspec- 
tion, but  with  regard  to  internal  organs,  especially  abdominal  ones,  we 
derive  more  exact  information  from  palpation  conjoined  with  percussion, 
as  in  cases  of  hypertrophied  liver  and  spleen,  or  when  some  tumor 
exists.  In  such  cases  we  can  feel  from  the  increased  density  and  resist- 
ance the  size  and  outline  of  the  morbid  growths,  which  will  be  more  or 
less  distinct,  in  proportion  as  they  are  near  the  surface,  and  circumscribed 
in  form.  Occasionally  organs  are  diminished  in  size,  and  cannot  be  felt 
in  their  normal  positions,  as  when  the  inferior  margin  of  the  liver  cannot 
be  detected  in  this  way,  from  atrophy.  The  natural  elasticity  of  parts 
may  also  be  increased  or  diminished.  Thus  the  abdomen  is  more  elastic 
when  air  is  in  excess  in  the  intestines,  and  less  so  when  the  peritoneum 
contains  liquid.  The  integuments  also  may  be  more  rigid  and  indurated, 
as  in  chronic  skin  diseases,  or,  on  the  other  hand,  soft  and  doughy,  as  in 
tedema,  when  they  pit  on  pressure,  from  diminished  elasticity. 

3.  Certain  motions  in  the  thoracic  and  abdominal  cavities,  as  well  as 
in  other  parts  of  the  body,  are  best  judged  of  by  palpation.  It  is  in  this 
way  that  the  character  and  situation  of  pulsation  at  the  heart,  root  of  the 
neck,  or  elsewhere,  are  determined.  The  expansive  motion  of  the  thorax 
and  abdomen  during  respiration  is  also  thus  ascertained.  If  we  place 
the  two  hands,  with  the  fingers  spread  out  like  a fan  in  the  axillae  or 
flanks,  and  bring  the  two  thumbs  towards  each  other,  near  the  sternum 
or  umbilicus,  we  can  judge  by  their  approach  and  separation  of  the 
amount  of  expansion  or  retraction  that  takes  place.  Application  of  the 
hand  also  allows  us  to  detect  undulatory  motioLS  below  the  integument, 
and  to  determine  the  existence  of  vibrations,  frictions,  gratings,  and  crepi- 
tations. Kostan  relates  a case  where  all  the  symptoms  of  acute  intercos- 
tal rheumatism  were  present  (which  disease  was  diagnosed),  caused  by  a 
broken  rib,  that  was  overlooked  from  the  diseased  part  not  having  been 
examined  by  palpation.  There  is  a natural  fremitus  or  thrill  perceptible 
on  placing  the  hand  on  the  chest,  when  a person  is  speaking,  which  is 
increased  in  some  diseases  of  the  chest,  and  lessened  in  others.  This 
sensation  is  also  sometimes  felt  over  the  large  blood-vessels.  It  resembles 
more  or  less  the  vibration  felt  on  placing  the  hand  on  the  back  of  a cat 
while  purring.  Fluctuation  is  another  sensation,  caused  by  pressing  on 
or  percussing  parts  in  such  a way  as  to  cause  displacement  of  their  con- 
tained fluids.  A modification  of  it  is  known  under  the  name  of  succussion, 
which  is  effected  by  shaking  the  patient — a proceeding,  however,  which 
»is  seldom  necessary. 


BY  MENSURATION. 


45 


MENSURATION. 

The  simplest  way  of  measuring  the  circumference  of  parts,  or  the 
distance  between  any  two  fixed  points,  is  by  means  of  a graduated 
tape.  In  ascertaining  the  circular  measurement  of  the  chest  or  abdomen, 
that  moment  should  be  chosen  when  the  patient  holds  his  breath  at  the 
end  of  an  ordinary  expiration,  great  care  being  taken  that  the  tape  is 
carried  evenly  round  the  body.  The  relative  mensuration  of  the  two 
sides  of  the  chest  or  abdomen  is  best  accomplished  by  choosing  the 
spinous  processes  of  the  vertebrae  as  fixed  points  on  the  one  hand,  and  a 
line  drawn  through  the  centre  of  the  sternum  and  umbilicus  on  the  other. 
The  exact  levels  of  the  measurements  should  always  be  noted,  such  as  at 
the  nipples,  margin  of  the  lower  ribs  or  umbilicus,  which  are  those  most 


deserving  of  observation.  The  diameter  of  the  trunk  in  various  direc- 
tions is  best  ascertained  by  means  of  a pair  of  callipers. 

The  amount  of  motion  in  the  chest  and  abdomen,  and  of  its  various 
parts,  is  capable  of  being  accurately  determined  by  means  of  the  chest- 
measurer  of  Dr.  Sibson  (Fig.  20),  or  the  stethoraeter  of  Dr.  Quain  (Fig. 
18).  Both  instruments  are  composed  of  a brass  box,  having  a dial  and 
an  index,  which  is  moved  by  a rack  attached  to  a prolonged  pinion  or  a 
string.  One  revolution  of  the  index  indicates  an  inch  of  motion  in  the 
chest ; the  intervening  space  being  graduated.  It  has  been  found 
necessary,  when  making  observations  on  the  respiratory  movements, 
whether  of  the  chest  or  of  the  abdomen,  to  divert  the  patient’s  attention, 
and  make  him  look  straight  forwards,  otherwise  these  movements  become 
so  affected  as  to  vitiate  the  results.  The  instruments  may  be  applied  in 
the  sitting  or  recumbent  posture.  The  method  of  applying  them  with  a 
string  attached  is  shown  in  Fig.  19,  and  the  mode  of  using  Dr.  Sibson’s 
chest-measurer  by  placing  the  pinion  on  the  nail  of  the  observer’s  finger, 

Fig.  18.  The  stethoraeter  of  Dr.  Quain — half  the  real  size. 

Fig.  19.  Mode  of  applying  the  instrument  when  the  string  is  used. — {R.  Quain.) 


46 


EXAMINATION  OF  THE  PATIENT 


moving  with  the  chest,  is  seen  Fig.  21.  if  held  in  the  hand,  as  in  Figs. 
19  and  21,  great  steadiness  and  care  are  requisite  to  arrive  at  exact  results. 
Dr.  Sibson’s  instrument  may  be  attached  to  brass  rods,  which  are  bent  at 
right  angles,  so  as  to  present  the  form  of  ].  The  upper  arm  is  movable, 
and  admits  of  elongation  by  means  of  a split  tube,  so  that  in  this  way 
great  steadiness  is  arrived  at,  while  the  instrument  itself  can  be  carried 


Fig.  20. 


Fig.  21. 


to  any  part  of  the  chest  or  abdomen,  without  disturbing  the  position  of 
the  patient,  as  seen  in  Fig.  22. 

There  is,  however,  considerable  variation  even  in  health  in  different 
persons.  Some,  for  instance,  can  cause  the  second  rib  to  advance  two 
and  a quarter  inches  during  forced  inspiration,  whilst  others  can  only 
cause  it  to  advance  three  quarters  of  an  inch.  The  motion  of  the  whole 
left  side,  excepting  that  of  the  second  rib,  is  somewhat  less  than  on  the 
right  side.  It  should  also  be  remembered  that  the  motion  of  the  tenth 
rib  indicates  that  of  the  diaphragm.  The  pressure  of  the  stays  in  the 
female  exaggerates  the  thoracic  and  diminishes  the  abdominal  movements. 

Fig.  20.  The  chest-measurer  of  Dr.  Sibson,  natural  size. 

Fig.  21.  Mode  of  applying  the  chest-measurer. — (Sibson.) 


BY  MENSURATIOIY. 


47 


According  to  the  observations  of  Dr.  Sibson,  naade  with  this  instru- 


Fig.  22. 

ment,  the  respiratory  movements  in  health  may  be  thus  represented  in 
lOOth’s  of  an  inch. 


Instrument  applied  to 


Side. 


Centre  of  sternum  between  2d  costal 
cartilages 

2d  Rib  near  the  costal  cartilage.  . . . 


right 

left 


Lower  end  of  sternum 


6th  Costal  cartilages  near  the  rib. . . 

6th  Rib  at  the  side 

10th  Rib 


( right 
] left 
j right 
1 left 


right 

left 


Abdomen 


( centre 

i right 
[left 


Involuntary 

tranquil 

respiration 


boy 

man 


3 to  6 
3 “ 7 
3 “ 7 
2 “ 6 
3 “ 6 
2 “ 5 
6 
3 

10 

9 

25 

25  to  30 
9 
8 


Voluntary 
forced 
I'espi  ration 
about 


100 

110 

110 

95 

95 

85 

70 

60 

65 

60 

90 

100 


In  disease  it  may  be  observed  as  a general  rule,  that  if  the  respira- 
tory movements  are  restrained  in  one  place,  they  are  increased  elsewhere. 
We  have  already  alluded  to  the  relation  existing  between  thoracic  and 
abdominal  movements  (see  Inspection).  The  amount  of  these  may  be 
exactly  ascertained  by  the  chest-measurer.  In  the  same  manner  the  di- 
minished movements  on  one  side  of  the  chest  in  pleuritis,  pneumonia, 
and  incipient  phthisis,  can  be  determined  and  compared  with  the  ex- 
aggerated motion  on  the  opposite.  Thus  in  phthisis,  instead  of  the 
indicator  of  the  instrument  placed  over  the  second  rib,  on  the  affected 
side,  moving  between  1 and  110  on  forced  inspiration,  as  in  health,  it 
may  only  move  between  1 and  30.  In  making  observations  with  the 
chest-measurer,  considerable  practice  and  skill  are  necessary,  as  in  the 
employment  of  all  other  instruments.  It  enables  us  to  arrive  at  great 
accuracy,  and  constitutes  an  extra  means  of  exploration,  without,  how- 

Fig.  22.  Mode  of  application  of  the  chest-measurer,  attached  to  brass  rods,  bent 
at  right  angles,  when  the  patient  is  in  the  horizontal  posture. — (Sibson.\ 


48 


EXAMINATION  OF  THE  PATIENT 


ever,  being  absolutely  necessary  for  arriving  at  a correct  diagnosis  in 
every  case. 

The  expansibility  of  the  lungs,  and  the  amount  of  air  expelled  from 
the  chest  after  full  inspiration,  may  also  be  measured  by  the  spirometer 
of  Mr.  Hutchinson.  But  the  necessity  of  determining  the  height  and 
weight  of  the  individual,  of  teaching  him  how  to  inspire  and  expire,  of 
paying  attention  to  the  muscular  force  and  other  circumstances,  so  inter- 
feres with  the  correct  conclusions  to  be  derived  from  this  mode  of  ex- 
ploration, as  to  render  it  valueless  in  the  examination  of  cases  gene- 
rally. As  a means  of  physiological  research  in  determining  the  vital 
capacity  of  the  chest,  Mr.  Hutchinson’s  investigations  are  of  the  utmost 
importance. 

Dr.  Scott  Alison  has  invented  an  instrument  for  measuring  the  an- 
gles of  the  chest.  It  will  also  enable  us  to  judge  approximatively  of  the 
curves  under  various  altered  conditions.  He  calls  it  stetho-goniometer, 
a term  derived  from  three  Greek  words,  signifying  chest,  angle,  and 
measUl’€.  Dr.  S.  Alison  believes  that  it  will  afford  data  not  to  be  ob- 


obtained  by  other  means,  and  assist  in  the  diagnosis  of  disease  in  its 
early  as  well  as  in  its  later  stages.* 


PERCUSSION. 

The  object  of  percussion  is  to  ascertain  the  resistance  and  size  of 

organs.  It  may  be  practised 
directly,  or  through  the  me- 
dium of  an  interposed  body 
(mediate  percussion)  — the 
last  being  the  only  satisfac- 
tory way.  Without  knowing 
how  to  strike,  and  to  produce 
clear  tones,  we  can  never  edu«» 
cate  the  ear,  or  the  sense  of 
resistance.  This  preliminary 
education  in  the  art  of  percussion  requires  a certain  dexterity,  which 
some  find  it  very  difficult  to  obtain.  The  difficulty  seems  to  depend,  in 

* Beale’s  Archives  of  Medicine,  vol.  i.  p.  60. 

F:g.  23.  Stetho-goniometer,  for  measuring  the  inclination  of  different  parts  of  the 
walls  of  the  thorax  in  cases  of  disease,  aa,  The  arms ; 6,  the  arc  of  a circle  graduated ; 
c,  the  vernier,  with  an  arrow,  also  graduated ; c?,  vernier  arm  ; e,  joint. — {Scott  Alison.) 


BY  PERCUSSION. 


49 


some  cases,  on  an  alteration  in  the  proportions  usually  existing  between 
the  length  of  the  fingers.  Thus,  I have  seen  more  than  one  person  who 

had  the  index  finger  nearly  an 
inch  shorter  than  the  middle 
one,  and  who,  consequently, 
found  it  impossible  to  strike 
the  pleximcter  fairly  with  the 
tips  of  the  two  fingers  at  once. 
By  far  the  most  common  cause  of  failure,  however,  is 
want  of  patience  and  perseverance  in  overcoming  the 
first  mechanical  difficulties ; and  there  is  every  rea- 
son to  believe  that  could  this  be  surmounted,  accu- 
rate percussion  would  become  more  universal  and 
better  appreciated.  Without  entering  into  the  nu- 
merous discussions  which  have  arisen  as  to  the  supe- 
rior advantages  of  one  plan  as  compared  with  another, 
or  of  using  this  or  that  instrument,  I may  mention,, 
that  for  the  last  twenty-three  years  I have  employed 
a pleximeter  and  a hammer.  These  instruments  I 
can  confidently  recommend  to  you  as  the  readiest 
means  of  obtaining  accurate  results  at  the  bed-side 
by  means  of  percussion. 

The  ivory  pleximeter  I use  is  that  of  M.  Piorry, 
as  modified  by  M.  Mailliot.  Its  length  is  two  inches, 
and  breadth  one.  It  possesses  two  handles,  and  an 
inch  and  half  scale  drawn  upon  the  surface.  It  may 
be  applied  with  great  precision  to  every  part  of  the 
chest,  even  in  emaciated  subjects  (Fig.  24). 

The  hammer  is  the  invention  of  Dr.  Winterich 
of  Wurzburgh.  The  advantages  it  possesses  are, — 
1st,  That  the  tone  produced  by  it,  in  clearness,  pene- 
trativeness, and  quality,  far  surpasses  that  which  the 
most  practised  percusser  is  able  to  occasion  by  other 
means.  2d,  It  is  especially  useful  in  clinical  instruc- 
tion, as  the  student  most  distant  from  the  patient  is 
enabled  to  distinguish  the  varieties  of  tone  with  the 
greatest  ease.  3d,  It  at  once  enables  those  to  percuss, 
who,  from  peculiar  formation  of  the  fingers,  want  of 
opportunity,  time,  practice,  etc.,  are  deficient  in  the 
necessary  dexterity  (Fig.  25).^ 

With  the  assistance  of  the  instruments  I now 
recommend  to  you,  every  student  acquainted  with 
the  relative  situations  of  the  different  thoracic  and 
abdominal  organs,  is  himself  enabled,  without  other 
preliminary  education,  to  detect  the  different  degrees 
of  sonoriety  they  possess  in  a state  of  health  and’ 
disease.  I may  say,  that  by  means  of  these  instru- 
ments, after  one  hour’s  practice  on  a dead  body,  he 
Fig.  25.  is  placed  on  a par  (as  regards  the  art  of  percussion) 

* The  hammer  and  pleximeter  are  carefully  made  by  Mr.  Young,  cutler,  North 
Bridge,  Edinburgh — in  a neat  case,  price  7s.  6d. 

4 


50 


EXAMINATION  OF  THE  PATIENT 


with  the  generality  of  experienced  practitioners  in  this  country ; and 
any  of  you,  after  one  mouth’s  employment  of  them,  will  be  enabled  to 
mark  out  accurately  on  the  surface  of  the  body,  the  size  and  form  of  the 
heart,  liver,  spleen,  etc. 

I have  tried  a smaller  and  lighter  hammer  kindly  sent  to  me  by  Br. 
Winterich,  as  well  as  balls  surrounded  by  thick  rings  of  caoutchouc,  and 
attached  to  elastic  pieces  of  whalebone.  But  a certain  weight  is  neces- 
sary to  obtain  a penetrative  sound,  and  rigidity  of  the  handle  is  necessary 
to  judge  of  the  sense  of  resistance.  In  my  opinion,  no  better  hammer 
has  been  invented  than  the  one  figured  on  the  preceding  page. 

Of  the  Different  Sounds  produced  by  Percussion. 

The  sounds  produced  by  percussion  arise  from  the  vibrations  occa- 
sioned in  the  solid  textures  of  the  organ  percussed.  The  different  density 
and  elasticity  of  these  textures  will  of  course  more  or  less  modify  the  num- 
ber and  continuance  of  the  vibrations,  and  give  rise  to  different  sounds. 

M.  Piorry  considers  that  nine  elementary  sounds  are  thus  formed, 
which  he  has  designated,  from  the  organ  or  part  which  originates  them, 
'"''femoral^  jecoral^  cardial,,  pulmonal^  intestinal,,  stomacal,  osteal,  humo- 
rique,  and  hydatique.’'''  I consider  that  all  these  sounds  may  be  reduced 
to  three  elementary  ones ; that,  in  point  of  fact,  there  are  only  three 
tones  occasioned  by  percussion,  and  that  all  the  others  are  intermediate. 
These  three  tones  are  respectively  dependent, — 1st,  On  the  organ  con- 
taining air ; 2d,  On  its  containing  fluid ; and  3d,  On  its  being  formed 
of  a dense  uniform  parenchymatous  tissue  throughout.  These  tones, 
therefore,  may  bo  termed  the  tympanitic,  the  humoral,  and  the  paren- 
chymatous. Percussion  over  the  empty  stomach  gives  the  best  example 
of  the  first  kind  of  sound ; over  the  distended  bladder,  of  the  second ; 
and  over  the  liver,  of  the  third.  Certain  modifications  of  these  sounds 
occasion  the  metallic  and  the  crached-pot  sound.  The  latter  is  made 
audible  over  the  chest  under  a variety  of  circumstances,  by  percussing 
with  the  mouth  open.  The  terms  jecoral,  cardial,  pulmonal,  intestinal, 
and  stomacal,  however,  may  be  used  to  express  those  modifications  of 
sound  produced  in  percussing  respectively  the  liver,  heart,  lungs,  intes- 
tines, and  stomach. 

ISo  description  will  suffice  to  convey  proper  ideas  of  the  various 
alterations  of  tone  occasioned  by  percussing  over  the  different  thoracic 
and  abdominal  viscera.  To  become  acquainted  with  these,  it  is  absolutely 
necessary  to  apply  the  pleximeter  to  the  body,  and  then  half  an  hour’s 
practice  with  this  instrument  and  the  hammer  will  be  sufficient  to  render 
any  one  conversant  with  those  which  may  be  heard  in  a normal  state. 

It  must  be  remembered,  however,  that  the  tones  even  then  may  vary 
according  to  circumstances.  Thus,  immediately  after  a deep  inspiration, 
the  pulmonal  sound  will  be  rendered  more  tympanitic,  and,  after  expira- 
tion, more  parenchymatous.  In  the  same  manner  the  stomach  and  in- 
testines may  give  out  different  sounds  according  to  the  nature  of  their 
contents.  In  the  left  or  right  iliac  fossa  a clear  tympanitic  sound  will 
be  heard  when  the  intestine  below  is  empty,  and  a dull  parenchymatous 
sound  when  it  is  full  of  faeces. 


BY  PERCUSSION. 


51 


A study  of  the  ditferent  modifications  of  sound,  which  various  organs 
thus  produce  in  a state  of  health,  readily  leads  to  the  comprehension  of 
the  sounds  which  may  be  elicited  in  a morbid  state.  Thus,  the  lungs 
may  occasion  a dull  or  parenchymatous  sound,  from  solidification,  the 
result  of  exudation,  or,  on  the  other  hand,  become  more  tympanitic,  from 
the  presence  of  emphysema.  The  abdomen  may  give  out  a parenchy- 
matous sound,  from  enlargement  of  the  uterus  or  an  ovarian  tumor ; or 
a dull  humoral  sound,  from  the  effusion  of  fluid  into  the  cavity  of  the 
peritoneum. 

Of  the  Sense  of  Kesistance  produced  by  Percussion. 

By  the  sense  of  resistance  is  understood  the  peculiar  sensation  re- 
sulting from  those  impressions  which  are  communicated  to  the  fingers 
on  striking  hard,  soft,  or  elastic  bodies.  It  is  of  the  greatest  service  in 
determining  the  physical  condition  of  the  organ  percussed.  The  sense 
of  resistance  bears  relation  to  the  density  of  the  object  struck, — hence, 
firm  and  solid  textures  offer  more  resistance  than  those  which  are  soft  or 
elastic.  The  thorax  of  a child  is  elastic,  whilst  that  of  the  adult  is  un- 
yielding. Of  all  the  thoracic  and  abdominal  organs,  the  liver  presents 
the  greatest  degree  of  resistance,  and  the  stomach  the  least.  The  pres- 
ence of  fluid  in  the  hollow  viscera  offers  an  amount  of  resistance  between 
the  parenchymatous  organs  on  the  one  hand,  and  those  containing  air  on 
the  other.  But  air  much  condensed,  or  fluid  contained  within  the  rigid 
walls  of  the  thorax,  may  offer  a considerable  degree  of  resistance. 

The  sense  of  resistance  should  be  as  much  educated  by  the  physician 
as  the  sense  of  hearing,  and  it  would  be  difficult  for  an  individual,  prac- 
tised in  the  art  of  percussion,  to  say  which  of  these  two  points  is  the  more 
valuable  to  him.  Both  are  only  to  be  learnt  by  practice,  and  consider- 
ing it  perfectly  useless  to. describe  that  in  words  which  may  be  learnt  in 
half  an  hour,  by  the  use  of  the  pleximeter  and  hammer  on  a dead  body, 
or  the  living  subject,  I shall  now  proceed  to  describe  the 

General  Kules  to  be  followed  in  the  Practice  of  Mediate 

Percussion. 

1.  The  pleximeter  should  be  held  by  the  projecting  handles  between 
the  thumb  and  index  finger  of  the  left  hand,  and  pressed  firmly  down 
upon  the  organ  to  be  percussed.  Much  depends  upon  this  rule  being 
followed,  as  the  sound  and  sense  of  resistance  are  considerably  modified 
according  to  the  pressure  made  by  the  pleximeter.  A very  easy  expe- 
riment will  prove  this.  If,  for  instance,  the  pleximeter  be  struck  while 
it  rests  lightly  on  the  abdomen  over  the  umbilicus,  and  again,  when  it 
is  pressed  firmly  down  amongst  the  viscera,  the  change  in  tone  will  be 
at  once  perceived.  In  the  first  case,  a dull  sound  is  produced,  from  the 
muscles  and  integuments  being  alone  influenced  by  the  force  of  the  blow ; 
in  the  second  case,  a clear  tympanitic  sound  is  occasioned  from  the  vibra- 
tion of  the  walls  of  the  intestine.  In  every  instance,  therefore,  the 
pleximeter  should  be  so  held  and  pressed  down,  as  to  render  it,  so  to 
speak,  a part  of  the  organ  we  wish  to  percuss. 


52 


EXAMINATION  OF  THE  PATIENT 


2.  Great  care  must  be  taken  that  no  inequality  exist  between  the 
inferior  surface  of  the  plexirneter  and  the  skin.  Firmly  pressing  it 
down  will  always  obviate  this  when  the  abdomen  is  examined.  As  re- 
gards the  thorax,  the  groove  over  the  anterior  mediastinum,  the  promi- 
nence of  the  clavicles  and  of  the  ribs,  in  emaciated  subjects,  may  allow 
a hollow  to  exist  under  the  instrument,  by  which  a deceptive  tympanitic 
sound  is  occasioned.  By  a little  management,  however,  with  the  small 
and  oval  plexirneter  I have  recommended,  this  may  readily  be  avoided. 

3.  The  hammer  should  be  held,  as  advised  by  Dr.  Winterich,  be- 
tween the  thumb  and  the  first  and  third  fingers,  the  extremities  of  which 
are  to  be  placed  in  hollows  prepared  for  them  in  the  handle  of  the  in- 
strument. By  some  these  are  considered  useless,  but  in  all  cases  where 
slight  differences  in  tone  are  to  be  appreciated,  I have  found  this  the 
best  mode  of  employing  it.  Ordinarily,  however,  it  will  be  sufficient  to 
hold  it  by  the  extremity  of  the  handle,  merely  in  such  a manner  as  will 
enable  the  practitioner  to  strike  the  plexirneter  lightly,  or  with  force,  as 
occasion  may  require. 

4.  Care  must  be  taken  to  strike  the  plexirneter  fairly  and  perpen- 
dicularly. Unless  this  be  done,  vibrations  are  communicated  to  textures 
in  the  neighborhood  of  the  organ  to  be  percussed,  and  fallacious  results 
are  the  consequence.  If  in  percussing  the  lungs,  for  example,  the  blow 
be  made  obliquely,  we  obtain  the  dull  sound  produced  by  the  rib,  and  I 
have  seen  considerable  error  in  the  diagnosis  thus  occasioned. 

5.  A strong  or  gentle  stroke  with  the  hammer  will  modify  the  tone 
and  sense  of  resistance,  inasmuch  as  the  impulse  may  be  communicated 
by  one  or  the  other  to  a deep-seated  or  a superficial  organ.  Thus  a 
gentle  stroke  will  elicit  a pulmonal  tympanitic  sound  just  below  the 
fourth  rib,  where  a thin  layer  of  lung  covers  the  liver,  but  a strong  one 
will  cause  a jecoral  parenchymatous  sound.  At  the  inferior  margin  of 
the  liver,  on  the  other  hand,  where  a thin  layer  of  the  organ  covers  the 
intestines,  the  reverse  of  this  takes  place,  a gentle  stroke  occasioning  a 
dull,  and  a strong  one  a clear  sound. 

6.  By  withdrawing  the  hammer  immediately  after  the  blow,  we  are 
better  able  to  judge  of  the  sound;  by  allowing  it  to  remain  a moment, 
we  can  judge  better  of  the  sense  of  resistance. 

7.  The  integuments  should  not  be  stretched  over  the  part  percussed, 
as  when  the  stethoscope  is  employed,  for  an  unnatural  degree  of  resist- 
ance is  thus  communicated  to  the  hand  of  the  operator  from  the  muscu- 
lar tension.  In  every  case,  especially  where  the  abdomen  is  examined, 
the  integuments  and  superficial  muscles  should  be  rendered  as  flaccid  as 
possible. 

8.  It  is  always  best  to  percuss  on  the  naked  skin.  It  is  not  abso- 
lutely essential,  however ; and  in  cases  where,  from  motives  of  delicacy, 
it  is  desirable  that  the  chest  or  abdomen  be  not  exposed,  it  only  becomes 
necessary  that  the  covering  of  linen  or  flannel  be  of  equal  thickness 
throughout,  and  not  thrown  into  folds. 

9.  When  percussion  causes  pain,  the  force  of  the  blow  must  of  course 
be  diminished.  Under  such  circumstances,  however,  it  will  often  be 
necessary  to  distrust  the  results. 

10.  The  position  in  which  the  individual  examined  should  be  placed, 


BY  PERCUSSION. 


53 


will  vary  according  to  the  organ  explored.  In  percussing  the  thoracic 
organs  and  the  liver,  a standing  or  sitting  position  is  most  convenient. 
The  stomach,  intestines,  uterus,  bladder,  and  abdominal  tumors  or 
effusions,  are  best  examined  when  the  patient  is  lying  on  the  back,  with 
the  knees  flexed  so  as  to  relax  the  abdominal  walls,  and,  if  necessary,  the 
head  and  neck  bent  forward,  and  supported  by  pillows.  In  percussing 
the  spleen,  the  individual  should  lie  on  the  right  side ; and  when  the 
kidneys  are  examined,  he  should  lie  on  the  breast  and  abdomen.  In 
cases  of  effusion  into  the  serous  cavities,  a change  of  position  furnishes 
most  valuable  indications. 

11,  In  percussing  any  particular  organ,  the  pleximeter  should  be  first 
applied  over  its  centre,  where  the  sound  and  sense  of  resistance  it  may 
furnish  are  most  characteristic.  Two  blows  with  the  hammer  are  gene- 
rally sufficient  to  determine  this.  From  the  centre,  the  pleximeter  should 
be  moved  gradually  towards  the  periphery,  or  margin  of  the  organ,  and 
struck  as  it  proceeds  with  the  hammer,  now  forcibly,  now  lightly,  until 
the  characteristic  sound  of  the  next  organ  be  elicited.  The  pleximeter 
is  then  gradually  to  be  returned  towards  the  organ  under  examination, 
until  the  difference  of  tone  and  sense  of  resistance  become  manifest.  In 
this  manner  having  first  heard  the  two  distinct  sounds  well  characterised, 
we  shall  be  better  enabled  to  determine  with  accuracy  the  limit  between 
the  one  and  the  other.  This  may  be  done  exactly,  after  having  deter- 
mined whereabouts  the  line  of  separation  is,  by  placing  the  long  diameter 
of  the  pleximeter  transversely  across  it,  and  striking,  first  one  end  of  the 
instrument,  and  then  the  other,  till  the  precise  spot  is  determined.  This 
spot  should  now  be  marked,  by  placing  with  a pen  a dot  of  ink  on  the 
skin,  or  employing  for  this  purpose  a very  soft  black-lead  pencil.  The  oppo- 
site and  then  other  portions  of  the  margin  of  the  organ  should  be  limited 
in  the  same  manner,  and  these  in  turn  should  be  marked  until  the  whole 
organ  be  completely  examined.  Then  by  uniting  all  these  marks  with  a 
line  of  ink  or  pencil,  we  have  the  exact  form  of  the  organ  drawn  upon  the 
skin.  When  it  is  thought  necessary  to  render  the  first  line  permanent, 
in  order  to  see  if  any  subsequent  change  take  place  in  the  size  of  the 
organ,  or  extent  of  the  dulness,  it  may  be  rendered  so  by  carrying  lightly 
over  the  ink  line  a stick  of  nitrate  of  silver  previously  moistened. 

Special  Rules  to  be  followed  in  Percussing  Particular  Organs. 

Before  proceeding  to  percuss  individual  organs  in  persons  laboring 
under  disease,  you  should  obtain  a general  knowledge  of  the  limits  and 
intensity  of  dulness  on  percussing  the  thoracic  and  abdominal  viscera  in 
health.  The  accompanying  figures  convey  this  information  with  great 
accuracy,  the  depth  of  tint  corresponding  to  the  dulness  of  tone  and 
amount  of  resistance.  The  normal  sonoriety  and  dulness  exhibited 
(Figs  26  and  27)  will  enable  you  to  compare  with  readiness  the  altera- 
tions revealed  by  percussion  under  a variety  of  diseased  conditions. 

Lungs. — Percussion  of  the  lungs  generally  bears  reference  to  a change 
in  density,  which  is  only  to  be  detected  by  comparing  the  healthy  with 
the  morbid  portions.  The  great  practical  rule  here  to  be  followed  is,  to 
apply  the  pleximeter  with  the  same  firmness,  and  exactly  in  the  same 


54 


EXAMINATION  OF  THE  PATIENT 


situation,  to  each  side  of  the  chest  in  succession,  and  to  let  the  blow  with 
the  hammer  be  given  with  an  equal  force.  Care  must  be  taken  that  the 
position  of  both  arms  be  alike,  as  the  contraction  of  the  pectoral  muscles 
on  one  side  more  than  on  the  other  may  induce  error.  In  short,  every  cir- 
cumstance must  be  the  same  before  it  is  possible  to  determine,  in  delicate 


Fig.  26.  Fig.  27. 


cases,  either  from  the  tone  or  sense  of  resistance,  whether  change  of  den- 
sity exist  in  the  lungs.  When  circumscribed  alterations  are  discovered 
in  the  pulmonary  tissue,  their  limits  may  be  marked  out  on  the  surface 
of  the  skin,  in  the  manner  previously  indicated.  In  this  way  I have  fre- 
quently succeeded  in  determining  with  accuracy  the  size  and  form  of  cir- 
cumscribed indurations,  arising  from  partial  pneumonia  and  pulmonary 
apoplexy.  Under  the  clavicles,  the  pleximeter  must  be  applied  with  great 
firmness.  Inferiorly,  a thin  layer  of  lung  lies  over  the  superior  surface 
of  the  liver ; and  to  determine  the  exact  place  where  its  inferior  border 
terminates,  the  blows  with  the  hammer  should  be  very  slight.  Posteriorly, 
also,  the  pleximeter  must  be  firmly  applied,  and  the  force  of  the  blows 
considerable;  but  they  should  decrease  in  force  inferiorly,  where  a thin 
layer  of  lung  descends  over  the  liver  much  deeper  than  anteriorly. 

In  a healthy  state,  a distinct  difference  may  be  observed  in  the 
sonoriety  of  the  lungs  immediately  after  a full  expiration  and  a full  in- 
spiration. This  does  not  take  place  when  the  tissue  becomes  indurated 
from  any  cause ; and  thus  we  are  furnished  with  a valuable  diagnostic 
sign.  Congestion  of  the  lung,  and  pneumonia  in  its  first  stage,  cause 

Fig.  26,  Anterior,  and  Fig.  27,  posterior  view  of  the  normal  limits  and  intensity 
of  dulness  on  percussion.  P,  pulmonal  sound  ; C,  cardiac  sound  ; H,  hepatic  sound  ; 
S,  splenic  sound ; G,  gastric  sound  (here  the  stomach  is  moderately  distended  with 
air) ; E,  enteric  sound.  In  the  anterior  view  the  intestines  are  tolerably  free  from 
air,  except  CO,  colic  sound,  from  distended  colon.  The  descending  colon  and  rectum 
are  filled,  and  sound  dull.  HU,  humoral  soimd,  over  a distended  bladder ; M,  mus- 
cular, and  0,  osteal  sounds. — {Piorry.) 


BY  PERCUSSION. 


55 


only  slight  dulness  and  increased  resistance,  which,  however,  may  occa- 
sionally be  detected  by  the  practised  percussor.  In  the  second  and  third 
stage  of  pneumonia,  and  in  apoplexy  of 
the  lung,  this  dulness  and  resistance 
are  well  marked,  and  even  an  impres- 
sion of  hardness  and  solidity  commu- 
nicated to  the  hand.  When,  however, 
the  lung  is  infiltrated  with  tubercle,  the 
induration  is  most  intense,  and  the 
greatest  degree  of  resistance  commu- 
nicated. 

Partial  indurations  from  apoplexy 
or  simple  cancerous  and  tubercular  ex- 
udation, may  be  detected  by  percus- 
sion, even  when  deep-seated  and  cov- 
ered by  healthy  portions  of  the  lungs. 

In  this  case,  by  pressing  with  the  plex- 
imeter,  and  striking  lightly,  a tympan- 
itic sound  only  is  heard ; but  by  press- 
ing the  pleximeter  down  firmly,  and 
striking  with  force,  the  dull  sound 
may  be  elicited  and  circumscribed. 

When  indurations,  however,  exist  in- 
feriorly  in  those  portions  of  the  lungs  which  overlap  the  liver,  it  requires 
great  practice  to  detect  them  with  certainty.  Caverns  in  the  lungs,  when 
large  and  filled  with  air,  induce  a tympanitic  sound  (Fig.  28,  3)  ; but 
they  are  generally  more  or  less  full  of  viscous  and  fluid  matters,  and 
give  rise  to  dulness. 

Two  or  three  ounces  of  fluid  may  be  detected  in  the  pleural  cavity, 
by  causing  the  patient  to  sit  up.  The  height  or  level  of  the  fluid  is 
readily  determined,  and  should  be  marked  daily  by  a line  made  with 
nitrate  of  silver.  If  the  effusion  be  only  on  one  side,  the  increased  dul- 
ness is  more  easily  detected.  It  disappears  on  placing  the  patient  in 
such  a position  as  will  cause  the  fluid  to  accumulate  in  another  part  of 
the  pleural  cavity,  when  the  space  which  was  previously  dull  becomes 
clear  (Fig,  29).  When  the  effusion  entirely  fills  the  pleural  cavity,  no 
limit,  of  course,  can  be  detected  ; but,  even  then,  the  dulness  is  distin- 
guished from  that  of  the  liver  by  the  diminished  feeling  of  resistance. 

When  the  lung  is  emphysematous,  or  if  air  be  present  in  the  pleura, 
the  sound  becomes  unusually  tympanitic  ; this  tympanitic  note  on  per- 
cussion, however,  may  exist  under  a variety  of  circumstances,  which  it 
is  of  great  importance  to  be  acquainted  with.  Thus,  condensation  from 
pneumonia  at  the  posterior  part  of  the  lung,  or  partial  pleurisy,  by  caus- 
ing the  anterior  portion  of  the  organ  to  be  over-distended  with  air,  or 
compressed  and  pushed  forward,  may  give  origin  to  this  sound.  The 
same  occurs  in  chronic  phthisis,  over  parts  which  were  once  dull,  either 

Fig.  28.  Phthisis — Atrophied  heart  and  liver — Prolonged  abstinence.  1,  Atrophied 
heart ; 2,  Infiltrated  tubercle  on  left  side ; 3,  the  same  on  right  side  with  a cavity ; 4, 
Atrophied  liver ; 6,  Spleen ; 6,  unusual  dulness  over  abdomen,  from  prolonged  absti- 
nence. — {Piorry. ) 


56 


EXAMINATION  OF  THE  PATIENT 


from  large  dry  cavities  filled  with  air,  or  from  the  emphysema  which 
accompanies  cicatrices  and  partial  condensation  of  pulmonary  texture. 

On  percussing  the  chest  with  the 
mouth  open,  there  may  frequently 
be  elicited  a sound,  which  Laennec 
first  likened  to  gently  striking  a 
cracked  pot.  It  may  be  very  closely 
imitated  by  crossing  the  palms  of 
both  hands,  so  as  to  leave  a hollow 
between  them,  and  then  striking  the 
knuckles  of  the  inferior  hand 
against  the  knee,  so  as  to  produce  a 
clinking  sound.  I have  produced  it 
by  percussing  the  chest  in  cases  of 
pleurisy,  pneumonia,  and  phthisis; 
of  congested,  apoplectic,  and  emphy- 
sematous lungs,  and  even  when 
these  organs  were  quite  healthy,  if,  as 
in  young  subjects,  the  ribs  are  very 
elastic.  The  conditions  which  seem 
favorable  for  the  production  of  this 
sound  are,  1st,  A certain  amount  of 
confined  air  rendering  the  tissue  of 
the  lung  tense;  2d,  The  sudden  com- 
pression of  this  air  by  a solid  body 
in  its  neighborhood ; 3d,  Communication  of  this  air  with  the  external 
atmosphere.  Hence  it  is  not  diagnostic  of  any  particular  disorder,  or 
pathological  state,  such  as  a pulmonary  cavity,  so  much  as  of  a physical 
condition,  which,  however,  if  rightly  interpreted,  is  likely  to  be  of  the 
utmost  advantage  in  our  efforts  at  detecting  the  nature  of  diseases.* 

Heart. — To  mark  out  the  precise  limits  of  the  heart  constitutes  the 
first  difficult  lesson  in  the  art  of  percussion.  M.  Piorry  commences  by 
determining  the  clear  sound  at  the  upper  end  of  the  sternum,  and  bring- 
ing the  pleximeter  gradually  downwards  till  the  dull  sound  of  the  heart 
be  heard.  1 have  found  it  best  to  place  the  instrument  first  under  and 
a little  inside  the  left  nipple,  where  the  cardiac  dulness  is  most  intense ; 
then  to  carry  it  upwards,  striking  it  continually  with  the  hammer  until 
the  clear  sound  of  the  lung  be  elicited ; then  by  bringing  it  down  again 
towards  the  heart,  we  shall  readily  distinguish  the  line  where  cardial 
dulness  commences,  and  thus  limit  the  superior  margin  of  the  organ. 
The  same  method  is  to  be  followed  in  determining  the  situation  of  the 
lateral  margins,  only  carrying  the  pleximeter  outwards  or  inwards,  strik- 
ing more  and  more  forcibly  with  the  hammer,  until  the  clear  tympanitic 
sound  of  the  lung  only  be  heard.  It  is  more  difficult  to  determine  the 

* See  the  author’s  “ Clinical  Investigation  into  the  diagnostic  value  of  the  cracked- 
pot  sound.” — Edinburgh  Medical  ^Journal  for  Marc\  1856. 

Fig.  29.  Pleurisy.  1,  On  the  right  side  when  in  the  erect  position ; 2,  On  the 
left  side,  when  lying  on  the  right ; 3,  Kidneys,  the  left  enlarged  ; 4,  Spleen. — 
{Piorry.) 


BY  PERCUSSION. 


51 


situation  of  the  apex  of  the  heart ; for  as  this  rests  on  the  diaphragm, 
and  this  again  upon  the  left  lobe  of  the  liver,  it  cannot  readily  be  distin- 
guished from  them.  The  size  of  the  heart,  however,  may  be  pretty 
accurately  estimated,  by  limiting  its  superior  and  lateral  margins.  In 
females,  the  left  mammary  gland 
should  be  drawn  upwards  and  out- 
wardsby  an  assistant.  In  the  natural 
position  of  the  organ  (Figs.  1 and  2) 
it  is  well  to  remember  that  the  auri- 
cles are  on  the  right,  and  the  ventri- 
cles on  the  left  side 

The  normal  size  of  the  heart  differs 
in  different  persons.  As  a general 
rule,  however,  it  may  be  considered 
that,  if  the  transverse  diameter  of  the 
dulness  measure  more  than  two  inches, 
it  is  abnormally  enlarged.  It  has  been 
known  to  measure  seven  inches.  (Pi- 
orry.)  In  hydropericardium,  the  dul- 
ness has  been  remarked  to  exist  rather 
at  the  superior  part  of  the  sternum, 
than  on  one  side  or  the  other.  (Pior- 
ry,  Reynaud.)  In  pericarditis  it 
bulges  out  inferiorly  (Fig.  30,  1).  In 
hypertrophy  and  dilatation  of  the  right  auricle,  the  increased  extent  of  the 
dulness  stretches  toward  the  median  line,  and  sometimes  passes  over  it 
(Fig.  31,  3).  In  similar  hypertrophy  of  the  left  ventricle,  the  dulness 
extends  on  the  left  side  more  or  less,  according  to  the  increased  size  of 
the  heart  (Fig.  31,  1,  and  Fig.  32).  In  concentric  hypertrophy  there  is 
little  or  no  enlargement,  but  the  density  is  greatly  increased. 

The  presence  of  tubercle  in  the  lungs  surrounding  the  heart;  aneu- 
risms or  other  tumors  pressing  upon,  or  in  the  neighborhood  of,  the 
organ  ; hypertrophied  liver,  extensive  empyema,  etc.,  etc.,  may  render 
the  mensuration  of  the  extent  of  its  dulness  difficult  or  impossible.  The 
changes  in  position  of  the  heart  produced  by  a pleurisy  on  one  side  push- 
ing it  towards  the  opposite  one,  or  by  the  pregnant  uterus,  or  an  ovarian 
tumor  or  ascites  thrusting  it  upwards,  may  also  be  determined  by  per- 
cussion, especially  if  the  impulse  can  be  distinguished  by  palpation  or 
auscultation. 

Liver. — Limitation  of  the  size  of  the  liver  should^  be  commenced  by 
placing  the  pleximeter  over  the  organ  on  the  right  side,  where  the  dul- 
ness and  resistance  are  greatest.  It  should  then  be  carried  upwards  un- 
til the  clear  sound  of  the  lung  be  distinguished,  when  it  ought  again  to 
be  brought  down  and  the  limit  marked.  This  limit,  however,  may  indi- 
cate either  the  inferior  margin  of  the  lung,  or  superior  convex  surface 
of  the  liver. 

Now  as  a thin  layer  of  lung  descends  in  front  of  the  liver,  it  will  be 

Fig.  30.  Pericarditis^  'pneumonia.^  and  loaded  rectum,  1,  Pericarditis;  2,  Pneu- 
monia separable  from  the  extreme  dulness  of  the  liver  ; 3,  Loaded  rectum. — {Piorry.) 


58 


EXAMINATION  OF  THE  PATIENT 


necessary  to  determine  where  the  tympanitic  sound  ceases  inferiorly,  by 
striking  gently  with  the  hammer,  and  where  the  parenchymatous  sound 
ceases  superiorly,  by  striking  forcibly,  so  that  vibrations  may  be  commu- 
nicated to  the  organ  through  the  layer  of  lung.  The  space  bkween  these 
two  lines  thus  marked  on  the  surface  is  wider  in  some  individuals  than 
in  others,  and  deeper  and  more  extensive  posteriorly,  than  anteriorly. 
By  carrying  the  pleximeter  from  the  right  side  anteriorly,  and  then  pos- 
teriorly towards  the  left  of  the  patient,  the  whole  superior  margin  may 
be  thus  detected,  and  marked  with  ink  upon  the  surface,  except  where 
the  liver  comes  in  contact,  through  the  medium  of  the  diaphragm,  with 

the  apex  of  the  heart.  The  inferior 
margin  is  for  the  most  part  readily  de- 
tected. It  must  be  remembered, 
however,  that  in  the  same  manner  as 
a thin  layer  of  lung  covers  the  upper 
margin,  so  a thin  layer  of  liver  de- 
scends on  the  right  side  over  the  intes- 
tine. It  is,  therefore,  necessary  to  be 
cautious  in  determining  the  inferior 
margins,  for  a tolerably  strong  blow 
with  a hammer  may  give  rise  to  a tym- 
panitic sound  from  the  intestine,  heard 
through  the  liver.  The  lower  margin 
must  be  percussed  in  an  inverse  man- 
ner to  the  superior,  and  as  we  proceed 
downwards,  the  force  of  the  blow 
should  be  diminished.  The  inferior 
margin  of  the  liver  is  in  general  readily 
detected,  from  the  contrast  which,  on 
percussion,  its  dulness  and  density  pre- 
sent, contrasted  with  the  tympanitic 
and  elastic  feel  of  the  intestines  and  stomach. 

The  superior  limit  of  this  organ  is  generally  found  about  two  inches 
below  the  right  nipple,  at  a point  corresponding  with  the  fifth  rib.  Its 
inferior  border  descends  to  the  lower  margin  of  the  ribs.  The  extent  of 
the  jecoral  dulness  in  the  healthy  state  is  in  general  two  inches  on  the 
left  side,  three  inches  in  the  hepatic  region  anteriorly,  and  four  inches 
in  the  hepatic  region  laterally.  (Piorry.) 

Variations  in  the  size  of  the  liver,  from  congestion,  inflammation, 
abscesses,  hydatids,  tumors,  atrophy,  etc.,  etc.,  may  often  be  exactly  de- 
termined by  means  of  percussion.  In  icterus,  the  increase  and  diminu- 
tion of  this  organ,  as  evinced  by  lines  marked  on  the  skin,  will  generally 
be  found  to  bear  a proportion  to  the  intensity  of  organic  disease.  When 
tumors  are  present,  the  inferior  border  often  presents  an  irregular  form. 
If  the  inferior  lobes  of  the  lung  be  indurated  by  tubercles  or  hepatisation, 
it  becomes  difficult  or  impossible  to  draw  the  limit  between  them  and  the 
liver.  When  fluid  effusion  exists  in  the  pleura,  the  increased  density  of 

Fig.  31.  Hypertrophy  of  liver  and  heart  1,  Hypertrophied  liver,  which  may  be 
still  further  enlarged  to  the  dotted  lines  over  the  abdomen ; 2,  Distended  gall-bladder ; 
3,  Hypertrophied  right  auricle — 1 , Hypertrophied  ventricles  ; 4,  Loaded  coecum ; 
6,  Loaded  rectum  and  descending  colon. — {Piorry.) 


BY  PERCUSSION. 


59 


the  liver  may  still  serve  to  distinguish  it,  and  by  changing  the  position 
of  the  patient,  its  upper  edge  in  the  majority  of  cases  may  be  limited. 
In  cases  of  ascites,  we  must  lay  the 
patient  on  the  left  side  in  order  to 
measure  the  right  lobe — on  the  right 
side  to  measure  the  left  lobe,  and  on 
the  abdomen  to  percuss  it  posteriorly. 

Sometimes  the  right  lobe  of  the  liver 
is  so  enormously  hypertrophied,  that 
its  inferior  margin  extends  to  the 
right  iliac  fossa  (thg.  32). 

When  the  gall-bladder  is  much 
distended  with  bile,  or  contains  gall- 
stones to  any  amount,  it  may  readily 
be  detected  by  percussion,  and  the 
dulness  it  occasions  immediately  un- 
der the  inferior  margin  of  the  liver, 
anteriorly  and  somewhat  laterally, 
may  be  marked  off  (Fig.  31,  2). 

Spleen. — In  percussing  the  spleen, 
it  is  necessary 
that  the  patient 
lie  on  the  right 

side,  and  it  is  advantageous  that  the  examination  be 
made  before,  rather  than  after,  meals.  Anteriorly 
the  sonoriety  of  the  stomach  and  intestines  causes 
the  margin  readily  to  be  distinguished.  Posterior- 
ly, however,  where  the  organ  approaches  towards 
the  kidneys,  this  is  more  difficult.  Its  superior 
and  inferior  margins  may  be  made  out  by  striking 
the  instrument  with  some  force,  and  following  the 
rule  (No.  10)  previously  given,  p.  53.  This  organ 
offers  great  resistance  on  percussion. 

In  health  the  spleen  never  projects  below  the 
false  ribs,  even  during  a deep  inspiration.  Its 
general  size  is  about  four  inches  long  and  three 
inches  wide.  (Piorry.)  In  diseased  states  it  may 
be  atrophied  or  enlarged.  I have  seen  it  measure 
upwards  of  twelve  inches  long  and  eight  wide,  and 
it  then  may  project  upwards  and  downwards,  as 
indicated  by  the  dotted  lines  in  Fig.  33.  A pleu- 
ritic effusion,  ascites,  pneumonia,  or  tubercular  de- 
position in  the  inferior  lobe  of  the  left  lung,  may 
of  this  organ  difficult  or  impossible.  If  the 

Fig.  32.  Hypertrophied  liver  and  spleen  in  leucocythemia — Enlarged  heart.  1, 

, Hypertrophied  heart  with  dilatation;  2,  Great  dulness  over  the  larger  part  of  abdomen 
from  enlarged  liver  on  the  right  side;  and  enlarged  spleen  on  the  left. — [Partly  from 
Piorry. ) 

Fig.  33.  1,  Slightly  enlarged  spleen,  pushed  somewhat  upwards.  The  dotted 

lines  indicate  how  the  organ  may  be  enlarged  in  various  diseases.  7,  Elongation 
downwards  in  leucocythemia. — [Slightly  modified  from  Piorry.) 


60 


EXAMINATION  OP  THE  PATIENT 


dulness  cannot  be  detected,  we  may  infer  that  its  dimensions  are  small. 
(Mailliot.) 

S'omach  ayid  Intestines. — The  sounds  elicited  by  percussion  of  the 
stomach  and  intestines  are  of  the  greatest  service  to  the  practitioner: — 
1st,  As  furnishing  him  with  the  means  of  determining  the  form  of  other 
organs,  as  the  liver,  spleen,  or  bladder;  2dly,  As  enabling  him  to  dis- 
tinguish the  presence  or  absence  of  fsecal  or  alimentary  matter;  and, 
3dly,  As  the  means  of  diagnosing  abdominal  tumors.  Hence  it  is  in- 
cumbent on  every  physician  to  be  able  at  once  to  recognise  the  differ- 
ence between  the  tones  furnished  by  the  stomach,  small  and  large  intes- 
tines, under  various  circumstances.  To  arrive  at  this  knowledge,  it  is 
necessary  to  be  acquainted  with  the  relative  positions  of  the  different 
abdominal  viscera,  and  the  regions  of  the  abdomen  to  which  they  corre- 
spond. For  instance,  it  is  usually  the  liver  and  not  the  stomach  that 
occupies  the  so-called  epigastric  region  just  below  the  end  of  the  ster- 
num. The  last-named  organ  is  for  the  most  part  situated  within  the  left 
lower  costal  walls,  just  below  the  heart  and  the  base  of  the  left  lung. 
(Figs.  1 and  2.) 

In  exploring  the  abdomen  by  means  of  percussion,  the  pleximeter 
should  first  be  placed  immediately  below  the  xiphoid  cartilage,  pressed 
firmly  down,  and  carried  along  the  median  line  towards  the  pubes,  strik- 
ing it  all  the  way,  now  hard,  now  gently,  with  the  hammer.  The  differ- 
ent tones  which  the  stomach,  colon,  and  small  intestines  furnish,  will 
thus  be  distinctly  heard.  The  pleximeter  should  then  be  carried  late- 
rally, alternately  to  the  one  side,  and  then  to  the  other,  till  the  whole 
surface  be  percussed.  In  this  manner  the  different  tones  produced  by 
the  coecum  and  ascending  colon  on  the  right  side,  as  well  as  by  the  stomach 
and  descending  colon  on  the  left,  will  be  respectively  distinguished  from 
that  furnished  by  the  small  intestines.  The  sounds  and  sense  of  resist- 
ance will  be  modified  according  as  the  different  viscera  are  full  or  empty, 
as  any  one  can  determine  on  his  own  body  by  means  of  the  pleximeter 
and  hammer.  When  the  intestines  are  full  of  fluid  or  solid  contents, 
such  portions  may  be  circumscribed  and  marked  out  on  the  surface  of 
the  skin.  I have  thus  often  succeeded  in  determining  the  internal 
margin  of  the  colon,  in  its  ascending,  transverse,  or  descending  portions. 
Sometimes  a portion  of  intestine  is  found  lying  between  the  abdominal 
walls  and  the  stomach.  The  latter,  however,  may  be  readily  limited,  by 
pressing  down  the  pleximeter,  causing  the  patient  to  eat  or  drink,  or  by 
examining  after  dinner.  The  small  intestines  rarely  ever  fail  to  yield  a 
tympanitic  sound — a circumstance  by  which  they  may  readily  be  dis- 
tinguished from  the  stomach  and  large  intestines.  The  distance  of  any 
particular  knuckle  of  intestine  from  the  abdominal  walls  may  be  pretty 
accurately  calculated  by  the  force  necessary  to  be  employed  in  pressing 
down  the  pleximeter,  and  striking  with  the  hammer,  in  order  to  elicit 
a tympanitic  or  dull  sound. 

It  is  unnecessary  to  point  out  the  numerous  circumstances,  and 
morbid  conditions,  in  which  percussion  of  the  abdomen  may  prove  useful 
in  practice.  Displacements  and  variations  in  size  of  the  stomach  or 
intestines,  femoral  and  scrotal  hernia,  mesenteric,  ovarian,  and  other 


BY  PERCUSSIONo 


61 


tumors,  peritoneal  adhesions  and  effusions,  may  all  frequently  be  di- 
agnosed, and  their  limits  determined,  by  a careful  examination  with 
the  plexirneter  and  hammer.  By  means  of  percussion,  even  the  nature 
of  the  tumor  may  often  be  arrived  at ; as,  for  instance,  whether  it  be 
fungus  hematodes,  scirrhous,  encysted,  osseous,  etc.,  by  the  different 
degrees  of  resistance  they  possess.  Care,  however,  must  be  taken  not 
to  confound  with  tumors  an  enlarged  spleen  or  liver,  a distended  uterus 
or  bladder,  stomach  full  of  alimentary  matter,  etc.  It  should  also  be 
remembered  that  when  tlie  patient  lies  on  his  back  the  percussion  sound 
over  the  stomach  is  resonant,  but  when 
he  stands  it  is  generally  dull  from  the 
gravitation  of  the  food. 

In  a practical  point  of  view  it  is 
often  useful  to  determine,  by  means  of 
percussion,  whether  an  enema  or  a pur- 
gative by  the  mouth  is  likely  to  open  the 
bowels  most  rapidly.  If,  for  instance, 
there  be  dulness  in  the  left  iliac  fossa, 
in  the  track  of  the  descending  colon, 
that  part  of  the  intestine  must  be  full 
of  faeces,  and  an  enema  is  indicated. 

If,  on  the  other  hand,  the  left  iliac 
fossa  sound  tympanitic,  and  the  right 
sound  dull,  an  enema  is  of  little  service, 
as  it  will  not  extend  to  the  coecum,  and 
purgatives  by  the  mouth  are  indicated 
(Figs.  30  and  31). 

Effusion  of  fluid  into  the  peritone- 
um may  be  determined  with  great  ex- 
actitude by  means  of  percussion,  and  the  height  of  the  fluid  marked,  as 
in  the  case  of  pleuritic  effusion.  In  the  same  manner,  a change  of  po- 
sition furnishes  similar  results.  Abdominal  distension  from  accumulation 
of  air  may  also  be  determined.  If  it  be  within  the  intestine,  the  tym- 
panitic note  is  partial  and  limited,  if  in  the  peritoneal  cavity  more  equa- 
ble and  diffused  (Fig.  34). 

Kidneys. — To  percuss  the  kidneys,  the  patient  should  lie  on  the 
abdomen  and  chest;  a position  which  allows  any  ascitic  fluid  that  may 
be  present  to  gravitate  downwards,  whilst  the  intestines  float  upwards. 
The  dulness  and  great  resistance  offered  by  the  renal  organs  are,  under 
such  circumstances,  at  once  determined  (Figs.  27  and  29).  Their 
external  margins  may  for  the  most  be  easily  limited,  in  consequence  of 
the  loud  tympanitic  note  of  the  intestines,  which  can  be  elicited  round 
their  external  circumference  in  the  two  flanks.  Internally  the  dulness 
merges  into  that  of  the  spinal  column.  Enlargement  of  one  or  both  of 
these  organs  from  calculous  or  scrofulous  nephritis,  pyelitis,  or  other 

Fig.  34.  Dropsy  of  the  abdomen.,  enlarged  heart,  and  aneurism.  1,  Aneurism  pro- 
jecting from  the  arch  of  the  aorta  on  the  right  side  ; 2,  Hypertrophied  heart,  es- 
pecially of  the  right  auricle  ; 3,  Liver,  pushed  upwards ; 4,  Ascitic  fluid,  gravitating 
inferiorly,  the  patient  being  on  the  back ; 5 and  6,  Stomach  and  intestines,  superiorly 
and  anteriorly. — {Piorry.) 


62 


EXAMINATION  OF  THE  PATIENT 


diseases,  may  in  this  manner  be  made  out,  as  seen  (Fig.  29)  on  the  left 
side.  Atrophy  of  these  organs  is  more  difficult  to  determine  with  ex“ 
actitude,  hut  may  be  demonstrated  by  careful  percussion. 

Bladder. — This  viscus  is  only  to  be  detected  by  percussion,  when  it 
is  more  or  less  distended,  and  rises  above  the  pubes.  It  may  then  be  dis- 
tinguished, and  its  circular  margin  limited,  by  observing  the  tympanitic 
sound  of  the  intestines,  on  the  one  hand,  and  the  dull  sound  furnished 
by  the  bladder,  with  increased  resistance  on  the  other.  When  covered 
by  intestines,  it  will  be  necessary  to  press  down  the  pleximeter  with 
tolerable  firmness,  but  not  in  such  a manner  as  to  give  the  patient  pain. 
In  the  infant,  the  situation  of  the  bladder  is  not  so  deep  in  the  pelvis,  and 
a small  quantity  of  fluid  renders  it  cognizable  by  means  of  percussion. 

A ready  approximation  of  the  state  of  the  bladder  will  be  found  of 
great  service  in  cases  of  fever,  apoplexy,  delirium,  imbecility,  paraplegia, 
etc.  etc.  In  several  cases  it  has  been  found  dangerously  distended,  on 
percussing  the  abdomen  to  determine  the  state  of  the  intestines. 

I have  here  only  noticed  those  circumstances  in  the  art  of  percus- 
sion which  may  be  readily  accomplished,  and  which  every  one  may 
master  in  a few  months  by  care  and  attention.  For  a description  of 
the  more  delicate  points,  such  as  percussion  of  the  foetus  in  utero, 
accurately  limiting  the  auricles  and  ventricles,  determining  and  marking 


out  the  ascending  and  transverse  portions  of  the  arch  of  the  aorta,  etc., 
I must  refer  you  to  the  admirable  works  of  MM.  Piorry^  and  Mailliot.f 

^ De  la  Percussion  Mediate,  etc.,  Paris,  1828.  Du  Precede  Operatcire,  Paris,  1831. 
De  I’Examen  Plessimetrique  de  I’Aorte  Ascendante,  et  de  la  Crosse  Aortique,  etc. 
Archives  Gen.  de  Med.,  vol.  ix.,  1940,  p.  431.  On  Percussion  of  the  Uterus,  and  its 
Results  in  the  Diagnosis  of  Pregnancy:  Monthly  Journal,  1846-7,  p.  857.  Atlas  de 
Plessimetrisme,  Paris,  1851. 

f Mailliot  (L.)  Traite  de  la  Percussion  Mediate,  etc.,  Paris  ; translated  into  English, 
with  notes,  by  Dr.  George  Smith  of  Madras. 

Figs.  35  and  36.  Anterior  and  Posterior  outlines  of  the  trunk,  for  marking  more 
readily  the  results  of  Percussion  and  Auscultation. 


BY  AUSCULTATION. 


63 


A very  convenient  method  of  recording  the  results  of  percussion, 
consists  in  filling  in  an  outline  of  the  trunk,  with  pencil,  so  as  to  mark, 
by  different  shading,  the  intensity  or  extent  of  the  dulness.  With  this 
view  I have  caused  the  small  outlines  of  the  trunk,  anteriorly  and  pos- 
teriorly, here  figured,  to  be  printed  in  sheets,  which  are  gummed  at  the 
back.  They  can  in  this  way  be  kept  in  the  pocket  of  your  note-book, 
and  easily  attached  to  the  paper  when  required.  The  same  outlines  will 
serve  to  mark  the  position  of  sounds  heard  in  the  chest,  when  the  upper 
part  of  the  outline  only  may  be  used.^ 

AUSCULTATION. 

The  object  of  auscultation  is  to  ascertain  and  appreciate  the  nature 
of  the  various  sounds  which  occur  in  the  interior  of  the  body.  It  has 
been  found  most  useful  when  applied  to  the  pulmonary  and  circulatory 
organs.  Auscultation  of  the  abdomen  is  occasionally  serviceable, 
especially  in  certain  cases  of  pregnancy,  and  during  labor.  It  has  also 
been  applied  to  the  head,  although  I have  never  been  able  to  make  out 
any  useful  results  from  the  practice. 

General  Rules  to  be  followed  in  the  Practice  of 
Auscultation. 

1.  Auscultation  may  be  practised  directly  by  applying  the  ear  to 
the  part,  or  indirectly  through  the  medium  of  a stethoscope.  Generally 
speaking,  direct  auscultation  answers  every  necessary  purpose  except 
when  the  surface  is  unequal,  or  when  it  is  desirable  to  limit  the  sounds 


Fig.  37.  Fig.  38,  Fig.  39.  Fig.  40.  Fig.  41. 

to  a small  region,  as  during  auscultation  of  the  heart.  In  either  of  these 

* These  sheets  may  be  obtained  of  Mr.  Thin,  bookseller.  South  Bridge. 

Figs.  3Y  and  38.  Stethoscopes  with  different  sized  trumpet  extremities,  the  smaller 
one  for  auscultating  the  heart,  oi  emaciated  subjects. 

Fig.  39.  Stethoscope  capable  of  being  shortened,  by  screwing  one  half  into  the  other. 
Fig.  40.  Stethoscope  invented  under  the  notion  that  its  form  would  facilitate  the 
conduction  of  sound. 

Fig.  41.  Stethoscope  invented  under  the  idea  that  the  spiral  form,  like  that  of  a 
shell,  would  increase  the  intensity  of  sound. 


64 


EXAMINATION  OF  THE  PATIENT 


cases  a stethoscope  is  necessary.  The  instrument  is  also  useful  to 
confirm  or  nullify  the  existence  of  certain  finer  sounds  which  may  be 
detected  by  the  naked  ear ; to  remove  the  head  of  the  practitioner  a 
respectable  distance  from  the  bodies  of  persons  not  distinguished  for 
cleanliness ; and  lastly,  as  the  most  delicate  method  of  auscultating  the 
chest  anteriorly  in  women.  You  should  regard  the  stethoscope  merely 
as  a means  to  an  end — that  end  being  the  right  appreciation  of  the 
pathological  changes  indicated  by  certain  sounds. 

2.  In  the  choice  of  a stethoscope,  you  should  observe,  1st,  That  the 
ear-piece  fits  your  own  ear;  2d,  That  the  trumpet- 
shaped  extremity  is  not  above  an  inch  and  a half  in 
diameter,  and  is  rounded  so  as  not  to  injure  the 
patient’s  skin  when  pressure  is  made  upon  it;  3d, 

That  it  is  light  and  portable.  The  instruments 
recently  made  of  gutta  percha  fulfil  all  these  condi- 
tions. 

The  forms  of  stethoscopes  vary  infinitely : those 
represented  (Figs.  37  to  39)  are  the  most  convenient, 
that  having  the  smaller  trumpet-shaped  end  being 
best  for  emaciated  subjects,  or  for  limiting  the  sounds 


Fig.  42.  Fig  43. 

of  the  heart.  Figs.  40  and  41  are  two  stethoscopes  which  were  presented 


Fig.  44. 

to  me  by  two  students,  both  of  whom  imagined  that  the  form  they  had 
given  the  instruments  intensified  the  sound.  This  result,  however,  is 
unquestionably  attained  by  the  double  stethoscope  of  Canman  (Fig.  43) 
and  the  dilFerential  stethoscope  of  Scott  Alison  (Fig.  44).  In  many 

Fig.  42.  Flexible  stethoscope. 

Fig.  43.  Canman’s  stethoscope. 

Fig.  44.  Differential  stethoscope  of  Dr.  Scott  Alison. 


BY  AUSCULTATION. 


65 


cases,  where  sounds  were  doubtful  with  the  ordinary  instruments,  they 
have  been  rendered  at  once  appreciable  and  positive  by  the  differential 
stethoscope.  Dr.  Scott  Alison  also  found  that  water  enclosed  in  a flat 
circular  bag  of  caoutchouc,  still  farther  increased  the  sound,  when  flexible 
stethoscopes  were  employed,  and  I have  satisfied  myself,  that  when  with 
these  instruments  no  sound  (friction  or  crepitation)  is  audible,  they  are 
at  once  rendered  so  by  employing  this  bag 
or  hydrophone  (Fig.  45).  Although  these 
flexible  stethoscopes  have  hitherto  seldom 
been  used,  I have  frequently,  during  the 
last  four  or  five  years,  met  with  cases  in 
which  the  differential  instrument  of  Dr. 

Scott  Alison  has  been  of  great  service.^ 

3.  In  applying  the  ear,  the  body  of 
the  patient  should  be  covered  only  with  a 
smooth  piece  of  linen  or  a towel.  But 
the  stethoscope  should  be  applied  to  the 
naked  skin,  and  held  steady  immediately 
above  the  trumpet-shaped  extremity  by  the 
thumb  and  index  finger , it  should  be 
pressed  down  with  tolerable  firmness, 
whilst  with  the  second,  third,  and  fourth 
fingers,  you  ascertain  whether  the  circular 
edge  be  perfectly  applied,  which  is  abso- 
lutely essential. 

4.  The  position  of  the  patient  will 

vary  according  to  the  part  examined.  In 
auscultating  the  lungs  anteriorly,  the  erect 
or  recumbent  positions  may  be  chosen,  the  Fig.  45. 

two  arras  being  placed  in  a symmetrical  position  by  the  side.  If  the- 
chest  be  examined  posteriorly,  the  individual  should  lean  somewhat 
forward  and  cross  the  arms  in  front.  In  auscultation  of  the  abdomen, 
various  positions  will  be  required,  according  as  the  anterior,  lateral,  or 
posterior  regions  demand  investigation.  The  practitioner,  also,  should 
choose  such  a position  as  will  prevent  too  much  stooping  or  straining. 
Grenerally  speaking,  the  beds  in  the  Infirmary  here  are  too  low,  and  ren- 
der auscultation  very  fatiguing  to  the  physician.  In  young  children  or 
infants  we  should  place  our  ears  on  their  backs. 

5.  Whenever  individuals  are  thrown  into  such  a state  of  agitation  as 
to  iuterfere  with  the  regular  action  of  the  heart  or  lungs,  the  examina- 
tion should  be  deferred  until  their  fear  diminishes,  or  the  greatest  cau- 
tion should  be  exercised  in  drawing  conclusions.  Non-attention  to  this 
rule  has  led  to  many  errors. 

6.  Before  examining  patients  in  a hospital,  it  is  necessary  that  you 
should  have  made  yourselves  perfectly  acquainted  with  the  sounds  which 
are  continually  going  on  in  the  healthy  body.  Omission  of  this  rule 

* See  his  valuable  work,  “ The  Physical  Examination  of  the  Chest  in  Pulmonary 
Consumption,  etc.”  London,  1861. 


Fig.  45.  The  Hydrophone  of  Dr.  Scott  Alison. 
5 


66 


EXAMINATION  OF  THE  PATIENT 


r<ot  only  renders  the  examination  of  patients  useless,  but  betrays  great 
want  of  consideration.  For,  as  it  is  only  from  the  alterations  the  healthy 
sounds  undergo,  or  from  their  being  replaced  by  others,  that  we  draw 
conclusions,  how  can  this  be  accomplished  if  we  are  ignorant  of  their 
character  in  the  first  instance  ? It  is  expected,  therefore,  of  every  ex- 
amining pupil,  that  he  should  be  familiar  with  the  character  and  theory 
of  the  various  sounds  heard  in  the  healthy  body  before  coming  to  the 
bed-side.  This  study  belongs  to  the  Institutes  of  Medicine,  rather  than 
to  that  of  Clinical  Instruction. 

Special  Rules  to  be  followed  during  Auscultation 
OF  THE  Pulmonary  Organs. 

1.  In  listening  to  the  sounds  produced  by  the  action  of  the  lungs, 
we  should  pay  attention  to  three  things : 1st,  The  natural  respiration; 
2d,  The  forced  or  exaggerated  respiration  ; and  3d,  The  vocal  resonance. 
For  this  purpose,  having  listened  to  the  sounds  during  ordinary  breath- 
ing, we  direct  the  patient  to  take  a deep  breath,  and  then,  still  listening, 
we  ask  him  a question,  and  during  his  reply  judge  of  the  vocal  re- 
sonance. 

2.  You  should  commence  the  examination  immediately  under  the 
centre  of  one  clavicle;  and  having  ascertained  the  nature  of  the  sounds 
and  vocal  resonance  there,  you  should  immediately  listen  at  exactly  ihe 
corresponding  spot  on  the  opposite  side.  The  examination  should  be 
continued  alternately  from  one  side  to  the  other,  in  corresponding  places, 
until  the  whole  anterior  surface  of  the  chest  is  explored.  The  posterior 
surface  is  then  to  be  examined  in  like  manner. 

3.  When  in  the  course  of  the  examination,  anything  different  from 
the  normal  condition  is  discovered  at  a particular  place,  that  place  and 
the  parts  adjacent  should  be  made  the  subject  of  special  examination, 
until  all  the  facts  regarding  the  lesion  be  ascertained. 

4.  It  is  occasionally  useful  to  tell  the  patient  to  cough,  in  which 
case  we  are  enabled  to  judge, — 1st,  Of  forced  inspiration,  as  it  precedes 
the  cough;  and  2d,  Of  the  resonance  which  the  cough  itself  occasions. 

Of  the  Sounds  produced  by  the  Pulmonary  Organs  in 
Health  and  in  Disease. 

I am  anxious  to  impress  upon  you,  that  the  sounds  which  may  be 
heard  in  the  lungs  are  like  nothing  but  themselves.  Students  are  too 
apt  to  take  up  erroneous  notions  from  reading  on  this  subject,  and, 
instead  of  listening  to  the  sound  actually  produced,  fatigue  themselves 
in  a vain  endeavor  to  hear  something  like  the  crackling  of  salt,  the 
rubbing  of  hair,  foaming  of  beer,  or  other  noises  to  which  these  sounds 
have  been  likened.  Preconceived  notions  frequently  oppose  themselves 
to  the  reception  of  the  truth,  and  have  to  be  got  rid  of  before  the  real 
state  of  matters  can  be  ascertained.  Hence  the  great  importance  of 
deriving  your  first  impressions  of  the  sounds  to  be  heard  by  auscultation, 
not  from  books  or  lectures,  but  from  the  living  body  itself. 

If  ^ou  listen  through  your  stethoscope,  placed  over  the  larynx  and 


BY  AUSCULTATION. 


67 


trachea  oi  a healthy  man,  you  will  hear  two  noises — one  accompanying 
the  act  of  inspiration,  and  the  other  that  of  expiration.  These  are 
called  the  laryngeal  and  tracheal  sounds  or  murmurs.  If  you  next 
place  your  stethoscope  a little  to  the  right  or  left  of  the  manubrium  of 
the  steriiuin,  you  will  hear  the  same  sounds  diminished  in  intensity. 
T lese  arc  the  hronchial  sounds  or  murmurs.  If  now  you  listen  under 
and  outside  the  nip.de  on  the  right  side,  or  posteriorly  over  the  inferior 
lobe  of  either  lung,  you  will  hear  two  very  fine  murmurs.  That  accom- 
panying the  inspiration  is  much  more  distinct  than  that  accompanying 
the  expiration.  By  some,  on  account  of  its  excessive  fineness,  it  is 
stated  that  there  is  no  expiratory  murmur  in  health ; but  this  is  incor- 
rect. These  sounds,  then,  are  the  vesicular  respiratory  murmurs.  All 
these  sounds  become  exaggerated  during  forced  respiration,  but  in  a 
state  of  health  they  never  lose  their  soft  character.  Again,  if  you  listen 
in  the  same  places,  whilst  the  individual  speaks,  you  will  hear  a peculiar 
resonance  of  the  voice,  which  has  been  called,  in  the  first  situation, 
pectoriloquy ; in  the  second  bronchophony ; while  in  the  third  it  is 
scarcely  audible.  A knowledge  of  these  circumstances,  and  a capability 
of  appreciating  these  sounds,  are  necessary  preliminary  steps  to  the 
right  comprehension  and  detection  of  the  murmurs  which  may  be  heard 
during  disease. 

I have  to  suppose,  then,  that  you  have  made  your  ears  familiar  with 
these  sounds,  and  that  you  are  acquainted  with  the  present  state  of 
theory  regarding  their  formation.  This  last  may  be  stated  in  very  few 
words  to  be,  that  the  respiratory  murmurs  are  occasioned  by  the  vibra- 
tion of  the  tubes  through  which  the  air  rushes,  according  to  the  well- 
known  acoustic  principles.  Hence  they  are  loudest  in  the  trachea,  finer 
in  the  large  bronchi,  and  finest  in  their  ultimate  ramifications.  The 
vocal  resonance,  on  the  other  hand,  originates  in  the  larnyx ; and 
diminishes  or  increases — 1st,  According  to  the  distance  of  any  point  from 
the  source  of  the  sound  ; and,  2d,  According  to  the  power  which  textures 
have  in  propagating  it. 

If  now  you  examine,  in  succession,  any  six  of  the  cases  in  the  wards 
which  are  laboring  under  well-marked  pulmonary  diseases,  you  will  have 
no  difficulty  in  recognising  that  all  the  sounds  you  hear  may  be  classified 
into  two  divisions  : 1st,  Alterations  of  the  natural  sounds , 2d,  New,  or 
abnormal  sounds,  never  heard  during  health. 

I.  Alterations  of  the  Natural  Sounds. — All  the  sounds  of  which 
we  have  spoken,  and  which  can  be  heard  in  the  lungs  during  health,  may, 
in  certain  diseased  conditions,  be  increased,  diminished,  or  absent;  their 
character  or  position  may  be  changed  ; and  with  regard  to  the  respiratory 
murmurs,  they  may  present  alterations  in  rhythm  or  duration  with 
respect  to  each  other. 

Alterations  in  Intensity. — Some  persons  have  naturally  louder 
respiratory  murmurs  than  others  ; if  this  occur  uniformly  on  both  sides, 
it  is  a healthy  condition.  Occasionally,  however,  the  sounds  are  evi- 
dently stronger  at  one  place,  or  on  one  side  {puerile  respiration).,  and  then 
they  generally  indicate  increased  action  of  the  lung,  supplementary  to 
diminis’ied  action  in  some  other  part.  In  the  same  manner,  there 


68 


EXAMISTATIOJi  OF  THE  PATIENT 


may  be  feeble  respiration  simply  from  diminished  action,  as  in  feeble  or 
old  persons;  but  it  may  also  be  occasioned  by  pleurodynia,  obstructions 
in  the  larnyx,  trachea,  or  bronchi — pleurisy,  or  pulmonary  emphysema, 
or  exudations  filling  up  a greater  or  less  number  of  the  air-cells  and 
smaller  tubes,  as  in  pneumonia,  phthisis,  etc.  Complete  absence  of 
respiration  occurs  where  there  is  extensive  pleuritic  efi'usion  or  hydro- 
thorax. 

Alterations  in  Character. — The  various  respiratory  murmurs  may,  in 
certain  conditions  of  the  lung,  assume  a peculiar  harshness,  which,  to  the 
ear  of  the  practised  auscultator,  is  a valuable  sign,  indicative  of  altered 
texture.  Thus,  in  incipient  phthisis,  the  vesicular  murmur  under  the 
clavicle  is  often  rude  or  harsh.  In  pneumonia  the  bronchial  or  tubular 
respiratory  murmur  presents  a similar  character.  When  a cavity  is 
formed,  it  becomes  what  is  called  cavernous  (hoarse  or  blowing) , and  in 
certain  cases  of  pneumothorax  with  pulmonary  fistula,  it  assumes  an 
amphoric  character. 

Alterations  in  Position. — It  frequently  happens  that  the  sounds  which 
are  natural  in  certain  parts  of  the  chest  are  heard  distinctly  at  places 
wherein  health  they  are  never  detected.  Thus,  in  pneumonia,  Ironchialy 
or  tubular  breathing^  as  it  is  sometimes  called,  may  be  evident,  where  only 
a vesicular  murmur  ought  to  exist.  This  is  often  well  marked  with  re- 
gard to  the  vocal  resonance,  as  certain  lesions,  which  occasion  condensa- 
tion or  ulceration  of  the  lungs,  will  enable  us  to  hear  either  broncho- 
phony or  pectoriloquy,  where,  under  ordinary  circumstances,  no  voice 
can  be  heard. 

Alterations  in  Rhythm. — In  health,  the  irspiration  is  usually  three 
times  as  long  as  the  expiration.  In  certain  diseased  conditions  this  rela- 
tion is  altered,  or  even  inverted.  In  incipient  phthisis  we  often  find  the 
expiration  unnaturally  prolonged.  In  chronic  bronchitis  and  emphysema 
it  is  three  or  four  times  longer  than  the  inspiration. 

II.  New  or  Abnormal  Sounds. — These  are  of  three  kinds  : 1st,  Kub- 
bing  or  friction  sounds  ; 2d,  Moist  rattles  ; 3d,  Vibrating  murmurs. 

1.  Rubbing  or  Friction  Sounds  are  caused  in  the  pulmonary  apparatus 
by  some  morbid  change  in  the  pleurae,  whereby,  instead  of  sliding  noise- 
lessly on  one  another,  they  emit  a rubbing  sound.  This  may  be  so  fine 
as  to  resemble  the  rustling  of  the  softest  silk,  or  so  coarse  as  to  sound 
like  the  creaking  of  a saddle,  grating,  rasping,  etc. , and  between  these 
two  extremes  you  may  have  every  intermediate  shade  of  friction  noise. 
This  variation  in  sound  is  dependent  on  the  nature  of  the  alteration 
which  the  pleurae  have  undergone.  If  covered  with  a softened  thin  exu- 
dation, the  murmur  will  be  soft ; if  it  be  tougher  and  thicker,  the  sound 
will  be  louder ; if  hard,  dense,  and  rough,  it  will  assume  a creaking, 
harsh,  or  grating  character.  These  noises  are  heard  in  the  various  forms 
of  pleurisy. 

2.  Moist  Rattles  are  produced  by  bubbles  of  air  traversing  or  breaking 
in  a somewhat  viscous  fluid.  This  may  occur  in  the  bronchi,  when  they 
contain  liquid  exudation,  mucus  or  pus,  or  in  ulcers  of  various  sizes. 
They  may  be  so  fine  as  to  be  scarcely  audible  (when  they  have  been 
called  crepitating).,  or  so  coarse  as  to  resemble  gurgling  or  splashing,  when 


BY  AUSCULTATION. 


69 


they  have  received  the  name  of  cavernous.  Here,  again,  between  these 
two  extremes,  we  may  have  every  kind  of  gradation,  to  which  auscultators 
have  attached  names,  such  as,  mucous.,  submucous,  sub cr epilating , etc.  etc. 
With  these  names  you  need  not  trouble  yourselves ; all  that  it  is  imjDor- 
tant  for  you  to  determine  is,  whether  or  not  the  sound  be  moist,  and  you 
will  easily  recognise  that  the  rattles  are  coarse  or  large,  in  proportion  to 
the  size  of  the  tubes  or  ulcers  in  which  they  are  produced,  and  the  amount 
of  fluid  present.  These  rattles  may  be  heard  in  pneumonia,  phthisis 
pulmonalis,  bronchitis,  pulmonary  apoplexy,  etc.  etc. 

3.  Dry  Vibrating  Murmurs  arise  when  the  air-tubes  are  obstructed, 
constricted,  or  lose  their  elasticity  and  become  enlarged,  whereby  the 
vibrations  into  which  they  are  thrown  by  the  column  of  air  produce 
sounds  or  tones  of  an  abnormal  character.  Hence  murmurs  may  be 
occasioned  of  a fine  squeaking  {sibilous  murmur),  or  of  a hoarse  snoring 
character  {sonorous  murmur),  and  between  the  two  extremes,  there  may 
be  all  kinds  of  variations,  to  which  ingenious  people  have  applied  names. 
These  only  cause  confusion ; all  that  is  necessary  is  to  ascertain  that  the 
murmur  is  dry,  and  you  will  readily  understand  that  the  fineness  or 
coarseness  of  the  sound  will  depend  on  the  calibre  of  the  tube  or  cavity 
thrown  into  vibrations.  They  are  usually  heard  in- cases  of  bronchitis 
and  emphysema.  Occasionally  they  present  a blowing  character,  as 
when  ulcers  are  dry,  a condition  which  often  occurs  in  phthisis. 

The  vocal  resonance,  besides  undergoing  the  changes  already  noticed 
in  intensity,  character,  and  position,  may  give  rise  to  abnormal  sounds. 
Occasionally  it  presents  a soft  reverberating  or  trembling  noise,  like  the 
bleating  of  a goat  {oejopliomj).  The  value  of  this  sign,  as  indicative  of 
pleurisy,  was  much  overrated  by  Laennec.  At  present  it  is  little 
esteemed.  Sometimes  the  resonance  gives  rise  to  a metallie  tinkling,  a 
noise  similar  to  that  caused  by  dropping  a shot  into  a large  metallic 
basin,  or  the  note  produced  by  rubbing  a wet  finger  round  the  edge  of  a 
tumbler  or  glass  vessel.  This  is  often  best  heard  immediately  after  a 
cough  in  certain  cases  of  chronic  phthisis.  jHgophony  is  supposed  to  be 
produced  when  a thin  layer  of  serous  fluid  between  the  pleurae  is  thrown 
into  vibrations.  The  cause  of  metallic  tinkling  has  created  great  dis- 
cussion, and  is  not  yet  ascertained. 

Such,  then,  are  the  principal  sounds  which  may  be  heard  on  auscul- 
tation of  the  pulmonary  organs  in  health  and  during  disease.  Many 
writers  have  endeavored  to  point  out  their  diagnostic  importance,  and 
drawn  up  rules  which  have  always  appeared  to  me  much  too  arbitrary. 
Indeed,  in  so  far  as  the  education  of  medical  students  is  concerned,  I 
have  long  been  persuaded  that  the  study  of  these  rules  has  retarded  their 
powers  of  diagnosis,  and  afterwards  led  to  dangerous  errors  in  practice. 
I know  of  no  dogma,  for  instance,  more  mischievous  than  the  one  which 
asserts  a crepitating  (that  is,  a fine  moist)  rattle  to  be  pathognomonic  of 
pneumonia,  because  such  a rattle  is  just  as  common  in  phthisis,  and  is 
frequently  heard  in  various  other  lesions  of  the  pulmonary  organs.  Hence 
we  should  regard  a crepitating  rattle,  not  as  distinctive  of  this  or  that 
so-called  disease,  but  simply  of  fluid  in  the  smaller  air-passages ; so  also 
an  increased  resonance  of  the  voice,  as  indicating  hollow  spaces  with 


70 


EXAMI^xVTION  OF  THE  PATIENT 


vibrating  walls,  or  increased  induration  of  the  pulmonary  textures,  and 
not  as  diagnostic  of  phthisis,  pneumonia,  and  so  on.  I wish,  then, 
strongly  to  impress  upon  you, — 

1st,  That  the  different  sounds  are  only  indicative  of  certain  physical 
conditions  of  the  lung,  and  in  themselves  bear  no  fixed  relation  to  the 
so-called  diseases  of  systematic  writers. 

2d,  No  single  acoustic  sign,  or  combination  of  signs,  is  invariably 
pathognomonic  of  any  certain  pathological  state, — and  conversely,  there  is 
no  pathological  state  which  is  invariably  accompanied  by  any  series  of 
physical  signs. 

3d,  Auscultation  is  only  one  of  the  means  whereby  we  can  arrive  at 
a just  diagnosis,  and  should  never  be  depended  on  alone.  (See  intro- 
duction to  diseases  of  the  respiratory  system.) 


Special  Rules  to  be  followed  during  Auscultation  of  the 
Circulatory  Organs. 

1.  In  listening  to  the  sounds  produced  by  the  action  of  the  heart 
and  arteries,  we  should  pay  attention — l.-t,  To  the  impulse;  2d,  To  the 
character  and  rhythm  of  the  sounds;  Sd,  To  the  place  where  they  aie 
heard  loudest,  and  the  direction  in  which  they  are  propagated.* 

2.  You  should  commence  the  examination  by  feeling  for  the  spot 
where  the  apex  of  the  heart  beats  against  the  walls  of  the  chest,  which 
will  enable  you  to  judge  of  the  impulse.  This  ascertained,  place  your 
stethoscope  immediately  over  it,  and  listen  to  the  sounds.  Then  place 
the  instrument  above,  and  a little  to  the  inside  of,  the  nipple,  near  the 
margin  of  the  sternum,  and  listen  to  the  sounds  there.  In  the  one  situa- 
tion you  will  hear  the  first  or  systolic  sound,  in  the  other  the  second  or 
diastolic  sound  louder. 

3.  If  anything  different  from  the  normal  condition  be  discovered  in 
either  one  or  the  other  position,  or  in  both,  this  should  be  again  care- 
fully examined,  and  by  moving  the  stethoscope  below  and  round  the  apex 
of  the  heart,  or  above,  in  the  course  of  the  aortic  arch  or  carotids,  on  the 
right  and  left  side,  etc.  etc.,  it  should  be  ascertained  at  what  point,  or 
over  what  space,  the  abnormal  sounds  are  heard  loudest,  and  whether 
they  be  or  be  not  propagated  in  the  course  of  the  large  vessels.  Occasion- 
ally listening  over  the  back  and  in  the  course  of  the  descending  aorta 
may  be  useful. 

4.  When,  during  the  above  examination,  we  discover  a new  source  of 
impulse  or  of  sound  in  one  of  the  large  vessels,  this  must  be  especially 
examined,  the  limits  of  such  impulse  and  sound  carefully  ascertained — 
whether  it  be  or  be  not  synchronous  with  those  originating  in  the  heart 
— its  direction,  etc. 

5.  Under  ordinary  circumstances,  the  respiratory  do  not  interfere  with 

* The  numerous  instruments  recently  invented  for  rendering  ebservations  on  the 
impulse  of  the  heart  and  on  the  pulse  more  accurate  should  not  be  overlooked.  Among 
these  are  the  sphygmoscopes  of  Scott  Alison,  the  sphygmosphone  of  Upham,  and  the 
sphygmographs  of  Vierodt,  Marey,  and  Czermack.  They  have  not  yet  been  used 
much  at  the  bed-side,  although  the  smaller  one  of  Marey,  made  by  Breguet  of  Paris, 
admits  of  ready  application  whenever  a particularly  accurate  observation  is  required. 


BY  AUSCULTATiOX. 


VI 


the  detection  of  the  cardiac  sounds ; but  where  the  former  are  very  loud 
and  the  latter  indistinct,  it  is  useful  to  direct  the  individual  to  hold  his 
breath  for  a few  moments.  Sometimes  the  impulse  and  sounds  of  the 
heart  are  heard  better  by  directing  the  patient  to  lean  forward ; they 
may  also,  if  necessary,  be  exaggerated  and  rendered  more  distinct  by  di- 
recting him  to  walk  quickly,  or  to  make  some  exertion  for  a short  time. 

Of  the  Sounds  produced  by  the  Circulatory  Organs  in  Health 
AND  Disease. 

On  placing  your  ear  over  the  cardiac  region  in  a healthy  person,  you 
will  feel  a beating,  and  hear  two  sounds,  which  have  been  likened  to  the 
tic-tac  of  a watch,  but  to  which  they  bear  no  resemblance.  They  may 
be  imitated,  however,  very  nearly,  as  pointed  out  by  Dr.  Williams,  by 
pronouncing  in  succession  the  syllables  lup’p,  dupp.  The  first  of  these 
sounds,  which  is  dull,  deep,  and  more  prolonged  than  the  second,  coin- 
cides with  the  shock  of  the  apex  of  the  heart  against  the  thorax,  and 
immediately  precedes  the  radial  pulse ; it  has  its  maximum  intensity 
over  the  apex  of  the  heart — below  and  somewhat  to  the  inside  of  the 
nipple.  The  second  sound,  which  is  sharper,  shorter,  and  more  super- 
ficial, has  its  maximum  intensity  nearly  on  a level  with  the  third  rib,  and 
a little  above  and  to  the  right  of  the  nipple — near  the  left  edge  of  the 
sternum.  These  sounds,  therefore,  in  addition  to  the  terms  first  and 
second,  have  also  been  called  inferior  and  superior,  long  and  short,  dull 
and  sharp,  systolic  and  diastolic — which  expressions,  so  far  as  giving  a 
name  is  concerned,  are  synonymous. 

The  two  sounds  are  repeated  in  couples,  which,  if  we  commence  with 
the  first  one,  follow  each  other  with  their  intervening  pauses  thus — 1st, 
There  is  the  long  dull  sound  coinciding  with  the  shock  of  the  heart;  2d, 
There  is  a short  pause  ; 3d,  The  short  sharp  sound ; and  4th,  a longer 
pause,  all  which  correspond  with  one  pulsation.  In  figures,  the  duration 
of  these  sounds  and  pauses  by  some  has  been  represented  thus, — the  first 
sound  occupies  a third,  the  short  pause  a sixth,  the  second  sound  a sixth, 
and  the  long  pause  a third.  Others  have  divided  the  whole  period  into 
four  parts ; of  which  the  two  first  are  occupied  by  the  first  sound,  the 
third  by  the  second  sound,  and  the  fourth  by  the  pause.  The  duration, 
as  well  as  the  loudness,  of  the  sounds,  however,  are  very  variable,  even 
in  health,  and  are  influenced  by  the  force  and  rapidity  of  the  heart’s 
action,  individual  peculiarity,  and  form  of  the  thorax.  Their  extent  also 
differs  greatly.  They  are  generally  distinctly  heard  at  the  precordial 
region,  and  diminish  in  proportion  as  we  withdraw  the  ear  from  it. 
They  are  less  audible  anteriorly  on  the  right  side,  and  still  less  so  pos- 
teriorly on  the  left  side.  On  the  right  side  posteriorly  they  cannot  be 
heard.  Their  tone  also  varies  in  different  persons;  but  in  health  they 
are  free  from  a harsh  or  blowing  character. 

Great  diversity  of  opinion  has  existed  regarding  the  causes  of  these 
sounds — which  you  will  have  heard  discussed  before  coming  here.  You 
must  never  forget,  however,  the  cardiac  actions  which  coincide  with  them; 
for  our  reasoning  from  any  changes  we  may  detect  in  the  sounds  will 
entirely  depend  upon  our  knowledge  of  these  coincidences.  We  may 


12 


EXAMINATION  OF  THE  PATIENT 


consider,  then,  that  there  occur  with  the  first  sound — 1st,  The  impulse, 
or  striking  of  the  apex  against  the  thoracic  walls ; 2d,  Contraction  of  the 
ventricles;  3d,  Rushing  of  the  blood  through  the  aortic  orifices;  and  4th, 
Flapping  together  of  the  auriculo-ventricular  valves.  There  coincide  with 
the  second  sound — 1st,  Rushing  of  the  blood  through  the  auriculo-ven- 
tricular valves  ; and  2d,  Flapping  together  of  the  aortic  valves.  Contrac- 
tion of  the  auricles  immediately  precedes  that  of  the  ventricles.  The 
result  of  numerous  pathological  observations,  and  of  many  experiments, 
is,  that  in  health  the  first  sound  is  produced  by  the  combined  action  of 
the  auriculo-ventricular  valves,  of  the  ventricles,  and  of  the  rushing  of  the 
blood,  which  sound  is  augmented  in  intensity  by  the  impulsion  of  the 
heart’s  apex  against  the  thorax  ; whereas  the  second  sound  is  caused  only 
by  the  flapping  together  of  the  sigmoid  valves. 

With  the  cardiac  as  with  the  respiratory  sounds,  the  alterations  which 
take  place  during  disease  may  be  divided  into — 1st,  Modification  of  the 
sounds  heard  in  health;  2d,  New  or  abnormal  sounds. 

I.  Modifications  op  the  Healthy  Sounds. — These  refer  to  the  vari- 
ations the  healthy  sounds  present  in  their  seat,  intensity,  extent,  character, 
and  rhythm. 

Seat. — The  sounds  may  be  heard  at  their  maximum  intensity  lower 
than  at  the  points  previously  indicated,  as  in  cases  of  dilated  hypertro- 
phy of  the  left  ventricle,  enlargement  of  the  auricles,  or  of  tumors  at 
the  base,  depressing  the  organ.  They  may  be  higher.,  owing  to  any  kind 
of  abdominal  swelling  pusliing  up  the  diaphragm.  They  may  be  more 
on  one  side  or  the  other,  in  cases  where  the  heart  is  pushed  laterally  by 
effusions  of  air  or  fluid  in  a pleural  cavity.  Various  other  circumstances 
may  also  modify  their  natural  position,  such  as  tumors  in  the  anterior 
or  posterior  mediastinum,  aneurisms  of  the  large  vessels,  adhesions  of 
the  pericardium,  deformity  in  the  bones  of  tbe  chest,  etc.  etc. 

Intensity  and  extent. — These  are  diminished  in  cases  where  the  heart  is 
atrophied  or  softened  ; when  there  is  pericardial  effusion,  concentric 
hypertrophy  of  the  left  ventricle,  or  emphysema  at  the  anterior  border  of 
the  left  lung.  They  are  increased  in  cases  of  dilated  hypertrophy,  of  ner- 
vous palpitations,  and  when  neighboring  portions  of  the  lung  are  indu- 
rated, especially  in  certain  cases  of  pneumonia  and  phthisis  pulraonalis. 

Character. — The  sounds  become  clearer  or  duller  than  usual,  accord- 
ing as  the  walls  of  the  heart  are  thinner  or  thicker.  Occasionally  they 
sound  muffled  in  cases  of  hypertrophy  or  softening  of  the  muscular  walls 
Not  unfrequently  there  is  a certain  degree  of  roughness,  which  is  difi&cult 
to  determine  as  being  healthy  or  morbid.  Occasionally  it  ushers  in  more 
decided  changes;  at  other  times  it  continues  for  years  without  altera- 
tion. These  alterations  in  character  are  distinguished  by  some  auscultators 
as  variations  in  the  tone  of  the  sounds. 

Rhjthm  or  Time. — I need  not  say  that  the  frequency  of  the  pulsa- 
tions differs  greatly  in  numerous  affections  altogether  independent  of  any 
special  disease  in  the  heart.  In  certain  cardiac  affections,  however,  the 
beats  are  intermittent.,  in  others  irregular — that  is,  they  succeed  each  other 
at  unexpected  intervals.  The  numher  of  the  sounds  also  varies.  Some- 
times only  one  can  be  distinguished,  it  being  so  prolonged  as  to  mask  the 


BY  AUSCULTATION. 


73 


other.  Occasionally  three  or  even  four  sounds  may  he  heard,  depending 
either  on  reduplication  in  the  action  of  the  valves  when  diseased,  or  on 
want  of  synchronism  between  the  two  sides  of  the  heart.  Not  unfre- 
queatly  the  increased  and  irregular  movements  of  the  organ,  combined 
with  the  sounds,  are  of  such  a character  as  to  receive  the  name  of 
tumultuous. 

II.  New  or  Abnormal  Sounds. — These  are  of  two  kinds — 1st,  Fric* 
tion  murmurs  ; 2d,  Blowing  or  vibrating  murmurs.  Dr.  Latham  has 
called  them  exocardial  and  endocardial.  I am  in  the  habit  of  denomi- 
nating them  pericardial  and  valvular. 

Pericardial  or  Friction  Murmurs. — These  murmurs  are  the  same  in 
character,  and  originate  from  the  same  causes  as  the  friction  noises  con- 
nected with  the  pulmonary  organs.  It  is  only  necessary  to  observe,  that 
occasionally  they  are  so  soft  as  closely  to  resemble  blowing  murmurs, 
from  which  they  are  only  to  be  distinguished  by  their  superficial  charac- 
ter and  limited  extent. 

Valvular  or  Vibrating  Murmurs. — These  murmurs  vary  greatly  in 
character ; some  being  so  soft  as  to  resemble  the  passage  of  the  gentlest 
wind ; others  are  like  the  blowing  or  puff  from  the  nozzle  of  a bellows 
{bellows  murmurs) ; whilst  others  are  harsher,  resembling  the  noise  pro- 
duced by  grating.,  filing.,  sawing,  etc.  They  are  all  occasioned,  however, 
by  diseases  interfering  with  the  functions  of  the  valves.  Sometimes 
these  do  not  close,  and  the  blood  consequently  regurgitates  through  them; 
at  others,  whilst  this  is  the  case,  they  are  constricted,  indurated,  rough- 
ened, and  even  calcareous — whence  the  harsher  sounds.  They  may  be 
single  or  double,  and  have  their  origin  either  in  the  auriculo-ventricular 
or  arterial  valves,  or  in  both  at  once,  the  detection  of  which  constitutes 
the  diagnosis  of  the  special  diseases  of  the  organ.  Occasionally  these 
sounds  resemble  musical  notes,  more  or  less  resembling  the  cooing  of  a 
dove,  singing  or  twittering  of  certain  small  birds,  whistling,  tinkling,  etc. 
etc.  These  depend  either  upon  excessive  narrowing  of  the  orifices,  or 
upon  any  causes  which  induce  vibrations  of  solids  in  the  current  of  blood 
— as,  when  there  are  perforations  in  the  valves,  irregularities  of  their 
margins,  string-like  or  other  shaped  exudations  on  their  surface,  etc.  etc. 


Auscultation  of  the  Abdomen. 

On  applying  the  stethoscope  over  the  stomach  and  intestines  in  a 
healthy  state,  various  gurgling  and  churning  noises  may  be  heard. 
In  the  former  they  may  assume  an  amphoric  or  metallic  character,  in 
the  latter  they  are  called  horhorygmi.  They  are  caused  by  the  displace- 
ments of  gas  and  water,  and  are  most  audible  during  the  period  of 
digestion,  and  the  action  of  a purgative  or  enema.  The  impulse  of  the 
aorta  can  be  detected  especially  in  thin  subjects,  when  the  pressure  of 
the  stethoscope  may  often  be  made  to  elicit  a blowing  sound. 

In  disease  these  sounds  may  be  increased  or  diminished,  and  in 
addition,  there  may  be  present  various  kinds  of  friction  or  grating  sounds 
when  the  surface  of  the  peritoneum  is  roughened,  owing  to  exudation 
or  the  unequal  pressure  of  tumors.  These  last'  may  also  give  rise  to 


V4 


EXAMINATION  OF  THE  PATIENT. 


blowing  murmurs,  when  it  often  becomes  difficult  to  determine  whether 
the  morbid  sound  originates  in  the  tumor  itself,  or  is  the  result  of  the 
pressure  it  exercises  on  the  aorta.  In  cases  of  doubtful  pregnancy,  the 
marked  rapidity  of  the  foetal  pulse  contrasted  with  that  of  the  individual 
examined,  constitutes  a positive  sign. 

Auscultation  of  the  Large  Vessels. 

On  listening  through  the  stethoscope  placed  over  the  arteries  in  the 
neighborhood  of  the  heart,  we  hear  the  same  sounds  as  are  produced  at 
the  sigmoid  valves,  propagated  along  its  course,  but  more  indistinctly 
as  we  remove  the  instrument  away  from  the  base  of  the  heart.  In  those 
which  are  more  distant  only  one  sound,  which  is  synchronous  with  their 
impulse  and  their  dilatation,  is  heard.  This  sound  is  of  a dull  character, 
but  in  health  always  soft. 

In  the  various  conditions  of  disease  we  have  a single  or  a double  bel- 
lows sound,  or  it  may  be  harsh,  grating,  rasping,  etc.  In  the  first  place, 
you  must  ascertain  whether  any  of  these  sounds  are  propagated  along 
the  artery  from  the  heart,  and  this  you  will  learn  by  listening  over  its 
course  from  that  organ,  and  by  observing  wffiether  they  increase  as  you 
proceed  towards  it.  If  the  sound  have  an  independent  origin,  it  may 
originate  from  disease  of  the  internal  surface  of  the  artery,  when  it  will 
be  harsh  in  proportion  to  the  roughness ; from  stricture  of,  or  pressure 
on  the  vessel,  or  from  its  dilatation.  Generally  speaking,  the  more 
dilated  and  superficially  seated  the  vessel  is,  the  sharper  is  the  sound. 
Sometimes  there  is  a double  murmur  in  the  course  of  a vessel,  having 
an  undoubtedly  independent  origin.  This  is  most  common  in  cases 
where  there  is  an  aneurismal  pouch,  into  which  the  blood  passes  in  and 
out  through  an  opening  narrower  than  the  swelling  itself.  Occasionally 
one  or  both  such  murmurs  may  possess  somewhat  of  a metallic  ringing, 
or  even  musical  character,  and  in  such  case  the  margins  of  the  opening 
are  probably  tense,  and  thrown  into  peculiar  vibrations. 

Not  unfrequently  a soft  systolic  blowing  is  audible  at  the  base  of  the 
heart,  or  over  the  carotids  and  deep  jugular  vein.  At  other  times  it  is 
continuous,  resembling  humming,  or  the  noise  of  a Parisian  toy  called 
le  diable.  These  murmurs  are  distinguished  from  valvular  ones — 1st, 
By  being  systolic  at  the  base  of  the  heart ; 2d,  By  their  softness ; 3d, 
By  not  being  permanent ; and  4th,  By  occurring  in  anaemic  or  debili- 
tated persons,  and  especially  in  young  girls. 

I have  already  told  you  never  to  form  a conclusion  as  to  the  nature 
of  the  disease  from  auscultation  alone.  Even  when  combined  with  per- 
cussion, it  is  not  safe  to  form  a diagnosis  without  a knowledge  of  all  the 
circumstances  of  the  case.  Hence  why  I repudiate  those  rules  which 
have  been  published  in  books,  that  have  for  their  object  the  establish- 
ment of  opinions  from  physical  signs  alone.  At  the  same  time,  there 
can  be  no  doubt  that  percussion  and  auscultation  are  absolutely  essential 
to  the  proper  investigation  of  maladies,  although  not  more  so  than  other 
modes  of  inquiry.  I have,  therefore,  thought  it  best  to  give  you  a con- 
densed resume  of  the  sounds  which  may  be  heard  by  auscultation  of  the 


USE  OF  THE  MICEOSCOFE. 


75 


lungs,  heart,  abdomen,  and  large  vessels ; pointing  out  a few  of  the 
diseased  states  in  which  they  may  be  sometimes  (not  always)  heard, 
and  especially  indicating  the  physical  conditions  on  which  they  are 
supposed  to  depend.  Their  true  diagnostic  value  can  only  be  learned 
by  the  careful  examination  of  individual  cases.  I strongly  advise  you 
not  to  complicate  your  practical  study  of  this  important  subject  with 
certain  speculative  problems,  as  to  tlie  seat  of  sounds  originating  in  the 
tricuspid  valve  and  pulmonary  artery.  Careful  examinations  have  con- 
vinced me  that  these  latter  sounds  in  the  vast  majority  of  cases  cannot 
be  separated  from  those  originating  in  the  left  side  of  the  heart,  and 
that  all  diagnosis  based  upon  their  supposed  existence  in  fixed  areas  of 
the  pericardial  region  must  be  fallacious.  (See  introduction  to  diseases 
of  the  circulatory  system.) 

USE  OF  THE  MICROSCOPE. 

A knowledge  of  the  ultimate  structure  of  the  human  body,  in  its 
healthy  and  diseased  conditions,  is  now  so  advanced  as  to  necessitate 
the  introduction  of  the  microscope  among  the  ordinary  instruments  of 
the  medical  practitioner.  But  you  must  not  suppose  that  an  additional 
method  of  gaining  information  implies  abandonment  of  those,  the  utility 
of  which  has  stood  the  test  of  experience.  Men  must  learn  the  every- 
day use  of  their  senses ; must  know  how  to  feel,  hear,  and  see  in  the 
same  manner  as  they  did  before  instruments  were  invented  We  don’t 
see  the  stars  less  clearly  with  our  naked  sight,  because  the  telescope  is 
necessary  for  an  astronomer.  Neither  should  a physician  observe  the 
symptoms  of  a disease  less  accurately  because  he  examines  the  chest 
with  a stethoscope,  or  a surgeon  be  less  dexterous  with  the  knife,  be- 
cause it  is  only  by  means  of  the  microscope  he  can  determine  with 
exactitude  the  nature  of  a tumor.  But  it  is  unnecessary  to  enter  into 
a lengthened  argument  to  prove  that  the  science  and  art  of  medicine  are 
greatly  indebted,  in  modern  times,  to  the  invention  and  proper  applica- 
tion of  ingenious  instruments.  The  following  examples  will  serve  to 
convince  you  that  the  microscope  is  one  of  these : — 

Example  1. — Some  years  ago  I was  summoned  to  see  a Dispensary 
patient  laboring  under  bronchitis,  who  was  spitting  florid  blood.  On 
examining  the  sputum  with  a microscope,  I found  that  the  colored  blood 
corpuscles  were  those  of  a bird.  On  my  telling  her  she  had  mixed  a 
bird’s  blood  with  the  expectoration,  her  astonishment  was  unbounded, 
and  she  confessed  that  she  had  done  so  for  the  purpose  of  imposition. 

Example  2. — A gentleman,  for  some  years,  had  labored  under  a 
variety  of  anomalous  symptoms,  referable  to  the  head  and  digestive 
systems,  under  which  he  had  become  greatly  reduced.  He  had  con- 
sulted many  practitioners,  and  visited  innumerable  watering-places,  in 
a vain  search  after  health.  On  examining  the  urine  wdth  a microscope, 
I found  it  crowded  with  spermatozoa.  He  evidently  labored  under 
spermatorrhoea,  a disease  which  had  never  been  suspected,  but  which  was 
readily  cured  on  the  employment  of  an  appropriate  treatment. 

Example  3.—  A boy  was  brought  to  me  with  an  eruption  on  the 


76 


EXAMINATION  OF  THE  PATIENT. 


scalp,  which  was  of  so  indefinite  a character  that  its  nature  could  not  be 
determined.  He  had  lately  been  elected  to  occupy  a vacancy  in  one  of 
our  charitable  educational  establishments,  and  the  question  to  decide  was, 
whether  the  disease  was  or  was  not  contagious.  On  examiuing  the  scab  with 
a microscope,  I readily  discovered  the  Acliorion  Schoenleini,  or  fungus 
constituting  true  favus;  and  as  this  has  been  experimentally  proved  to  be 
inoculable,  I had  no  hesitation  in  preventing  his  admission  to  the  school. 

Example  4. — A child  was  supposed  to  be  affected  with  worms, 
because  it  passed  in  abundance  yellowish  shreds,  which,  to  the  naked  eye, 
closely  resembled  ascarides.  All  kinds  of  vermifuge  remedies  had  been 
tried  in  vain.  On  examining  the  shreds  with  a microscope,  I found 
them  to  consist  of  undigested  spiral  vessels  of  plants ; and  they  ceased 
to  appear  when  the  vegetable  broth  used  as  food  was  abandoned. 

JEixample  5. — I was  called  to  see  an  infant,  a month  old,  which  was 
in  a state  of  considerable  emaciation,  with  constant  diarrhoea.  The 
mother,  however,  maintained  that  her  milk  was  abundant,  and  that  it 
was  taken  in  sufiicient  quantity.  On  being  examined  with  a microscope, 
it  was  found  to  contain  numerous  compound  granular  bodies,  and  compara- 
tively few  milk  globules.  In  short,  it  presented,  in  an  exaggerated  de- 
gree, all  the  characters  of  colostrum,  and  this  thirty  days  after  delivery. 
It  was  evident,  then,  that  the  quality  of  the  milk  was  in  fault,  an  opinion 
-which  was  confirmed  by  the  recovery  of  the  infant,  when  a healthy  nurse 
was  procured. 

Example  6. — An  individual  was  supposed  to  be  laboring  under 
dysentery,  from  the  frequent  passage  of  yellowish  pulpy  masses  in  the 
stools,  accompanied  with  tormina  and  other  symptoms.  On  examining 
these  masses  with  the  microscope,  I found  them  to  consist  of  undigested 
potato  skins.  On  inquiry,  it  was  ascertained  that  this  person  had  eaten 
the  skins  with  the  potatoes.  On  causing  these  to  be  removed  before 
dinner,  the  alarming  appearance  ceased,  and  the  other  symptoms  also 
disappeared. 

Example  7. — An  elderly  lady  conceived  herself  to  be  affected  with 
insects  continually  forming  in  the  skin,  which  produced  incessant  itching 
and  tingling.  All  the  hair  was  removed,  and  every  kind  of  application, 
including  mercurial  preparations,  was  tried  without  effect.  On  rubbing 
the  surface,  she  always  saw  minute  white  rolls  and  black  specks,  which 
she  regarded  as  insects  in  different  stages  of  development.  The  torment 
and  anxiety  this  caused  her  for  many  months  it  is  scarcely  possible  to 
conceive.  At  length  she  labored  under  the  idea  that  she  was  communi- 
cating the  disease  to  her  husband  and  daughter,  when,  at  the  request 
of  her  medical  attendant  in  the  west  of  Scotland,  she  came  to  Edinburgh 
in  order  that  I might  investigate  and  treat  it.  I had  the  pleasure  of 
showing  this  lady,  under  the  microscope,  that  the  white  bodies  were 
minute  rolls  of  epidermis  or  of  the  cotton  cloth  with  which  she  rubbed  the 
skin,  and  that  the  black  specks  were  portions  of  dust  or  soot.  Her  hallu- 
cination being  in  this  way  dissipated,  she  returned  home  perfectly  well. 

Example  8. — A child  had  been  suffering  for  four  years  from  copious 
and  foetid  discharge  from  the  nostrils,  accompanied  with  great  pain.  At 
the  end  of  that  time,  a dark  brown  and  indurated  mass  was  discharged 
about  an  inch  long,  and  a quarter  of  an  inch  broad,  closely  resembling  a 


USE  OF  THE  MICROSCOPE. 


77 


sequestrum  of  bone.  This  mass  I was  requested  to  examine  microscopi- 
cally by  Dr.  Littlejohn,  under  whose  care  the  patient  was,  and  from  its 
structure  I readily  determined  that  it  consisted  of  some  fir  wood.  When 
this  was  known,  the  parents  remembered  that,  about  the  time  the  disease 
commenced,  alterations  were  made  in  the  house,  and  that  the  children 
used  to  play  with  the  wood  shavings.  There  could  be  little  doubt  that  a 
piece  of  shaving  had  been  thrust  up  the  nose,  and  been  the  cause  of  all 
the  symptoms. 

Examples  of  this  kind  could  be  readily  multiplied.  No  doubt  mis- 
takes will  be  made  with  this  instrument  in  the  hands  of  inexperienced 
persons,  in  the  same  manner  as  the  use  of  the  stethoscope,  or  of  a scalpel, 
may  lead  to  false  conclusion,  or  to  an  accident.  But  this,  so  far  from 
being  an  argument  opposed  to  their  employment,  only  proves  the  necessity 
of  becoming  more  skilful  in  their  use.  Certainly  there  is  no  instrument 
which  requires  more  expert  management  in  itself,  or  more  caution  in 
drawing  conclusions  from  its  employment,  than  the  microscope. 

Description  of  the  Microscope. 

It  is  not  my  intention  to  enter  upon  a description  of  the  optical 
principles  on  which  microscopes  are 
constructed,  although  you  will  find 
a knowledge  of  these  very  useful.  I 
shall  suppose  that  you  are  desirous 
of  obtaining  an  instrument  that  will 
answer  all  the  purposes  of  the  anato- 
mist and  physiologist,  as  well  as  afford 
you  every  possible  assistance  in  the 
way  of  diagnosis  as  medical  men.  For 
this  purpose,  you  should  learn  to  dis- 
tinguish what  is  necessary  from  what 
is  unnecessary,  in  order  that  you  may 
procure  the  former  in  as  convenient 
a form,  and  at  as  moderate  a cost  as 
possible. 

A microscope  may  be  divided  into 
mechanical  and  optical  parts.  The 
former  determine  its  general  form  and 
appearance.  Of  the  numerous  models 
which  have  been  invented,  the  one 
here  figured,  exactly  one-fourth  its  real 
size,  appears  to  me  the  most  useful  for 
all  the  purposes  of  the  physiologist 
and  medical  practitioner.  The  body 
consists  of  a telescope  tube,  eight  „ 

inches  in  length,  held  by  a split  tube,  thr^e  inches  long.  It  may  be 

Fig.  46.  Oberhaeuser’s  model,  made  at  my  suggestion  for  medical  men,  l-4th  the 
real  size.  This  instrument  may  be  procured  at  M.  O.’s  manufactory.  Place  Dau- 
phine,  Paris,  or  at  Mr.  Young’s,  cutler,  North  Bridge,  and  Mr.  Kemp’s,  Infirmary 
Street,  Edinburgh. 


IS 


EXAMIivATION  OF  THE  PATIENT. 


elevated  and  depressed  vith  great  readiness  by  a corb-screw  movement, 
communicated  to  it  by  the  hand,  and  this  constitutes  the  coarse  adjust- 
ment. It  is  attached  to  a cross-bar  and  pillar,  at  the  lower  portion  of 
which  last,  very  conveniently  placed  for  the  hand  of  the  observer,  is  the 
fine  adjustment.  The  stage  is  three  inches  broad,  and  two  and  a half 
inches  deep,  strong  and  solid,  with  a circular  diaphragm  below  it.  The 
base  of  the  instrument  is  heavily  loaded  with  lead  to  give  it  the  neces- 
sary steadiness. 

This  form  of  microscope  possesses  all  the  mechanical  qualities  re- 
quired in  such  an  instrument.  These  arc — 1st  Steadiness ; 2d,  Power 
of  easy  adjustment;  3d,  Facility  for  observation  and  demonstration; 
and,  4th,  Portability. 

1.  Steadiness. — It  must  be  evident  that  if  the  stage  of  the  microscope 
is  subject  to  any  sensible  vibration,  minute  objects,  when  magnified 
highly,  so  far  from  being  stationary,  may  be  thrown  altogether  out  of  the 
field  of  view.  Nothing  contributes  more  to  the  comfort  of  an  observer 
than  this  quality  of  a microscope,  and  great  pains  have  been  taken  to 
produce  it.  In  the  large  London  instruments  this  end  has  been  admir- 
ably attained,  but  at  so  much  cost  and  increase  of  bulk  as  to  render  it 
almost  useless.  In  the  small  model  I have  recommended,  all  the  steadi- 
ness required  is  present  in  the  most  convenient  form. 

2.  Fotcer  of  Easy  Adjustment. — It  is  a matter  of  great  importance 
to  those  who  use  the  instrument  much,  and  work  with  it  for  hours 
together,  that  the  adjustments  should  work  easily  and  rapidly,  and  be 
placed  in  convenient  situations.  Nothing  can  be  more  commodious  than 
the  manner  in  which  these  ends  are  arrived  at  in  the  model  figured. 
By  insertion  of  the  body  of  the  instrument  within  a split  tube,  you  may, 
by  a spiral  movement,  elevate  and  depress  it  with  the  greatest  rapidity, 
and  even  remove  it  altogether  if  necessary.  The  necessity  of  con- 
tinually turning  the  large  screws  affixed  to  most  microscopes  becomes 
fatiguing  in  the  extreme.  Then  the  fine  adjustment,  placed  conveniently 
behind  the  microscope,  near  the  hand  which  rests  on  the  table,  is  in  the 
very  best  position ; whereas,  in  some  London  instruments,  it  is  placed 
on  the  top  of  the  pillar,  so  that  you  must  raise  your  hand  and  arm  every 
time  it  is  touched.  In  other  London  instruments,  it  is  placed  in  front 
of  the  body,  so  that  you  must  stretch  out  the  arm  and  twist  the  wrist  to 
get  at  it.  No  one  could  work  long  with  so  inconvenient  a contrivance. 

3.  Facility  for  Observation  and  Demonstration. — For  facility  of 
observation  and  demonstration,  it  is  necessary  that  the  instrument  should 
be  of  a convenient  height,  and  that  the  stage  on  which  the  objects  are 
placed  should  be  easily  accessible.  Here,  again,  nothing  can  be  more 
commodious  than  the  microscope  I have  recommended,  for  when  it  is 
placed  on  a table,  its  height  is  almost  on  a level  with  the  eye,  and  we 
can  look  through  it  for  hours  without  the  slightest  fatigue.  On  the 
other  hand,  the  stage  is  elevated,  just  so  much  as  enables  the  two  hands, 
resting  on  their  external  edges,  to  manipulate  with  facility  all  kinds  of 
objects  placed  upon  it.  The  large  London  instruments  are  so  high  as  to 
render  it  necessary  to  stand  up  to  see  through  them.  To  obviate  this 
disadvantage,  a movement  is  given  to  the  body,  by  which  it  can  be 
depressed  to  any  angle.  But  this  movement  renders  the  stage  oblique, 


USE  OF  THE  MICROSCOPE. 


Y9 


and  removec  it  to  a distance,  where  it  becomes  very  inconvenient  to 
manipulate  on  its  surface.  To  obviate  this  difficulty,  the  stage  itself  has 
been  rendered  movable  in  various  ways  by  different  screws,  so  that  in 
this  way  complexity  has  been  added  to  complexity,  until  a mass  of  brass 
work  and  screws  is  accumulated,  to  the  advantage  of  the  optician,  but  to 
the  perplexity  and  fatigue  of  the  observer.  But  by  no  contrivance  is  it 
possible  to  avoid  the  aching  arms  which  such  a position  of  the  stage 
invariably  produces  in  those  who  work  with  such  a cumbrous  machine 
for  any  length  of  time. 

4.  Portahility, — This  is  a property  which  should  by  no  means  be 
overlooked  in  instruments  that  are  intended  more  for  utility  than  orna- 
ment. A medical  man  is  often  called  upon  to  verify  facts  in  various 
places;  at  his  own  house,  at  an  hospital,  at  the  bed-side  of  his  patient, 
or  at  a private  post-mortem  examination.  It  is  under  such  circum- 
stances that  the  value  of  portability  is  recognised.  The  large  London 
instruments  require  an  equipage  or  a porter  to  transport  them  from  place 
to  place ; even  the  putting  them  in  and  out  the  large  boxes  or  cabinets 
that  are  built  around  them,  is  a matter  of  labor.  In  short,  notwith- 
standing the  splendor  of  the  screws,  the  glittering  of  the  brass,  and 
the  fine  workmanship,  there  can  be  little  doubt  that,  on  the  whole, 
they  are  very  clumsy  affairs. 

There  are  many  occasions  on  which  a medical  man  may  find  it  useful 
to  carry  a microscope  with  him,  especially  in  the  case  of  post-mortem 
examinations.  Many  attempts  have  been  made  to  construct  a pocket 
microscope;  and  for  the  purposes  above  alluded  to,  I myself  caused 
one  to  be  made  some  years 
ago,  which,  with  its  case, 
resembled  a small  pocket 
telescope.  Dr.  Gruby  of 
Paris,  however,  has  planned 
the  most  ingenious  instru- 
ment of  this  kind,  which 
possesses  most  of  the  prop- 
erties we  have  enumerated, 
and  will  be  found  very  use- 
ful for  those  accustomed  to 
microscopic  manipulation. 

It  is  contained  in  a case, 
the  size  of  an  ordinary 
snuff-box,  and  possesses  all 
the  conveniences  of  the 
larger  instruments,  with 
various  lenses,  a microm- 
eter, slips  of  glass,  needle,  knife,  and  forceps,  in  that  small  com- 
pass. Figures  47  and  48,  representing  the  instrument,  exactly  one- 
half  the  real  size,  will  give  an  idea  of  this  ingenious  microscope, 
manufactured  by  the  late  M.  Brunner  of  Paris.  For  a more  minute 
description  of  it,  I must  refer  you  to  the  “ Monthly  Journal  of  Medical 
Science”  for  December  1846.  Equally  commodious  pocket  microscopes, 
but  on  a somewhat  different  model,  are  now  made  by  Nachet. 

Fig.  47.  Gruby’s  compound  pocket  microscope — exactly  one-half  the  real  size. 


Fig.  47. 


80 


EXAMINATION  OF  THE  PATIENT. 


There  is  a general  feeling  among  the  public  that  the  larger  a micros 
scope  is,  the  more  it  must  magnify;  but  I need  not  tell  you  this  is  error. 
A very  imposing  mass  of  brass  work  and  mechanical  complexity  is  no 
guarantee  that  you  will  see  objects  better,  or,  what  is  of  more  consequence, 
become  good  observers.  On  the  contrary,  the  more  unwieldy  the  in- 
strument, the  less  disposed  will  you  be  to  use  it.  Besides,  the  habitual 
employment  of  artificial  methods  of  moving  about  the  object,  as  by  the 
screws  of  a movable  stage,  will  prevent  your  acquiring  that  dexterous 
use  of  your  fingers  and  accuracy  of  manipulation  which  are  at  all  times 
so  useful.  Nothing,  indeed,  can  be  more  amusine  than  to  see  a man 
twisting  his  screws,  pushing  his  heavy  awkward  stage  about,  and 
laboriously  wasting  time  to  find  a minute  object  which  another  can  do 
in  a moment,  and  without  fatigue,  by  the  simple  use  of  his  fingers.  But 
perhaps  you  will  consider  the  weightiest  objection  to  the  large  instru- 
ments is  the  expense  they  necessitate, — the  cost  being  necessarily  in  pro- 
portion to  the  amount  of  brass  and  mechanical  labor  employed  upon 


them.  If,  then,  you  have  to  choose  between  a complex  model  and  & 
simple  one,  I strongly  advise  you  as  a matter  of  real  economy,  to  choose 
the  latter.  Indeed  the  former,  to  a practical  histologist,  is  worthless. 

I have  found  the  clinical  microscope  of  Dr.  Beale  (Fig.  49)  very  useful 
at  the  bedside,  as  it  allows  the  object  to  be  passed  from  hand  to  hand  of  the 
students  attending.  It  consists  of  a split  tube,  with  a widened  extremity, 
having  a spring  and  screw  which  firmly  fixes  the  object  glass.  The  focus 
is  obtained  by  lengthening  or  shortening  the  tube,  as  with  a telescope. 
I have  made  a slight  modification  in  it,  which  admits  of  the  application 
of  a diaphragm.  The  extra  tube  can  be  had  separately,  so  that  any  of 
you  who  possess  an  Oberhaeuser’s  microscope  can  apply  it  to  the  body 

Fig.  48.  Cri  uby’s  pocket  microscope  mounted,  ready  for  use — half  the  real  size. 

Fig.  49.  Beale’s  clinical  microscope — one-fourth  the  real  size. 


USE  OF  THE  MICE03C0PE. 


81 


of  that  instrument,  and  thus,  at  a moderate  expense,  convert  it  into  a 
clinical  and  pocket  microscope. 

We  have  next  to  speak  of  the  optical  parts  of  microscopes,  which  are 
certainly  much  more  important  than  the  mechanical  ones — for  everything 
depends  upon  obtaining  a clear  and  distinct  image  of  the  object  examined. 
Under  this  head  we  may  describe  the  objective,  the  eye-piece,  and 
methods  of  illumination. 

1.  The  ohjective^  or  series  of  Achromatic  Lenses^  is  that  part  of  the 
optical  portion  of  a microscope  which  is  placed  at  the  bottom  of  the  tube 
or  body,  and  is  near  the  object  to  be  examined.  This  may  be  considered 
the  most  important  part  of  the  instrument,  and  the  greatest  pains  have 
been  taken  by  all  opticians  in  the  manufacture  of  good  lenses.  It  is 
here  I consider  that  the  London  opticians  are  pre-eminent,  for  I am  not 
aware  that  in  any  part  of  the  world  such  perfect  objectives  have  been 
manufactured  as  the  eighth  of  an  inch  by  Smith,  the  twelfth  of  an  inch 
by  Ross,  and  the  sixteenth  of  an  inch  by  Powell.  But  when  we  come 
down  to  the  one-fourth  of  an  inch,  which  is  by  far  the  most  useful  objec- 
tive for  anatomical  and  medical  purposes,  the  superiority  of  the  London 
opticians  is  very  slight,  if  an3^  At  this  magnifying  power  the  compound 
lenses  of  Oberhaeuser,  and  Nachet  of  Paris;  Schiek  and  Pistor  of 
Berlin ; Frauenhofer  of  Munich,  and  Ploesl  of  Vienna  may  be  em- 
ployed with  the  greatest  confidence,  and  it  may  be  said  that  by  far  the 
largest  number  of  important  discoveries  in  science  have  been  made 
through  their  employment.  The  Parisian  lenses,  in  addition,  have  one 
great  advantage,  namely,  their  cheapness. 

The  London  opticians  have  succeeded  in  combining  the  lenses  of 
their  objectives,  so  as  to  obtain  a large  field  of  vision  with  as  little  loss 
of  light  as  possible.  These  qualities  are  valuable  in  the  lower  magnify- 
ing lenses  during  the  examination  of  opaque  objects,  and  in  the  higher 
ones  when  observing  transparent  objects  by  transmitted  light.  But  in 
the  lenses  of  medium  power,  such  as  the  one-fourth  of  an  inch,  the 
amount  of  light  is  so  great  as  to  be  almost  a defect.  Notwithstanding 
careful  management  of  the  mirror  and  diaphragm,  the  field  of  vision  is 
often  dazzling,  and  always  presents  a glare  most  detrimental  to  the  eyes 
of  the  observer.  I cannot  employ  Ross’s  fourth  of  an  inch  for  fifteen 
minutes  without  feeling  intense  headache,  and  I know  of  more  than  one 
excellent  observer  in  whom  the  sight  has  so  much  suffered  from  this 
cause  as  to  incapacitate  them  from  continuing  their  researches.  In  the 
same  manner,  certain  French  lenses  give  rise  to  a yellow  light  highly 
disagreeable ; while  those  of  Oberhaeuser,  Schiek  and  Pistor,  and  Frauen- 
hofer (with  Amici’s  and  Ploesl’s  I am  not  familiar),  present  a pale  blue 
light,  most  pleasant  to  work  with,  and  which  may  be  gazed  at  for  hours 
without  fatiguing  the  eye. 

For  the  above  reasons,  as  well  as  from  considerable  experience  in  the 
use  of  many  kinds  of  microscopes  by  different  manufacturers,  I am 
satisfied  that  the  best  lens  you  can  employ  for  ordinary  purposes  is 
Oberhaeuser’s  No.  7,  which  corresponds  to  what  is  called  in  England  the 
quarter  of  an  inch.  For  low  powers  you  may  have  Oberhaeuser’s  No.  3, 
or  the  one-inch  lens  of  the  London  opticians.  For  all  the  wants  of  the 
medical  man  these  will  be  sufficient.  The  anatomist  may  occasionally 
6 


82 


EXAMmATIOX  OF  THE  PATIEXT. 


require  a higher  lens,  as  during  the  examination  of  the  ultimate  fibrillse 
of  muscle,  when  the  eighth,  twelfth,  or  sixteenth  of  an  inch  of  the 
London  opticians  may  be  procured.  All  these  lenses  may  be  attached 
to  the  model  we  have  recommended  by  means  of  a brass  screw  made  on 
purpose. 

2.  The  Eye-piece, — This  is  that  portion  of  the  optical  apparatus 
which  is  placed  at  the  upper  end  of  the  tube  or  body,  and  is  near  the 
eye  of  the  observer.  While  the  objective  magnifies  the  object  itself,  the 
eye-piece  only  magnifies  the  image  transmitted  from  below.  Hence,  as  a 
source  of  magnifying  power,  it  is  inferior  to  the  lens;  and  when  this 
possesses  any  defects,  these  are  enlarged  by  the  eye-piece.  Two  eye- 
pieces are  all  that  is  necessary  with  the  model  I have  recommended,  and 
those  of  Oberhaeuser,  called  Nos.  3 and  4,  are  the  most  useful  for  the 
medical  man. 

3.  Methods  of  Illumination. — There  are  few  things  of  more  import- 
ance to  the  practical  histologist  than  the  mode  of  illumination.  This  is 
accomplished — 1st,  By  transmitted  light;  2d,  By  reflected  light;  and 
3d,  By  achromatic  light. 

Transmitted  light  is  obtained  by  means  of  a mirror  placed  below  the 
object,  which,  to  be  seen,  must  therefore  be  transparent.  In  large 
microscopes  the  m.rrors  are  provided  with  universal  joints,  so  that  they 
may  easily  be  turned  in  any  direction.  Below  the  stage  every  micro- 
scope should  possess  a diaphragm  pierced  with  variously  sized  holes, 
whereby  the  amount  of  light  furnished  by  the  mirror  may  be  moderated. 
In  Oberhaeuser’s  and  Nachet’s  instruments  the  smallest  aperture  should 
be  employed  for  the  higher  objective.  It  is  also  useful  in  the  examina- 
tion of  many  objects  that  the  light  should  be  directed  upon  them  side- 
ways; this  may  be  done  by  the  diaphragm,  or  by  the  mirror,  and  in  the 
small  model  formerly  figured  (Fig.  46),  is  admirably  attained  b}’  simply 
turning  the  whole  microscope.  The  best  light  for  microscopic  purposes 
is  that  obtained  by  catching  the  rays  which  are  reflected  from  a white 
cloud.  The  conjoined  use  of  the  mirror  and  diaphragm  can  only  be 
learned  from  actual  experience. 

Beflected  light  is  employed  in  the  examination  of  opaque  objects. 
The  lenses  of  low  power,  manufactured  by  the  principal  London  opticians, 
enable  us  to  do  this  without  assistance.  Occasionally,  however,  the  light 
of  the  sun  is  u eful ; and  when  this  cannot  be  obtained,  the  rays  of  a 
lamp  or  gas  light,  concentrated  by  a bull’s  eye  lens,  may  be  employed. 
Hence  every  microscope  should  be  possessed  of  such  a lens,  and  it  is  most 
convenient  to  have  it  attached  to  the  body  of  the  instrument  by  a movable 
ring,  and  stem  with  two  joints,  as  in  the  model  figured  (Fig.  46). 

Achromatic  light  is  only  serviceable  in  the  examination  of  very 
delicate  objects,  with  high  powers.  The  apparatus  necessary  for  obtain- 
ing it  is  occasionally  useful  in  ascertaining  the  ultimate  structure  of 
muscle,  or  the  nature  of  the  markings  on  minute  scales  or  fossils,  but  is 
useless  for  the  purposes  of  the  medical  man.  In  the  same  way  I know 
of  no  benefit  to  be  obtained  by  a polarising  apparatus. 

In  addition  to  the  mechanical  and  optical  parts  constituting  the 
microscope  itself,  the  box  which  contains  it  should  possess  a convenient 
place  for  holding  a few  slips  of  glass,  a pair  of  small  forceps,  a knife,  and 


USE  OF  THE  MICROSCOPE. 


83 


two  needles  firmly  set  in  handles.  A micrometer  to  measure  objects 
with  is  also  essential  to  those  who  are  making  observations  with  a view 
to  their  exact  description.  No  other  accessories  are  necessary. 

All  excellent  microscope  of  the  model  previously  figured,  by  Ober- 
haouser  (Fig.  46),  with  two  objectives  (Nos.  3 and  7),  two  eye-pieces 
(Nos.  3 and  4),  a neat  box  with  all  the  accessories  necessary  (with  the 
exception  of  a micrometer,  which  had  better  be  English),  may  be  ob- 
tained in  Paris  for  the  sum  of  about  150  francs  (£6),  and  are  .sold  in 
Edinburgh  by  Mr.  Young,  cutler.  North  Bridge,  for  £6: 15s.  Nachet’s 
instruments  are  mu  4i  cheaper,  as  are  the  smaller  models  of  Oberhaeuser. 
Either  of  them,  for  all  the  purposes  of  the  medical  man,  is  amply  suffi- 
cient. 

Test-  Objects  — The  defining  power  of  a microscope  is  generally  tested 
by  examining  with  it  a transparent  object,  having  certain  fine  markings, 
which  can  only  be  rendered  clearly  visible  when  the  glasses  are  good. 
In  all  such  cases,  it  is  of  course  necessary  to  be  familiar  with  the  structure 
of  the  test-object  in  the  first  instance.  If  you  are  not  confident  on  this 
point,  it  is  better  to  trust  to  the  judgment  of  a friend,  whose  knowledge 
of  histology  is  ascertained,  or  place  your  dependence  entirely  on  a respect- 
able optician.  One  of  the  best  test-objects  for  a quarter  of  an  inch  lens 
is  a drop  of  saliva  from  the  mouth.  For,  if  the  microscope  shows  with 
clearness  the  epithelial  scales,  the  structure  of  the  salivary  globules,  their 
nuclei,  and  contained  molecules,  you  may  be  satisfied  that  the  instrument 
will  exhibit  all  the  facts  with  which,  as  medical  men,  you  have  to  do — 
(See  Fig.  51). 

Mensuration  and  Demonstration. 

Having,  then,  obtained  a good  instrument,  and  tested  its  qualities  in 
the  manner  described,  you  should  next  determine  the  number  of  dia- 
meters linear  the  various  combinations  of  glasses  magnify.  This  you  may 
do  for  yourself  with  the  aid  of  a micrometer,  a pair  of  compasses,  and 
a,  measure. 

A micrometer  is  a piece  of  glass  on  which  lines  are  ruled  at  the  dis- 
tance of  To 0^^^  of  an  inch.  This  must  be  placed  under  the 

instrument,  when  the  lines  and  the  distances  between  them  will  of  course 
be  magnified  by  the  combination  of  glasses  employed,  like  any  other 
object.  Taking  a pair  of  compasses  in  one  hand,  we  separate  the  points, 
and  place  them  on  the  stage  (always  on  a level  with  the  micrometer 
magnified).  Now,  looking  through  the  instrument  with  one  eye,  we 
regard  the  points  of  the  compasses  with  the  other,  and  mark  off  by  the 
naked  sight,  say  the  inch,  as  magnified  by  the  instrument. 

Though  difficult  at  first,  a little  practice  enables  us  to  do  this  with  the 
.greatest  accuracy.  The  result  is,  that  if  the  distance  magnified  and  so 
marked  off  of  an  inch)  is  equal  to  three  inches,  the  instrument 

magnifies  300  times  linear ; if  two  inches,  200  times ; and  so  on. 

To  measure  the  size  of  objects,  they  may  be  placed  directly  on  the 
micrometer ; but  as  this  is  at  all  times  inconvenient,  whilst  the  object 
and  micrometer,  from  their  not  being  in  the  same  plane,  cannot,  under 
high  powers,  both  be  brought  into  focus  at  once,  it  is  better  to  use  an  eye- 
micrometer.  Many  ingenious  inventions  of  this  kind  are  to  be  procured. 


84 


EXAMIXATION  OF  THE  PATIENT. 


meters  hne^ 


The  most  simple  is  a ruled  micrometer  placed  in  the  focus  of  the  upper 
glass  of  the  eye-piece.  With  this  we  observe  how  many  divisions  of  the 
eye-micrometer  correspond  with  one  of  those  magnified  by  the  microscope, 
always  making  our  observation  in  the  centre  of  the  field,  where  the 
aberration  of  sphericity  is  least.  On  the  latter  being  removed  and  re- 
placed by  an  object,  it  becomes  a matter  of  mere  calculation  to  determine 
its  size.  Thus,  supposing  each  of  the  upper  spaces  in  Fig.  50  to  repre- 
sent the  y^’^^th  of  an  inch  magnified  250  diameters  linear,  and  five  of 
the  lower  spaces,  as  seen  in  an  eye-micrometer,  to  correspond  with  one 
F.g.  50.  of  these — it  follows  that  each  of  these  latter  must 

measure  j of  an  inch.  Oberhaeuser  has  made 
beautifully  ruled  eye-micrometers,  for  the  model  re- 
commended (Fig.  46),  which  those  who  wish  to  make 
measurements  would  do  well  to  procure. 

If  it  be  not  in  your  power  to  estimate  the 
magnifying  power  for  yourself,  the  optician  will 
give  you  a table,  setting  forth  the  various  degrees 
Spaces  equal  to  i-ioooth  of  enlargement  possessed  by  the  lenses,  and  dilFeretit 

eye-pieces,  with  the  tube  up  or  down.  This  table 
should  always  be  referred  to  during  the  description 
of  objects,  and  the  amount  of  magnifying  power 
invariably  stated. 


The  art  of  demonstrating  under  the  microscope 
is  only  to  be  acquired  by  long  practice,  and,  like 
Five  ruled  spaces  in  an  eye- everything  requiring  practical  skill,  cannot  be  learnt 

micrometer, corresponding^  ^ t i 

to  one  of  those  above,  and  irom  Dooks  or  Systematic  lectures,  i can  only, 

the  rS'th  of  a^iS  general  directions  on  this 

head. 

All  that  is  necessary  in  examining  fluid  substances  is  to  place  a drop 
in  the  centre  of  a slip  of  glass,  and  letting  a smaller  and  thinner  piece  of 
glass  fall  gently  upon  it,  so  as  to  exclude  air  bubbles,  place  it  upon  the 
stage  under  the  objective.  In  this  way  the  fluid  substance  will  be  diffused 
equally  over  a flat  surface,  and  evaporation  prevented,  which  would  dim 
the  objective.  The  illumination  must  now  be  carefully  arranged,  and 
the  focus  obtained,  first  by  means  of  the  coarse,  and  then  by  means  of 
the  fine  adjustment.  It  will  save  much  time,  in  examining  structures, 
to  employ  always,  at  one  sitting,  the  same  slips  of  glass,  as  it  is  easier  to 
clean  these  with  a towel,  after  dipping  them  in  water,  then  to  be  perpe- 
tually shifting  the  coarse  adjustment. 

The  action  of  water,  acetic  acid,  and  of  other  re-agents,  on  the  particles 
contained  in  a fluid,  may  be  observed  by  mixing  with  it  a drop  of  the 
re-agent  before  covering  with  the  upper  glass;  or  if  this  be  already  done, 
the  drop  of  re-agent  may  be  placed  at  the  edge  of  the  upper  glass,  when 
it  will  be  diffused  through  the  fluid  under  examination  by  imbibition. 

The  mode  of  demonstrating  solid  substances  will  vary  according  as 
they  are  soft  or  hard,  cellular  or  fibrous.  The  structure  of  a soft  tissue, 
such  as  the  kidney,  skin,  cartilage,  etc.,  is  determined  by  making  very 
minute,  thin,  and  L’ansparent  vslices  of  it  in  various  directions,  by  means 
of  a sharp  knife  or  razor.  These  sections  should  be  laid  upon  a slip  of 
glass,  then  covered  over,  and  slightly  pressed  flat,  by  means  of  an  upper 


USE  OF  THE  MICEOSCOPE. 


85 


one.  The  addition  of  a drop  of  water  renders  the  parts  more  clear,  and 
facilitates  the  examination,  although  it  should  never  be  forgotten  that 
most  cell  structures  are  thereby  enlarged  or  altered  in  shape  from  endos- 
mosis.  Acid  and  other  re-agenls  may  be  applied  in  like  manner.  The 
double-bladed  knife  of  Valentin  will  enable  you  to  obtain  large,  thin,  and 
equable  sections  of  such  tissues,  and  permit  you  to  see  the  manner  in 
which  the  various  elements  they  contain  are  arranged  with  regard  to  each 
other.  Harder  tissues,  such  as  wood,  horn,  indurated  cuticle,  etc.,  may 
also  be  examined  after  making  thin  sections  of  them.  Very  dense  tissues, 
such  as  bone,  teeth,  shell,  etc.,  require  to  be  cut  into  thin  sections  and 
afterwards  ground  down  to  the  necessary  thinness.  Preparations  of  this 
kind  are  now  manufactured  on  a large  scale,  and  may  be  obtained  at  a 
trifling  cost.  A cellular  parenchymatous  structure,  such  as  the  liver, 
may  be  examined  by  crushing  a minute  portion  between  two  glasses.  If 
it  be  membranous,  as  the  cuticle  of  plants,  epithelial  layers,  etc.,  the 
membrane  should  be  carefully  laid  flat  upon  the  lower  glass,  and  covered 
with  an  upper  one.  A fibrous  structure,  such  as  the  areolar,  elastic, 
muscular,  and  nervous  tissues,  must  be  separated  by  means  of  needles, 
and  then  spread  out  into  a thin  layer  before  examination,  with  or  with- 
out water,  etc. 

The  commencing  observer  should  not  be  discouraged  by  the  difficulties 
he  will  have  to  encounter  in  dissecting  and  displaying  many  tissues.  He 
must  remember  that  the  figures  he  sees  published  in  books  are  generally 
either  fortunate  or  very  carefully  prepared  specimens.  Practice  will  soon 
enable  him  to  obtain  the  necessary  dexterity,  and  to  convince  himself  of 
the  importance  of  this  mode  of  inquiry.  He  should  early  learn  to  draw 
the  various  objects  he  sees,  before  and  after  the  action  of  re-agents, 
not  only  because  such  copies  constitute  the  best  notes  he  can  keep,  but 
because  drawing  necessitates  a more  careful  and  accurate  examination 
,of  the  objects  themselves.  A note-book  and  pencil  for  the  purpose 
should  be  the  invariable  accompaniments  of  every  microscope. 

How  TO  Observe  with  a Microscope. 

The  art  of  observation  is  at  all  times  difficult,  but  is  especially  so 
with  a microscope,  which  presents  us  with  forms  and  structures  concern- 
ing which  we  had  no  previous  idea.  Rigid  and  exact  investigation,  there- 
fore, should  be  methodically  cultivated  from  the  first,  in  order  to  avoid 
those  errors  into  which  the  tyro,  when  using  a microscope,  is  particularly 
liable  to  fall.  Thus,  you  should  carefully  examine  the  physical  properties 
of  the  particles  and  ultimate  structures  you  may  see,  and  not  hastily  con- 
clude that  you  have  under  observation  so-called  pus,  tubercle,  or  cancer- 
corpuscles,  because  they  were  obtained  from  what  was,  d 'priori,  believed 
to  be  pus,  tubercle,  or  cancer.  Nothing  has  been  more  clearly  demon- 
strated by  the  progress  of  histology,  than  the  fact,  that  the  naked  sight 
has  confounded  different  structures  together,  from  a similarity  of  external 
appearance,  and  that  the  greatest  caution  is  required  at  all  times,  but 
especially  by  learners,  in  forming  opinions  as  to  the  nature  of  different 
tissues. 

The  physical  characters  which  distinguish  microscopic  objects  consist 


86 


EXAMINATION  OF  THE  PATIENT. 


of— 1st,  Shape;  2d,  Color;  3d,  Edge  or  border;  4th,  Size;  5th,  Trans- 
parency; 6th,  Surface;  7th,  Contents;  and  8th,  Effects  of  re-agents. 
These  we  may  notice  in  succession. 

1.  Shape. — Accurate  observation  of  the  shape  of  bodies  is  very  neces- 
sary, as  many  of  these  are  distinguished  by  this  physical  property.  Thus 
the  human  blood  globules,  presenting  a biconcave  round  disk,  are  in  this 
respect  different  from  the  oval  corpuscles  of  the  camelidae,  of  birds, 
reptiles,  and  fishes.  The  distinction  between  circular  and  globular  is 
very  necessary  to  be  attended  to.  Human  blood  corpuscles  are  circular 
and  flat,  but  they  become  globular  on  the  addition  of  water.  Minute 
structures  seen  under  the  microscope  may  also  be  likened  to  the  shape  of 
well-known  objects,  such  as  that  of  a pear,  balloon,  kidney,  heart,  etc.  etc. 

2.  Color. — ^^The  color  of  structures  varies  greatly,  and  ofcen  differs, 
under  the  microscope,  from  what  was  previously  conceived  regarding 
them.  Thus  the  colored  corpuscles  of  the  blood,  though  commonly 
called  red,  are  in  point  of  fact  yellow.  Many  objects  present  different 
colors,  according  to  the  mode  of  illumination — that  is,  as  the  light  is 
reflected  from,  or  transmitted  through  their  substance,  as  in  the  case  of 
certain  scales  of  insects,  feathers  of  birds,  etc.  Color  is  often  produced, 
modified,  or  lost  by  re  agents,  as  when  iodine  comes  in  contact  with 
starch  corpuscles,  when  nitric  acid  is  added  to  the  granules  of  chlorophyle, 
or  chlorine  water  affects  the  pigment  cells  of  the  choroid,  and  so  on. 

3.  Edge  or  Border. — The  edge  or  border  may  present  peculiarities 
which  are  worthy  of  notice.  Thus,  it  may  be  dark  and  abrupt  on  the 
field  of  the  microscope,  or  so  fine  as  to  be  scarcely  visible.  It  may  be 
smooth,  irregular,  serrated,  beaded,  etc.  etc. 

4.  Size. — The  size  of  the  minute  bodies,  fibres,  or  tubes,  which  are 
found  in  the  various  textures  of  animals,  can  only  be  determined  with 
exactitude  by  actual  measurement,  in  the  manner  formerly  described.  It 
will  be  observed,  for  the  most  part,  that  these  minute  structures  vary  in 
diameter,  so  that  when  their  medium  size  cannot  be  determined,  the 
variations  in  size  from  the  smaller  to  the  larger  should  be  stated.  Human 
blood  globules  in  a state  of  health  have  a pretty  general  medium  size,  and 
these  may  consequently  be  taken  as  a standard  with  advantage,  and 
bodies  may  be  described  as  being  two,  three,  or  more  times  larger  than 
this  structure. 

5.  Transparency. — This  visible  property  varies  greatly  in  the  ulti- 
mate elements  of  numerous  textures.  Some  corpuscles  are  quite  dia- 
phanous, others  are  more  or  less  opaque.  The  opacity  may  depend  upon 
corrugation  or  irregularities  on  the  external  surface,  or  upon  contents  of 
different  kinds.  Some  bodies  are  so  opaque  as  to  prevent  the  transmis- 
sion of  the  rays  of  light,  when  they  look  black  by  transmitted  light, 
although  they  be  white,  seen  by  reflected  light.  Others,  such  as  fatty 
particles  and  oil  globules,  refract  the  rays  of  light  strongly,  and  present  a 
peculiar  luminous  appearance. 

6.  Surface. — Many  textures,  especially  laminated  ones,  present  a dif- 
ferent structure  on  the  surface  from  that  which  exists  below.  If,  then, 
in  the  demonstration,  these  have  not  been  separated,  the  focal  point  must 
be  changed  by  means  of  the  fine  adjustment.  In  this  way  the  capillaries  in 
the  web  of  the  frog’s  foot  may  seem  to  be  covered  w;th  an  epidermic 


USE  OF  THE  MICEOSCOPE. 


87 


layer,  and  the  cuticle  of  certain  minute  fungi  or  infusoria  to  possess 
peculiar  markings.  Not  unfrequently  the  fracture  of  such  structures 
enables  us,  on  examining  the  broken  edge,  to  distinguish  the  difi'erence 
in  structure  between  the  surface  and  the  deeper  layer  of  the  tissue  under 
examination. 

7.  Contents. — The  contents  of  those  structures,  which  consist  of 
envelopes,  as  cells,  or  of  various  kinds  of  tubes,  are  very  important. 
These  may  consist  of  included  cells  or  nuclei,  granules  of  different  kinds, 
pigment  matter,  or  crystals.  Occasionally  their  contents  present  definite 
moving  currents,  as  in  the  cells  of  some  vegetables,  or  trembling  rotatory 
molecular  movements,  as  in  the  ordinary  globules  of  saliva  in  the  mouth. 

8.  Effects  of  Re-agents. — These  are  most  important  in  determining  the 
structure  and  chemical  composition  of  numerous  tissues.  Indeed,  in  the 
same  manner  that  the  anatomist  with  his  knife  separates  the  various 
layers  of  a texture  he  is  examining,  so  the  histologist,  by  the  use  of  re- 
agents, determines  the  exact  nature  and  composition  of  the  minute  bodies 
that  fall  under  his  inspection.  Thus,  ivater  generally  causes  cell  forma- 
tions to  swell  out  from  endosmosis ; whilst  syrup,  gum  water,  and  con- 
centrated saline  solutions,  cause  them  to  collapse  from  exosmosis.  Acetic 
acid  possesses  the  valuable  property  of  dissolving  coagulated  albumen, 
and,  in  consequence,  renders  the  whole  class  of  albuminous  tissues  more 
transparent.  Thus,  it  operates  on  cell  walls,  causing  them  either  to  dis- 
solve or  become  so  thin  as  to  display  their  contents  more  clearly.  Aether., 
on  the  other  hand,  and  the  alkalies,  operate  on  the  fatty  compounds,  caus- 
ing their  solution  and  disappearance.  The  mineral  acids  dissolve  most  of 
the  mineral  constituents  that  are  met  with,  so  that  in  this  way  we  are 
enabled  to  tell,  with  tolerable  certainty,  at  all  events  the  group  of  chemi- 
cal compounds  to  which  any  particular  structure  may  be  referred. 

PRINCIPAL  APPLICATIONS  OF  THE  MICROSCOPE  TO 

DIAGNOSIS. 

A perfect  application  of  the  microscope,  for  the  purpose  of  diagnosis, 
can  only  be  arrived  at  by  obtaining,  in  the  first  instance,  a complete 
knowledge  of  the  tissues  of  plants  and  animals,  both  in  their  healthy 
and  diseased  conditions.  The  medical  practitioner  may  be  called  upon 
to  distinguish,  not  only  the  various  structures  which  enter  in  to  every 
species  of  food,  every  kind  of  animal  texture  and  fluid,  and  every  form 
of  morbid  product,  but  he  will  frequently  have  to  judge  of  these  when 
more  or  less  disintegrated,  changed,  or  otherwise  affected  by  the  pro- 
cesses of  mastication,  digestion,  expectoration,  ulceration,  putrefaction, 
maceration,  etc.  etc.  In  this  place,  however,  I propose  mei  ely  calling 
your  attention  to  those  points  which  are  more  likely  to  fall  under  your 
notice  at  the  bed-side.  No  doubt,  the  practical  applications  of  the 
microscope  are  daily  extending,  and  whilst  there  are  many  points  which 
may  be  said  to  be  scarcely  investigated,  those  which  have  been  most  so  re- 
quire to  be  further  studied.  At  the  same  time,  a careful  and  persevering 
examination  of  the  morphological  elements  found  in  the  various  excreta 
of  the  body,  as  modifled  by  different  diseases,  or  by  constitution  and  diet, 


88 


EXAMINATION  OF  THE  PATIENT. 


cannot  but  prove  of  great  importance  in  the  present  state  of  practical 
medicine.  Hence,  besides  shortly  discussing  what  is  known,  I shall 
especially  indicate  what  are  those  subjects  which  may  be  elucidated  by 
such  of  you  as,  by  previous  histological  observations,  are  qualified  for 
the  task. 

Saliva. 


The  readiest  way  of  examining  the  saliva  is  to  collect  a drop  of  that 
fluid  at  the  extremity  of  the  tongue,  and  let  it  fall  on  the  centre  of  a 
slip  of  glass.  It  should  be  allowed  to  remain  quiescent  for  a minute  or 
so,  until  most  of  the  bubbles  of  air  have  collected  in  a mass  on  the  sur- 
face. This  should  then  be  gently  scraped  off  or  placed  aside  with  a 
needle,  and  the  subjacent  fluid  covered  with  a thin  glass.  There  will 
now  be  observed,  with  a magnifying  power  of  250  diameters  linear — 
1st,  The  salivary  corpuscles;  2d,  Epithelial  scales  of  the  mouth ; 3d, 
Molecules  and  granules. 

1.  The  salivary  corpuscles  are  colorless  spherical  bodies,  with  smooth 
margins,  varying  in  size  from  the  -3^'^ ^0  the  y of  an  inch  in 
diameter.  They  contain  a round  nucleus,  varying  in  size,  but  generally 
occupying  a third  of  the  cell;  and  between  this  nucleus  and  the  cell  wall 
are  numerous  molecules  and  granules,  which  communicate  to  the  entire 

corpuscle  a finely  molecular  aspect.  The 
addition  of  water  causes  these  bodies  to  swell 
out  and  enlarge  from  endosmosis.  Acetic  acid 
somewhat  dissolves  the  cell  wall,  and  it  be- 
comes more  transparent ; while  the  nucleus 
appears  more  distinct  as  a single,  double,  or 
tripartite  body.  Both  water  and  acetic  acid 
produce  also  coagulation  of  the  albuminous 
matter  contained  in  the  fluid  of  the  saliva,  which 
assumes  the  form  of  molecular  fibres,  in  which 
the  corpuscles  and  epithelial  scales  become  entangled,  and  present  to 
the  naked  eye  a white  film. 

2.  The  Epithelial  scales  found  in  the  saliva  are  derived  from  the 

mouth,  and  consist  of  flat  plates,  variously  shaped,  but  generally  pre- 
senting an  oblong  or  squarish  form,  more  or  less  curled  up  at  the  sides. 
Not  uufrequently  these  have  five  or  six  sides,  and  are  assembled  together 
in  groups,  with  their  edges  adherent.  In  size  they  vary  from  the  j^oth 
to  the  5^0^^  length.  Embedded  in  their  substance  is  a 

round  or  oval  nucleus,  together  with  numerous  molecules  and  granules. 
Water  produces  no  change  in  these  bodies;  but  acetic  acid  renders  the 
scale  more  transparent,  and  causes  the  nucleus  to  appear  more  distinct 
with  a darker  edge. 

3.  Associated  with  the  salivary  corpuscles  and  epithelial  scales  are 
several  molecules  and  granules^  which  vary  in  number  in  difl'erent  peop.e, 
and  at  various  times  of  the  day. 

There  may  also  be  occasionally  found  in  the  saliva  various  foreign 
substances  derived  from  the  food, — such  as  granular  debris  of  different 
kinds,  starch  globules  or  vegetable  cells,  muscular  fasciculi,  portions  of 

Fig.  51.  Salivary  corpuscles,  epithelial  scales,  with  molecules  and  granules,  as  seen 
in  a drop  of  saliva.  ' Magnified  250  diam.  linear. 


USE  OF  THE  MICROSCOPE. 


89 


areolar  tissue,  tendon,  or  spiral  filaments,  etc.,  derived  from  pieces  of 
texture  which  have  adhered  to  the  teeth  during  mastication. 

The  saliva  may  present  various  alterations,  dependent  on  disease  of 
the  mucous  membranes  of  the  mouth  and  tongue.  This,  when  ulcerated, 
causes  an  increase  in  the  molecu- 
lar and  granular  matter.  Many 
of  the  epithelial  scales  also  lose 
their  transparent  character  and 
become  opaque,  from  an  aug- 
mentation of  granular  matter  in 
their  substance.  Not  unfre- 
quently,  under  such  circum- 
stances, they  give  rise  to  co  i- 
fervoid  growths,  which  mainly 
spring  up  in  the  debris  collected  in  the  mouth,  either  on  the  surface  of 
ulcers,  in  the  sordes  which  collect  on  the  teeth,  gums,  and  tongue  of 
individuals  laboring  under  fever,  or  even  in 
the  inspissated  mucus  of  persons  who  sleep 
for  a considerable  time  with  the  mouth  open 
(Fig.  52.)  In  infants,  the  tongue  and  cavity 
of  the  mouth  are  not  unfrequently  covered 
with  a yellowish  flocculent  matter  constituting 
the  disease  named  muguet  by  the  French,  in 
which  sporulcs  and  confervoid  filaments,  in  a 
high  state  of  development,  may  be  detected  in 
considerable  numbers  (Fig.  53). 

In  epithelial  cancroid  of  the  tongue,  the 
epithelial  scales  exhibit  a great  tendency  to 
split  up  and  form  fibres,  and  may  frequentl}!' 
be  found  on  the  surface  of  the  ulcer,  present- 
ing the  form  here  figured  (Fig.  54). 

An  histological  examination  of  the  saliva,  of  the  fur  and  load  of  the 
tongue,  in  the  great  majority  of  diseases,  is  still  a desideratum. 

Milk. 

On  examining  a drop  of  milk  * we  observe  a number  of  bodies  roll 
in  a clear  fluid.  These  bodies,  in  heaithy  milk,  are  perfectly  spheri- 
cal, with  dark  margins,  smooth  and  abrupt  on  the  field  of  the  microscope, 
with  a clear  transparent  centre,  which  strongly  refracts  light.  In  size 
they  vary  in  different  specimens,  from  a point  scarcely  measurable  up  to 
the  4 or  3jjU^th  of  an  inch  in  diameter.  In  excess  of  ether  they 

are  dissolved  or  disappear ; but  if  this  re-airent  be  in  small  quantity, 
exosmosis  takes  place,  and  the  field  of  the  microscope  is  covered  with 
loose  globules  of  oil,  of  various  forms.  W ater  causes  the  milk  globules 
* The  mode  of  examining  all  fluids  is  the  same,  and  is  described  p.  84. 

Fig.  52.  Minute  confervoid  filaments  springing  from  an  altered  epithelial  scale, 
scraped  from  the  surface  of  a cancroid  ulcer  of  the  tongue  { Leptothrix  bncccalis). 

Fig.  53.  Confervoid  filaments  and  sporules,  in  the  exudation  on  the  mouth  and 
gums,  constituting  muguet  in  infants. 

Fig  54.  Fringe-like  epithelium,  from  the  surface  of  an  ulcer  on  the  tongue.  250  di. 


90 


EXAMmATION  OF  THE  PATIENT. 


to  swell  out,  but  very  slightly.  Acetic  acid  coagulates  the  caseous  £uid 
in  which  they  swim,  and  causes  the  globules  to  be  aggregated  together  iu 
masses.  Several  of  the  globules  also  exhibit,  under  the  action  of  this  re- 
agent, a certain  flaccidity,  and  readily  run  into  one  another  uuder 
pressure. 

These  globules  consist  of  a delicate  envelope  of  casein,  enclosing  a 
drop  of  oil  or  butter.  The  membrane  keeps  them  separate,  so  loDfi  as  it 
is  intact ; but,  dissolved  by  means  of  acetic  acid,  or  ruptured  by  heat  or 
mechanical  violence  (as  in  the  churn),  the  butter  is  readily  separated  and 
collected.  Cream  is  composed  of  the  larger  of  these  globules,  which, 
owing  to  their  low  specific  gravity,  float  on  the  surface  of  milk  when 
allowed  to  repose. 

The  richness  of  milk  is  determined  by  the  quantity  of  these  globules. 
An  examination  of  cow’s  and  human  milk  will  at  once  show  that  the 
former  contains  a larger  number  than  the  latter.  In  all  efforts,  however, 
to  determine  the  relative  value  of  milk  by  microscopic  examination,  great 
care  must  be  taken  that  the  drop  of  fluid  examined  should  be  of  the 
same  bulk,  that  the  same  upper  glass  should  be  used  in  every  case,  and 
that  it  should  be  applied  and  pressed  down  with  the  same  force.  It  is 
very  difficult  at  all  times  strictly  to  fulfil  these  conditions,  for  not  only 
is  great  skill  in  manipulation  required,  but  an  intimate  acquaintance  with 
the  appearance  ofmilkasseen  under  the  microscope  is  necessary,  before 
any  confidence  can  be  placed  in  this  mode  of  testing  the  quality  of 
different  specimens  of  the  fluid.  At  the  same  time,  the  difi'erence  in  the 
amount  of  oily  constituents  between  the  milk  of  the  cow,  ass,  and  human 
female,  may  in  this  way  be  easily  determined. 

In  the  same  manner  the  various  adulterations  of  milk  are  at  once 
determined.  Water,  of  course,  separates  the  globules  more  and  more 

o other  according  to  its 

amount.  Flour  will  exhibit  the 
large  starch  corpuscles,  which  are 
ch^ged  blue  by  the  action  of 
iodine.  Chalk  shows  numerous 
irregular  mineral  particles,  which 
are  soluble  in  the  mineral  acids; 
Fig.  56.  and  broken-down  brain  will  be 

distinguished  by  large  oil  globules,  mingled  with  fragments  of  fine  nerve- 
tubes.  Milk,  when  acid,  exhibits  the  same  character  that  it  does  under 
the  action  of  acetic  acid. 

Healthy  and  fresh  milk  is  indicated  by  a certain  uniformity  in  the 
size  of  the  globules ; by  their  perfectly  globular  form ; by  their  rolling 
freely  over  each  other,  and  not  collecting  together  in  masses  (Fig.  55). 
When  the  latter  circumstance  occurs,  it  is  a sign  of  acidity. 

The  milk  first  secreted  after  parturition  is  called  the  colostrum.  It 
is  yellow  in  color,  and  may  be  seen  under  the  microscope  to  contain 
globules  more  variable  in  size,  mingled  with  a greater  or  less  number  of 
granule  cells  (Fig.  56).  These  latter  ought  to  disappear  in  the  human 
female  on  the  fifth  or  sixth  day  after  parturition,  but  occasionally  they 

Fig.  55.  Globules  of  cow’s  milk. 

Fig.  56.  Colostrum  of  the  human  female,  containing  milk  globules  greatly  varying 
in  size,  with  compound  granular  corpuscles.  260  dia?n. 


Fie  55. 


USE  OF  THE  MICROSCOPE. 


91 


remain,  when  the  milk  must  be  considered  as  unhealthy.  In  some  cases 
I have  seen  them  abundant  so  late  as  six  weeks  after  the  infant’s  birth. 

On  some  occasions,  milk  may  be  mixed  with  pus  and  blood,  which 
are  readily  detected  by  the  characters  distinctive  of  each.  Dr.  Peddie 
has  pointed  out  that  milk  can  be  squeezed  from  the  mamma  during  the 
early  months  of  pregnancy.  Under  such  circumstances,  it  constitutes  a 
most  important  sign  of  the  pregnant  state,  especially  of  a first  pregnancy  ; 
for  although  the  secretion  at  this  time  has  seldom  the  external  appear- 
ance of  milk,  but  is  serous- looking,  and  often  very  viscid  and  syrupy, 
still,  if  examined  with  the  microscope,  the  characteristic  milk  globules 
will  at  once  appear.  See  his  valuable  paper,  “ Monthly  Journal  of 
Medical  Science,”  August  1848. 


The  Blood. 


On  examining  a drop  of  blood  drawn  from  the  extremity  of  the  finger 
by  pricking  it,  there  will  be  seen  a multitude  of  yellow  round  bi-concave 
discs,  rolling  in  the  field  of  the  microscope,  which  soon  exhibit  a tendency 
to  turn  upon  their  edge,  and  arrange  themselves  in  rolls,  like  rouleaux 
of  coins.  These  rouleaux,  by  crossing  one  another,  dispose  themselves 
in  a kind  of  network,  between  which  may  be  seen  a few  colorless  spheri- 
cal corpuscles,  having  a molecular  surface,  and  a few  granules.  The 
colored  blood  corpuscles,  vary  in  size  from  the  ^^^^^^th  to  the  3 
an  inch  in  diameter,  their  average  size  being  about  the  ^^'jj-gth  of  an 
inch — according  to  Gulliver,  of  an  inch.  Owing  to  their  bi-con- 

cave form,  they  present  a bright  external  rim  with  a central  shadowed 
spot,  or  a bright  centre  and  a dark 
edge,  according  to  the  focal  point  in  f ^ 
which  they  are  viewed  (Fig.  57).  If  o V' 
the  blood  be  exposed  to  the  air  a little  u 
time  before  examination,  or  if  it  be  ob- 
tained  by  venesection,  the  edges  of  the 
corpuscles  may  often  be  observed  to 
have  lost  their  smooth  outline,  and  to 


Fig.  58. 


have  become  irregular,  notched,  ser- 
rated, beaded,  etc.  (Fig.  58).  Long  maceration  in  serum,  or  other  cir- 
cumstances, frequently  cause  them  to  diminish  in  bulk  half  their  natural 
size,  and  to  present  a perfectly  spherical  colored  body.  On  the  addition 
of  water,  the  blood  discs  become  spherical,  and  lose  their  color.  On 
adding  syrup,  they  become  flaccid  and  irregular.  Strong  acetic  acid  dis- 
solves them  rapidly,  and  very  weak  acetic  acid  does  so  slowly,  or  dimin- 
ishes their  bulk  by  one-half.  The  effects  of  wine,  as  pointed  out  by  Dr. 
Wm.  Addison,  and  of  magenta,  as  shown  by  Dr.  Boberts,  are  curious, 
but  need  not  be  alluded  to  here  at  length. 


Fig.  57.  Blood  corpuscles,  drawn  from  the  extremity  of  the  finger.  On  the  left 
of  the  figure  they  are  isolated,  some  flat  and  on  edsre,  some  having  a dark  and  others 
a light  centre,  according  to  the  focal  point  in  which  they  are  viewed.  On  the  right 
of  the  figure  several  rolls  have  formed.  Two  colorless  corpuscles  and  a few  granules 
are  also  visible. 

Fig.  68.  Blood  corpuscles  altered  in  shape  from  exosmosis. 


250  diam. 


92 


EXAMINATION  OF  THE  PATIENT. 


The  colorless  corpuscles  of  the  blood  are  spherical  in  form,  and  vary 
in  size  from  the  2 diameter.  Their 

surface  presents  a molecular  or  dotted  appearance,  almost  disappearing 
on  the  addition  of  water,  when  they  swell  out  by  endosmosis.  Acetic 
acid  renders  the  external  cell-wall  very  transparent,  and  brings  the 
nucleus  into  view,  consisting  of  one,  two,  or  three  round  granules. 

The  examination  of  the  blood  by  the  microscope  enables  us  to  deter- 
mine certain  pathological  conditions  of  that  fluid,  which,  though  few  in 
number,  are  by  no  means  unimportant. 

In  several  diseases,  the  blood  presents  unusual  spissitude,  depending 
on  excess  of  fibrin.  In  this  condition  the  colored  blood  corpuscles  easily 


iSiWf 


mt 

tt, 

w 

Fig.  59.  ^ Fig. 

lose  under  nressure  their  rounded  margin,  and  assume  a caudate,  flash- 
like,  or  fusiform  shape.  They  do  not  present  their  usual  tendency  to 
accumuhitein  rolls,  but  aggregate  themselves  together  in  irregular  masses, 
as  represented  Fig.  59.  Occasionally  the  fibrin  is  precipitated  in  the 
form  of  molecular  fibres,  serving  to  unite  the  changed  corpuscles  in 
bead-like  rows,  as  in  Fig.  60. 

In  certain  internal  hemorrhages  the  blood  corpuscles  break  down,  or 
become  partially  dissolved,  when  the  external  envelope  is  seen  very 
transparent,  the  shadowed  spot  disappears,  and  there  is  found  in  their 
interior  one  or  more  granules.  The  liquor  sanguinis 
also  contains  an  unusual  number  of  granules  (Fig  61). 
The  same  change  is  occasionally  observable  in  the  blood 
extravasated  below  the  skin  in  scurvy  or  purpura 
hemorrhagica. 

In  a woman  who  died  of  cholera.  Dr.  James  M. 
Cowan  observed  a remarkable  al- 
teration in  the  blood,  wdiich  he  was 
Fig.  61.  go  good  as  to  show  me.  It  con- 
sisted in  the  colored  corpuscles  being  paler  than  usual, 
and  the  colorless  ones  normal,  but  mingled  with  these 
were  others  varying  in  shape  and  size.  They  were 
generally  circular,  but  some  were  oval,  and  a few 
caudate.  They  had  a well-defined  external  smooth 
border,  having  one  or  two  bright  refracting  granules, 
generally  situated  in  the  external  membrane,  and  oc- 
casionally projecting  from  it.  When  seen  edgeways,  they  were  flattened. 

Fig.  59.  Blood  corpuscles  altered  in  form,  and  aggregated  together,  in  thickened 
blood. 

Fig.  60.  The  same,  united  together  in  chaplets  by  coagulated  fibrin. 

Fig.  61.  Altered  blood  corpuscles  in  the  fluid  of  an  haBinatocele. 

Fig.  62.  Appearance  of  blood  once  observed  in  a case  of  cholera.  250  diam. 


2J: 


’Q' 


Fig.  62. 


USE  OF  THE  MICEOSCOPE. 


93 


and  existed  in  the  proportion  of  one  to  seven  of  the  colored  corpuscles. 
Their  long  diameter  varied  from  the  2 of  an  inch, 

and  their  transverse  diameter  from  the  ^0  4 oVo^b  of  an  inch. 

The  addition  of  acetic  acid  made  them  swell  out,  dissolved  their  external 
wall,  and  liberated  the  granules.  Aqua  potassae  rendered  the  whole 
structure  paler,  and  a solution  of  muriate  of  soda  caused  them  to  become 
more  distinct,  and  of  smaller  size.* 

We  have  seen  that,  in  a healthy  condition,  the  blood  possesses  very 
few  colorless  corpuscles ; but  there  is  a certain  state  of  that  fluid  I was 
the  first  to  describe  in  1845,  and  have  since  called  “ Leucocythemia,” 
or  white-cell  blood,  in  which  they  are  very  numerous,  generally  associ- 
ated with  enlargement  of  the  spleen  or  other  lymphatic  glands.  The 


Fi-.  C3. 


\ i!Bi 

Fig.  65. 


blood  then  presents  the  characters  represented  in  the  accompanying 
figures.  (See  also  the  section  on  Leucocythemia.) 

It  has  been  affirmed  that  the  color  and  number  of  the  corpuscles 
of  the  blood  undergo  a change  in  plethora,  fever,  jaundice,  dropsies, 
cholera,  etc.,  but  exact  observations  are  wanted  to  confirm  the  statement. 
I have  never  been  able  to  satisfy  myself  that  any  such  changes  were 
observable  in  these  diseases  by  means  of  the  microscope.  In  chlorosis 
the  number  of  the  blood-globules  is  undoubtedly  diminished ; but  this 
is  determined  by  the  size  of  the  clot,  rather  than  by  microscopic  demon- 
stration. 

Occasionally  the  serum  of  the  blood  presents  a lactescent  appear- 
ance ; and,  on  being  allowed  to  remain  at  rest  some  hours,  a white 
creamy  pellicle  forms  on  the  surface.  This  consists  of  very  minute  par- 
ticles of  oil,  which  resemble  the  smaller  molecules  found  in  milk,  and  in 
the  chyle.  It  is  the  white  blood  of  ancient  authors. 


Pus. 


Normal  or  good  pus,  when  examined  under  a microscope,  is  found  to 
consist  of  numerous  corpuscles,  floating  in  a clear  fluid,  the  liquor  'pur is. 
The  corpuscles  are  globular  in  form,  having  a smooth  margin  and  finely 
granular  surface.  They  vary  in  size  from  the  ooVo^^ 
an  inch  in  diameter.  In  some  of  them  there  may  be  generally  olDserved 
a round  or  oval  nucleus,  which  is  very  distinct  on  the  addition  of  water, 

* See  Dr.  Cowan’s  case. — “Monthly  Journal  of  Medical  Science,”  March  1854. 


Fig*  63,  Colorless  corpuscles  slightly  increased  in  number. 
Fig.  64.  Appearance  of  a drop  of  blood,  in  Leucocythemia. 
Fig.  65.  The  same,  after  the  addition  of  acetic  acid. 


250  diam. 


94 


EXAMINATION  OF  THE  PATIENT. 


when  also  the  entire  corpuscle  becomes  distended  from  endosmosis,  and 

its  granular  surface  is  more  or  less 
© diminished.  On  the  addition  of 


a 


V.  ' ' I'O  W 

C ',:y/ 

• i 


C^) 


§ 


05 


Fi-  66. 


) f"^\  strong  acetic  acid  the  cell-wall  is 
® dissolved,  and  the  nuclei  liberated 
in  the  form  of  two,  three,  four,  or 
rarely  five  granules,  each  of  which 
^ has  a central  shadowed  spot.  If, 

however,  the  re-agent  be  weak, 
the  cell-wall  is  merely  rendered 
transparent  and  diaphanous,  through  which  the  divided  nucleus  is  very 
visible. 

Occasionally  these  bodies  are  seen  surrounded  by  another  fine  mem- 
brane, as  in  Fig.  68.  At  other  times  they  are  not  perfectly  globular, 
but  present  a more  or  less  irregular  y-y 

margin,  and  are  associated  with  /. ©.y.*"' 

numerous  molecules  and 
This  occurs  in  what  is  called 
fulous  pus,  and  various 
unhealthy  discharges  from 
and  granulating  surfaces  (Fig.  69).  Fig.  68.  Fig.  69. 

In  gangrenous  and  ichorous  sores,  we  find  a few  of  these  irregular  pus 
corpuscles  associated  with  a multitude  of  molecules  and  granules,  and 
with  transformed  and  broken-down  blood  globules,  the  debris  of  the 
involved  tissues,  etc.  etc. 


Sputum. 

A microscopic  examination  of  the  sputum  demands  a most  extensive 
knowledge  of  both  animal  and  vegetable  structures.  I have  found  in  it, 
— 1st,  All  the  tissues  which  enter  into  the  composition  of  the  lung,  such 
as  filamentous  tissue,  young  and  old  epithelial  cells ; blood  corpuscles, 
etc.  2d,  Mucus  from  the  oesophagus,  fauces,  or  mouth.  3d,  Morbid 
growths,  such  as  pus,  pyoid,  and  granular  cells ; tubercle  corpuscles, 
granules,  and  amorphous  molecular  matter;  pigmentary  deposits  of 
various  forms,  and  parasitic  vegetations,  which  are  occasionally  found 
on  the  lining  membrane  of  tubercular  cavities.  4th,  All  the  elements 
that  enter  into  the  composition  of  the  food,  whether  animal  or  vegetable, 
which  become  attached  to  the  mouth  or  teeth,  and  which  are  often 
mingled  with  the  sputum,  such  as  pieces  of  bone  or  cartilage,  muscular 
fasciculi,  portions  of  esculent  vegetables,  as  turnips,  carrots,  cabbages, 
etc. ; or  of  grain,  as  barley,  tapioca,  sago,  etc. ; or  of  bread  and  cakes ; 
or  of  fruit,  as  grapes,  apples,  oranges,  etc.  All  these  substances  render 
a microscopic  examination  of  expectorated  matters  anything  but  easy  to 
the  student. 

To  examine  sputum,  it  should  be  thrown  into  water,  when,  on 
account  of  the  air  it  contains,  it  will  generally  float  on  the  surface ; 
while  the  more  dense  portions,  such  as  masses  of  crude  tubercle  or  crcta- 


Fig.  66.  Pus  corpuscles,  as  seen  in  healthy  pus. 

Fig.  67.  The  same,  after  the  addition  of  acetic  acid. 

Fig.  68.  Pus  corpuscles,  surrounded  by  a delicate  cell-wall. 

Fig.  69.  Irregular-shaped  pus  corpuscles,  in  scrofulous  pus.  260  diam. 


USE  OF  THE  MICROSCOPE. 


95 


ceous  concretions;  occasionally  mingled  with  it,  will  fall  to  the  bottom. 
It  should  be  then  teased,  or  broken  up  with  a rod,  when  the  various 
elements  and  particles  it  contains  will  gradually  disengage  themselves, 
and  may  be  separated  from  the  mass  without  difficulty.  Nothing  is 
more  common,  on  examining  portions  of  sputum  with  a microscope,  than 
to  observe  the  various  aggregations  of  molecular  and  granular  matter 
here  figured — 


V ' 

«4 

Fig.  70. 

Fig.  71. 

Fig.  72. 

Fig.  73. 

Fig.  74. 

Occasionally  little  masses  of  a cheesy  substance,  and  yellowish 
color,  may  be  found  entangled  in  the  purulent  mucus,  or  collected  at 
the  bottom  of  the  vessel.  These,  when  examined,  present  a number 
of  irregular-shaped  bodies  approaching  a round,  oval  or  triangular 
form,  varying  in  their  longest  diameter  from  the  4 20’  0 

an  inch.  These  bodies  contain  from  one  to  seven  granules,  are 
unaffected  by  water,  but  are  rendered  very  transparent  by  acetic 
acid.  They  are  what  have  been  called  tubercle  corpuscles.  They  are 
frequently  mingled  with  a multitude  of  molecules  and 
granules,  which  are  more  numerous  in  proportion  to 
the  softness  of  the  tubercle  (Fig.  74),  (See  also  Tuber- 
culosis.) 

Sometimes  indurated  or  gritty  little  masses  are 
brought  up  with  the  sputum,  which  are  derived  from 
the  cretaceous  or  calcareous  transformation  of  chronic 
tubercle  in  the  lungs.  They  consist  of  irregular  masses 
of  phosphate  of  lime,  combined  with  more  or  less  animal 
matter.  On  squeezing  such  as  are  friable  between  Fig.  75. 
glasses,  and  examining  their  structure,  they  frequently  may  be  seen  to 
contain  the  elements  represented  in  Fig.  75. 

Sputum  frequently  presents  the  fibrillated  appearance  which  is  com- 
mon to  all  mucous  discharges.  It  is  caused  by  the  deposition  in  viscid 
mucus  of  molecules,  which  assume  a linear  arrangement.  This  deposi- 
tion is  increased  by  the  addition  of  water  and  acetic  acid,  so  that  they 
consist  of  albumen.  These  fine  molecular  fibres  (see  Figs.  82,  96,  99) 
must  be  distinguished  from  the  areolar  and  elastic  tissue  of  the  lung, 
which  is  not  unfrequently  found  in  sputum,  and  which  indicates  ulcera- 
tion or  sloughing  of  the  pulmonary  texture  (Figs.  76,  77,  78).  Shroeder 
van  der  Kolk  has  lately  stated  that  these  fragments  may  be  found  in  the 
sputum  before  the  physical  signs  of  ulceration  of  the  lung,  as  determined 
by  auscultation,  are  well  characterised.  This  fact  I have  confirmed,  and 
believe  it  to  be  one  of  great  diagnostic  importance. 


Fig.  70.  Mass,  consisting  of  minute  molecules,  frequently  seen  in  disintegrated 
tubercle. 

Figs.  71  and  72.  Masses  composed  of  molecules  and  oily  granules  varying  in  size 
and  mode  of  aggregation. 

Fig.  73.  Mass  partly  composed  of  the  debris  of  a fibrous  structure. 

Fig.  74.  Mass  composed  of  tubercle  corpuscles. 

Fig.  75.  Fragments  of  phosphate  of  lime  occasionally  found  in  the  sputum.  250  di. 


96 


EXAMINATION  OF  THE  PATIENT. 


In  acute  pneumonia,  the  sputum  frequently  contains  fibrinous  casts 
of  the  minute  bronchi,  which  present  a branched  mould  of  the  tubes. 


Fig.  76  Fig.  77.  Fig.  78. 

These  casts  (Fig.  79)  may  be  readily  separated  in  water,  as  previously 
described ; and  when  examined  with  the  microscope,  are  found  to  con- 


sist of  molecular  fibres,  in  which  pyoid  and  pus  corpuscles  are  infiltrated 
(Fig.  80). 

The  inspissated  sputum,  so  commonly  expectorated  in  the  morning,  is 
derived  from  the  fauces.  It  often  presents  a dirty  green  or  brownish 
color,  passing  into  black.  When  examined  with  a microscope,  it  may 
be  seen  to  consist  of  epithelial  cells,  more  or  less  compressed  together, 
and  varying  in  size  from  the  2 o*o  diameter. 

The  smaller  ones  are  round,  and  closely  resemble  pus  corpuscles ; the 
larger  ones  are  round  or  oval,  with  a distinct  nucleus.  In  the  dark- 
colored  portions  of  this  sputum,  the  cells  contain  numerous  granule  ■; 
and  molecules,  several  of  which  are  black  and  quite  opaque.  This  black 


Fig.  76.  Fragment  of  elastic  tissue  of  the  lung,  in  phthisical  sputum. 

Fig.  77.  Fragment  of  areolar  and  elastic  tissue,  still  exhibiting  the  form  of  air  cells, 
from  phthisical  sputum. 

Fig.  78.  Another  fragment. — ( Van  der  Kolk.)  250  diam. 

Fig.  79.  Fibrinous  coagula  in  sputum,  exhibiting  moulds  of  the  bronchi.  Natural 
size. — {After  Peacock.) 

Fig.  80.  Fibres,  with  corpuscles,  in  a fibrinous  coagulum  from  a bronchus.  250  diam. 


USE  Of  the  migeoscope. 


97 


matter  consists  of  carbon,  and  is  unaffected  by  re-agents.  The  addition 
of  acetic  acid  causes  coagulation  of  the  mucus  in  which  the  cells  are  em- 
bedded; and  whilst  it  produces 


little  change  in  the  older  cells,  it 
dissolves,  or  renders  transparent, 
the  walls  of  such  as  are  young, 
displaying  a round,  oval,  or  di- 
vided nucleus,  as  seen  in  the 
figure  (Fig.  82). 

In  the  “ black  phthisis  ” of 
colliers  the  sputum  is  ink-black.  Fig.  si. 

and  more  or  less  tenacious.  On  examination  with 
cells  in  it  are  seen  to  be  loaded  with  carbonaceous  pigment.  Several  of 
these  cells  are  perfectly  opaque,  whilst  others  are  almost  colorless ; 

and  between  the  two  extremes  there  is  every 
gradation  as  to  intensity  of  blackness.  This 
black  pigment  is  unaffected  by  the  strongest  re- 
agents, nitro-muriatic  acid,  chlorine,  and  even 
the  blow-pipe,  failing  to  decompose  it.  It  is, 
therefore,  pure  carbon,  and  differs  from  the  pig- 
ment contained  in  cells  of  similar  appearance  in  melanotic  tumors,  as 
in  these  latter  the  re-agents  just  mentioned  at  once  destroy  the  color. 
(See  Carbonaceous  Lungs.) 


microscope. 


Fig.  83. 


Fig.  84. 


Vomited  Matters. 

The  matters  rendered  by  vomiting  have  not  been  made  so  frequent 
an  object  of  microscopical  observation  as  is  necessary  for  the  purposes  of 
diagnosis.  In  organic  diseases  of  the  organ,  nothing  has  been  ascertained 
on  this  head.  In  other  cases,  it  almost  always  happens,  that  the  matters 
returned  consist — 1st,  Of  food  and  drink,  in  various  stages  of  decomposi- 
tion and  disintegration ; 2d,  Of  portions  of  the  epithelial  lining  mem- 
brane Of  the  stomach,  oesophagus  or  pharynx,  altered  in  its  characters, 
and  mingled  with  more  or  less  mucus ; 8d,  Of  certain  new  formations, 
which  are  produced  in  the  fluids  of  the  stomach. 

1.  It  would  constitute  a very  interesting  series  of  observations  to 
determine,  with  the  aid  of  the  microscope,  the  structural  changes  whic-h 
various  articles  of  food  undergo  during  the  process  of  digestion  in  the 
stomach.  This  has  not  yet  been  done  with  accuracy,  although  there  can 
be  little  doubt  that  compound  tissues  become  disintegrated  in  the  inverse 
order  to  that  in  which  they  are  produced — that  is  to  say,  fibres  become 
separated,  embedded  cells  become  loose,  and,  when  aggregated  together, 
their  cohesion  is  destroyed.  The  cell-walls  then  dissolve,  the  nucleus 
still  resisting  the  solvent  process  for  some  time;  but  at  length  the  whole 
is  resolved  into  a molecular  and  granular  mass,  which  in  its  turn  becomes 

Fig.  81.  Epithelial  cells,  embedded  in  mucus,  expectorated  trom  the  fauces.  Some 
are  seen  to  contain  black  pigment ; others  resemble  pus  corpuscles. 

Fig.  82.  Another  portion  of  expectorated  mucus  from  tlie  fauces,  acted  on  by  acetic 
acid,  showing  fibrillation  and  the  changes  in  the  young  cells. 

Figs.  83  and  84.  Cells  loaded  with  pigment  in  the  sputum  of  the  collier.  260  diam. 

7 


98 


EXAMINATION  OF  THE  PATIENT. 


fluid.  Sucli,  however,  are  the  different  soluble  properties  of  various  edible 
substances,  that,  in  a time  sufficient  for  the  perfect  solution  of  some,  others 
are  scarcely  affected.  It  may  readily  be  conceived,  that  the  transitions 
which  these  substances  undergo  may  occasionally 
render  their  detection  difficult;  and  such  is  really 
the  case.  Starch  corpuscles,  for  instance,  break 
down  into  rounded  granules  or  molecules,  and  are 
very  liable  to  puzzle  an  inexperienced  observer. 
Tincture  of  iodine,  from  its  peculiar  reaction  on 
these  bodies,  will  always  enable  us  to  recognise  them. 

2.  The  various  epithelial  cells  which  line  the 
passages  leading  to  the  stomach,  as  well  as  the  struc- 
tures peculiar  to  that  organ  itself,  may  be  found  in  the  vomited  matters — 
of  course  mingled  with  the  debris  of  edible  substances.  They  also  may 
have  undergone  various  changes  in  appearance,  from  endosmosis,  or  even 


Fig.  86. 


Fig.  87. 


partial  digestion.  In  cholera,  the  vomited  matter  consists  principally  of 
such  altered  epithelial  cells  or  scales,  many  of  which  are  derived  from 
the  fauces  or  oesophagus. 

3.  The  new  formations  which  may  be  produced  in  the  stomach  are 
principally  vegetable  fungi — such  as  various  kinds  of  torulae  (see  Fig. 
86,  c),  and  especially  one  first  discovered  in  vomited  matters  by  Mr. 
Goodsir,  and  which  he  has  called  Sarcina  Ventriculi.  It  consists  of 
square  particles,  which  apparently  increase  by  fissiparous  division  in 
regular  order,  so  that  they  present  square  bundles  of 
four,  sixteen,  or  some  other  multiple  of  four.  Although 
at  first  supposed  to  be  peculiar  to  the  stomach,  I have 
frequently  found  them  in  the  faeces;  and  in  one  case, 
in  the  urine.  They  have  also  been  found  by  Virchow 
and  by  myself  in  the  lung,  and  by  Robin  inside  the 
capsule  of  the  crystalline  lens. 

In  addition  to  the  bodies  now  alluded  to,  vomited  matters  may  contain 
various  morbid  products,  such  as  blood,  pus,  and  cancer-cells,  coloring 
matter  of  the  bile,  etc. 


Fig. 


Fig.  86.  Appearance  of  starch  corpuscles  after  partial  digestion  in  the  stomach. 

Fig.  86.  Flaice  in  the  rice-water  vomiting  of  a cholera  patient,  showing,  «,  large 
epithelial  cells ; milk  globules,  and  coagulated  caseine ; c,  tonilae ; and  c?,  half- 
digested  epithelial  scales,  wnth  liberated  nuclei,  more  or  less  broken  down. 

Fig.  87.  Structures  observed  in  certain  rice-water  vomitings  from  a cholera 
patienq  showing  bodies  which  consist  of  the  half-digested  uredo  in  bread. 

Fig.  88  Sarcina  Ventriculi.  250  dram. 


USE  OF  THE  MICROSCOPE. 


99 


FiECES. 


The  same  difficalty  attends  the  examination  of  the  faeces  as  of  the 
snutnm ; for  there  may  be  found  in  it, — 1st,  All  the  parts  which  com- 
the  structure  of  the  walls  of  the  alimentary  canal ; 2d,  All  kinds  of 
in  )rbid  products;  and  3d,  All  the  elements  which  enter  into  the  com- 
])ont,ion  of  food.  The  only  difference  is,  that  these  last  are  generally 
more  broken  down  and  disintegrated. 

Under  certain  circumstances,  the  diagnostic  value  attached  to  the 
examination  of  the  faeces  is  greater  than  that  of  the  sputum,  or  of 
vomited  matters.  For  instance,  when  pus  or  blood  globules  are  detected, 
we  may  infer  that  the  more  perfect  these  are,  the  nearer  to  the  anus  is 
their  origin.  In  examples  4 and  6 (p.  76)  I have  shown  how  the 
detection  of  certain  vegetable  structures,  used  as  food,  was  serviceable  in 
diagiosis;  but  this  subject  merits  more  extensive  attention  than  has 
hitherto  been  paid  to  it. 

Among  the  indigestible  articles  connected  with  the  food,  it  was 
observed  in  the  autumn  of  1849,  that  curious-shaped  bodies  were  detect- 
able, both  in  the  vomited  matters  and  stools  of  cholera  patients.  These 
were  supposed  to  be  parasitic  formations  connected  with  the  cause  of 
cholera,  but  were  pointed  out  by  Mr.  Busk  to  be  the  uredo-segitum^ 
occasionally  found  in  bread.  (Figs.  87  and  89.) 

On  one  occasion  a dispensary  patient  brought  to  me  a membranous 
mass,  which  had  been  evacuated  by  the  bowels.  It  resembled  a piece  of 


Fig.  89.  Fig.  90. 


boiled  fine  leather,  of  a greenish-yellow  color,  and  fibrous  structure. 
On  microscopic  examination,  it  was  found  to  be  made  up  of  an  inex- 
tricable meshwork  of  confervoid  growths,  consisting  of  long  tubes,  with 
joints,  and  a few  oval  sporules,  the  former  having  a great  tendency  to 
break  across.  (Figs.  90  and  91.) 

In  typhus,  and  other  putrid  fevers,  the  stools  contain  masses  of  large 
crystals  of  phosphates  or  carbonates,  as  in  the  case  of  a girl  of  18, 
admitted  into  Addinbroke’s  Hospital,  Cambridge.  The  material  passed 
from  the  bowel  was  of  a very  dark  color,  perfectly  fluid,  and  yielded  a 
precipitate  on  the  application  of  heat,  and  the  addition  of  nitric  acid. 
(See  Fig.  17,  Beale' 8 'Archives^  vol.  i.,  p.  141.)  In  dysentery  they  are 
loaded  with  pus  and  blood ; and  the  former  may  also  be  detected  on  the 
surface  of  faeoal  masses  when  the  intestine  is  ulcerated.  There  may  also 
be  observed  numerous  torulae,  and  occasionally  sarcinae.  In  cholera  the 


Fig.  89.  Portions  of  the  uredo  in  bread,  still  further  digested  and  disintegrated 
than  is  observable  in  the  vomited  matters  (Fig.  8Y.)  Some  torulm  are  also  present. 
Fig.  90.  Structure  of  confervoid  mass  passed  from  the  bowels. 

Fig.  91.  The  same,  magnified  500  diameters  linear,  showing  their  vegetable 
nature.  250  d’mm. 


100 


EXAMINATION  OF  THE  PATIENT. 


white  stools  consist  of  mucus,  in  which  the  debris  of  epithelial  cells  ia 


Fiff.  92. 


entangled;  and  as  the  nuclei  of  these  cells  resist  disintegration  for  a long 
^ — - - time,  these  round  or  oval  bodies  generally  exist  in 

C'O-  - considerable  number  (Fig.  87). 

^ In  a disease  very  common  in  Edinburgh,  especially 

— in  women,  flakes  of  membranous  matter  are  thrown 
Fig.  9^^  off  from  the  bowels  in  large  quantities ; these  present 
a very  similar  appearance  to  the  cholera  flakes  just  noticed. 

Uteeine  and  Vaginal  Discharges. 

The  diagnostic  indications  to  be  derived  from  the  microscopic  exami- 
nation of  these  discharges  have  not  been  much  investigated ; but  there 
are  few  subjects  which  hold  out  the  promise  of  more  useful  results  to  the 
medical  practitioner.  It  can  only  be  practised  by  the  obstetric  histolo- 
gist, who,  on  collecting  the  secretions  poured  out  from  the  os  uteri,  or  on 
the  vaginal  walls,  by  means  of  the  speculum,  should  observe  their 
structural  peculiarities  when  quite  fresh.* 

The  menstrual  discharge  will  be  found  to  consist  of  young  epithelial 
cells,  old  epithelial  scales,  and  blood  globules,  the  number  of  which  last 
will  be  greater  or  less  according  to  the  intensity  of  the  color.  A 
leucorrhoeal  discharge  always  consists  of  old  epithelial  scales,  which  may 
be  more  or  less  loaded  with  fat,  combined  with  numerous  young  epithe- 
lial cells  (round  or  oval),  and  pus  corpuscles.  (Fig.  94.) 

The  white  gelatinous  discharge,  so  frequently  seen  with  the  speculum 

* On  this  point  Dr.  Tyler  Smith’s  work  on  Leucorrhoea  may  be  consulted  with 
advantage. 

Fig.  92.  a.  Rounded  masses  of  earthy  matter,  probably  carbonate  and  phosphate 
of  lime.  b.  Crystals  of  triple  or  ammoniaco-magnesian  phosphate,  c.  Oval  masses, 
probably  fragments  of  a clot.  In  one  to  the  left  of  the  figure  the  outline  of  the  blood 
corpuscles  is  more  distinct  than  in  most,  and  in  a the  individual  corpuscles  can  be 
seen.  e.  Dark  amorphous  masses,  probably  derived  from  the  food.  f.  Ovum  of  an 
entozoon,  probably  an  ascaris.  g.  Small  collection  of  blood  globules. — (Beale.) 

Fig.  93.  Structure  of  flakes  in  a rice-water  stool,  from  a cholera  patient.  2.50  cUarn. 


USE  OF  THE  MICROSCOPE. 


101 


to  be  derived  from  the  os  uteri,  consists  of  gelatinous  mucus,  in  wliich 
round  or  oval  young  epithelial  cells  are  mingled.  The  mucus  is  copiously 
deposited  in  a molecular  form,  on  the  addition  of  acetic  acid  or  water 


whilst  the  walls  of  the  cells  are  rendered  transparent,  and  an  oval  granular 
nucleus  made  visible  (Figs.  95  and  96). 

Not  unfrequently  leucorrhoeal  and  other  discharges  contain  groups  of 
blood-globules,  the  shapes  of  which  are  almost  always  more  or  less  altered 
by  exosmosis,  on  account  of  the  viscid  fluid  mingled  with  them  (see  Fig. 
94).  Indeed,  the  variations  observable  in  these  discharges  are  dependent 
for  the  most  part  on  the  excess  of  one  or  other  of  the  elements  just 
mentioned — namely,  epithelial  cells  or  scales,  pus  or  blood  corpuscles, 
and  gelatinous  mucus.  In  dysmenorrhoea  considerable  patches  of  the 
epithelial  membrane  desquamate,  and  even  entire  casts  of  the  uterus  or 
vagina  have  been  separated. 

In  addition  to  the  fluid  discharges  poured  out  from  the  uterus  and 
vagina,  there  are  a variety  of  morbid  growths  connected  with  these 
organs,  the  diagnosis  of  which  may  be  materially  facilitated  by  micro- 


scopic examination.  The  separation  of  fibrous,  epithelial,  and  cancerous 
tumors  and  ulcers  belongs  to  this  category,  and  must  be  conducted  on 
the  principles  referable  to  the  diagnosis  of  morbid  growths  in  general.  I 
have  had  abundant  opportunities  of  satisfying  myself  of  the  importance 


Fig.  94.  Corpuscles  seen  in  a chronic  leucorrhoeal  discharge,  consisting  of, — 1 st, 
Large  epithelial  scales,  from  the  vagina  and  cervix  uteri.  On  the  left  of  the  figure, 
some  of  these  may  be  observed  to  have  undergone  the  fatty  degeneration.  2d, 
Numerous  pus  corpuscles ; and,  3d,  Blood  globules,  the  external  edges  of  which  are 
more  or  less  dentated  from  exosmosis. 

Fig.  95.  Structure  of  gelatinous  mucus  from  the  os  uteri. 

Fig.  96.  The  same,  after  the  addition  of  acetic  acid. 

Figs.  97  and  98.  Two  specimens  of  cancerous  juice  squeezed  from  the  uterus. 

250  diam. 


102 


EXAMINATION  OF  THE  PATIENT. 


of  this  mode  of  proceeding,  in  cases  where  the  substance,  mucous  surface 
or  cervix  of  the  uterus,  has  been  more  or  less  involved. 


Mucus. 

In  all  fluids  secreted  from  a mucous  membrane,  many  of  which  have 
been  noticed,  there  may  be  found  a gelatinous  material,  which  has  long 
been  called  mucus.  It  may  vary  in  color  from  a milk-white  to  a 
yellowish  brown  or  even  black  tint,  these  variations  being  dependent  on 
the  cell  structures  or  pigment  it  contains.  By  some  it  has  been  sup- 
posed that  there  are  certain  cell  formations  peculiar  to  mucus,  which 
have  been  called  “mucus  corpuscles;”  but  it  has  always  appeared  to  me 
that  the  various  bodies  found  in  this  secretion  are  either  diflerent  forms 
of  epithelium,  on  the  one  hand,  or  pus  cells  on  the  other.  Thus  the 
round  epithelial  cells  found  in  mucous  crypts,  or  the  bodies  constituting 
permanent  epithelium,  when  newly  formed,  before  they  have  had  time 
to  flatten  out,  and  become  perhaps  more  or  less  alfected  by  endosmosis, 
are  represented  Figs.  81  and  95.  These  are  the  mucous  corpuscles  of 
some  writers.  Again,  when  exudation  is  poured  out  on  a mucous  surface, 
and  is  mingled  in  greater  or  less  quantity  with  the  gelatinous  secretion, 
it  presents  a marked  tendency  to  be  transformed  into  pus  corpuscles,  and 
hence  why  all  irritations  of  mucous  surfaces  are  usually  accompanied  by 
purulent  discharges.  The  pus  corpuscles,  under  such  circumstances, 
present  all  the  characters  formerly  noticed  as  peculiar  to  these  bodies 
(see  Figs.  66  and  94). 

Hence,  properly  speaking,  there  is  no  such  body  as  a mucus  cor- 
puscle, the  cells  found  in  mucus  being  either  epithelial  or  pus  cells,  the 
number  of  which  present,  communicates  certain  peculiarities  to  the  dis- 
charge. Thus,  as  we  have  seen,  the  white  gelatinous  mucus  discharged 

from  the  os  uteri  contains  the  former, 
whilst  the  peculiar  fluid  characteristic  of  a 
gonorrhoea  or  catarrh,  in  either  sex,  abounds 
in  the  latter.  The  gelatinous  substance, 
however,  in  which  these  bodies  are  found 
(Mucin) ^ is  what  is  peculiar  to  the  fluid 
secreted  from  mucous  surfaces,  containing, 
as  it  does,  a large  amount  of  albumen  pos- 
sessing a remarkable  tendency  to  coagulate 
in  the  form  of  molecular  fibres  (Fig.  99). 
When  recent,  these  are  few  in  number,  but 
on  the  addition  of  water  or  acetic  acid  they 
are  precipitated  in  such  numbers  as  to  entangle  the  cell  formations,  and 
present  a semi-opaque  membranous  structure  (Figs.  82  and  96). 

The  more  healthy  a mucous  secretion,  the  more  it  abounds  in  this 
viscous  albuminous  matter,  and  the  fewer  are  its  cell  elements.  On  the 
other  hand,  when  altered  by  disease,  the  cell  elements  increase,  and  the 
viscosity  diminishes. 

Fi^.  99.  Viscid  greyish  yellow  sputa  of  pneumonia,  treated  with  dilute  acetic  acid, 
containing  fibrinous  mucin^  pus  corpuscles,  and  epithelial  cells  containing  fatty  and 
pigment  granules. — [After  Wedl.)  300  rfiam. 


USE  OF  THE  MICROSCOPE. 


103 


Dropsical  Fluids. 


The  fluids  obtained  by  puncture  of  dropsical  swellings  may  in  some 
cases,  when  examined  microscopically,  present  peculiarities  worthy  of 
notice.  Thus,  in  the  serum  collected  within  the  tunica  vaginalis  testis, 
numerous  spermatozoids  may  be  found,  constituting  what 
has  been  called  spermatocele.  How  these  bodies  find 
their  way  into  this  fluid  is  unknown,  as  no  direct  com- 
munication with  the  substance  of  the  testicle  has  ever 
been  seen ; neither  does  their  occurrence  seem  to  inter- 
fere in  any  way  with  the  successful  treatment  of  this  kind 
of  dropsy,  by  injections,  as  practised  in  hydrocele. 

In  the  fluid  of  ascites,  when  removed  from  the  body,  tiiere  may 
usually  be  observed  a few  epithelial  scales  from  the  serous  layer  of  the 
abdomen,  which  are  more  abundant  in  some  cases  than  in  others. 
Occasionally  blood  and  pus  corpuscles  may  be  detected  in  greater  or  less 
quantity. 

In  ovarian  dropsy,  various  products  may  be  found  in  the  evacuated 
fluid,  accordin<r  to  the  nature  of  the  contents  of  the  cyst.  Pus  and  blood 
^0  . »•  corpuscles  are  common  elements,  but  more  com- 

monly  epithelial  cells  and  scales,  which  occasion- 

• accumulate  in  the  cysts  of  ovarian  tumors 

* I" cJ  ^Fig.  101).  At  other  times,  masses  of  gelatinous 

or  colloid  matter  are  evacuated,  which  present 
yarious  appearances,  according  to  the  time  that  has 
since  its  formation  (see  Colloid  Cancer 
►varian  Dropsy). 

In  the  examination  of  dropsical  fluids,  also, 
K,g.  i ji.  there  can  be  little  doubt  that  further  research  will 

lead  to  very  important  results  in  diagnosis. 


Urine. 

Healthy  human  urine  examined  with  the  microscope,  when  recently 
passed,  is  absolutely  structureless.  Allowed  to  repose  for  twelve  hours, 
there  is  no  precipitate ; occasionally  a slight  cloudy  deposition  may  be 
observed,  in  which  may  be  discovered  a few  epithelial  scales  from  the 
bladder,  a slight  sediment  of  granular  urate  of  ammonia,  or  a few  crystals 
of  triple  phosphate.  In  certain  derangements  of  the  constitution,  how- 
ever, various  substances  are  found  in  the  urine,  which  in  a diagnostic 
point  of  view  are  highly  important,  and  which  we  shall  shortly  notice 
in  succession. 

^ To  examine  the  deposits  found  in  urine,  this  fluid  should  be  poured, 
in  the  first  instance,  and  left  to  stand  for  a time,  in  a tall  glass  jar  ; the 
clear  liquid  should  then  be  decanted,  and  the  lower  turbid  portion  put 
into  a tall  test  tube,  and  the  deposit  again  allowed  to  form.  In  this 
manner,  the  structural  elements  are  accumulated  in  the  smallest  possible 
compass,  so  that  a large  number  of  them  are  brought  into  the  field  of  the 
microscope  at  once.  The  quantity  of  any  salt  or  deposit  in  the  urine 


Fig.  100.  Spennatozoids  as  observed  in  the  fluid  of  Spermatocele. 
Fig.  101.  Cells  in  fluid  removed  from  an  ovarian  dropsy. 


260  diam. 


104 


EXAMIXATIOJ^  OF  THE  PATIENT. 


can  never  be  ascertained  by  the  microscope.  But  in  the  great  majority 
of  cases,  the  appearances  observed  with  that  instrument  are  sufficient  in 


Fi?.  102.  Fig.  103, 

themselves  to  distinguish  the  nature  the  various  kinds  of  sediment  met 
with,  and  these  consequently  are  all  that  need  be  described  in  this  place. 

Uric  Acid. — Uric  acid  crystals  are  almost  always  colored,  the  tint 
varying  from  a light  fawn  to  a deep  orange  red.  The  general  color  is 
yellow.  They  present  a great  variety  of  forms,  the  most  common  being 
rhomboidal.  The  lozenge-shaped  and  square  crystals,  which  are  more 
rarely  met  with,  isolated  and  in  groups,  are  represented  Fig.  102.  Not 
unfrequently  they  present  adhering  masses  or  flat  scales  with  transverse 
or  longitudinal  markings,  as  seen  Fig.  103.  Occasionally  they  assume 
the  form  of  truncated  rounded  columns,  as  represented,  with  other  struc- 
tures, Fig.  108. 

TJrate  of  Ammonia  most  commonly  assumes  a molecular  and  granular 
form,  occurring  in  irregularly  aggregated  amorphous  masses  (Fig.  105). 
This  may  be  separated  from  a similar-looking  deposit  of  phosphate  of 
lime  by  the  action  of  dilute  muriatic  acid,  which  immediately  dissolves 
the  last-named  salt,  but  acts  slowly  on  urate  of 
ammonia,  setting  free  the  uric  acid.  Sometimes, 
however,  it  occurs  in  spherical  bodies  of  a bistre 
brown  color,  varying  in  size  from  the  jpLjfth 
to  the  2oVo^^^  of  inch  in  diameter.  The 
latter  size  rarely  occurs.  Occasionally  they  as- 
sume a stellate  form,  needle  like  or  spicular  pro- 
longations coming  off  from  the  spherical  body, 
Fig.  104.  I have  seen  both  these  forms  associated,  and  the 

former  so  curiously  aggregated  together  as  to  assume  the  appearance  of  an 
organic  membrane,  for  which  by  some  observers 
it  was  mistaken,  until  it  was  found  to  dissolve 
under  the  action  of  dilute  nitric  acid  (Fig 

Triple  Phosphate  or  Ammonio-Phosphite 
of  Magnesia  - These  crystals  are  very  com- 
monly met  with  in  urine,  and  are  generally 
well  defined,  presenting  the  form  of  triangular 
prisms,  sometimes  truncated,  at  others  having 

terminal  facets  (Fig.  105).  If  an  excess  of  ammonia  exist,  or  be  added 


Fig.  102.  Lozenge-shaped  and  rhomboidal  crystals  of  uric  acid. 

Fig.  103.  Aggregated  and  flat  striated  crystals  of  uric  acid. 

Fig.  104.  Urate  of  ammonia  in  a granular  membranous  form,  and  in  rounded 
masses,  with  spicula. 

Fig,  105.  Triple  phosphate,  with  various  forms  of  urate  of  ammonia.  250  diam. 


USE  OF  THE  MICROSCOPE. 


105 


artificially,  they  present  a star-like  or  foliaceous  appearance,  which,  how- 
ever, is  seldom  seen  at  the  bedside. 

Most  of  the  forms  of  urate  of  ammonia  are  represented  Figs.  104. 
and  105  ; in  the  latter  they  are  associated  with  the  triple  phosphate. 

Oxalate  of  Lime  most  commonly  appears  in  the  form  of  octahedra, 
varying  in  size,  the  smaller  aggregated  together  in  masses.  Once  seen, 
these  bodies  are  readily  recognised  (Fig.  106).  Very  rarely  they  present 
the  form  of  dumb-bells,  or  of 
an  oval  body,  the  central  trans- 
parent portion  of  which  pre- 
sents a dumb-bell  shape,  while 
the  shadowed  dark  portion  fills 
up  the  concavities. 

Cystine  takes  the  form  of 
fiat  hexagonal  plates,  present- 
ing on  their  surface  marks  of 
similar  irregular  crystals  (Fig.  107 
having  radiations  more  or  less  numerous,  passing  towards  the  circumfer- 
ence. 


Fig.  106 


Occasionally  their  centre  is  opaque. 


In  addition  to  the  various  salts  found  in  urine,  there  may  occasionally 
be  found  different  organic  products,  such  as  blood  and  pus  corpuscles, 
spermatozoids.  vegetable  fungi,  exudation  and  other  casts  of  the  tubes,  or 
epithelial  scales  from  the  bladder  or  mucous  passages.  Frequently  one 
or  more  of  these  are  found  together,  as  in  the  following  figure : 


Fig.  108. 

Very  rarely  casts  of  the  tubes,  principally  composed  of  oily  granules, 
may  be  seen,  or  epithelial  cells,  more  or  less  loaded  with  similar  granules, 
several  of  which  also  float  loose  in  the  urine,  as  in  the  accompanying 
figure. 

Although  these  casts  of  the  tubes  were  at  one  time  confounded  to- 
gether, they  may  now  be  separated  into  at  least  four  distinct  kinds, 


Fig.  106.  Octahedral  and  dumb-bell  shaped  crystals  of  oxalate  of  lime. 

Fig.  107.  Flat  and  rosette-like  crystals  of  cystine. 

Fig.  108.  Bodies  observed  in  the  urine  of  a scarlatina  patient,  24  hours  after 
being  passed,  a,  Desquamated  fragment  of  uriniferous  tube,  b.  Exudation  casts  of 
uriniferous  tubes,  c,  Amorphous  urate  of  ammonia.  Columnar  crystals  of  uric 
acid,  c,  Blood  corpuscles.  /,  ?us  corpuscles.  Torulge  and  vegetable  fungi,  which 
had  been  formed  since  the  urine  was  excreted. 

Fig.  109.  Cast  of  a uriniferous  tube,  principally  composed  of  oil  granules,  with 
fatty  epithelial  cell,  and  free  oil  granules,  in  urine  of  Bright’s  disease.  250  diam^ 


106 


EXAMINATION  OF  THE  PATIENT. 


namely, — 1st,  Fibrinous  or  exudative  ; 2d,  Desquamative  ; 3d,  Fatty ; 
and  4th,  Waxy  casts.  The  inferences  to  be  derived  from  the  presence 
of  one  or  more  of  these  will  be  specially  dwelt  on  in  the  section  which 
treats  of  urinary  diseases. 

m .i 


considered  as  of  any  importance,  unless  accompanied  by  the  peculiar  symp- 
toms of  spermatorrhoea  (See  Fig.  100).  The  presence  of  torulse  in  consid- 
erable quantity  (Fig.  108,  y)  is  indicative  of  the  existence  of  sugar,  which 
requires,  however,  for  its  confirmation,  the  application  of  chemical  tests. 


All  the  various  appearances  here  noticed  are  only  diagnostic  when 
accompanied  by  concomitant  symptoms.  Alone  they  are  not  to  be 


depended  on ; but,  in  combination  with  the  history  and  accompanying 
phenomena,  they  are  capable  of  affording  the  greatest  assistance  in  the 
detection  of  disease. 

Fig.  110.  Fatty  casts,  at  an  early  period  of  formation  (/),  with  granule  cells  (e), 
and  crystals  of  triple-phosphate-. 

Fig.  111.  Fragments  of  fatty  and  waxy  casts.  One  of  the  latter  is  represented  at 
the  lower  part  of  the  figure. — {Christison.) 

Fig.  112.  Tyrozin  masses  in  the  urinary  sediment  of  a man  with  atrophy  of  the 
liver. — ( Frerichs. ) 

Fig.  101.  Leucin  in  a drop  of  the  same  urine,  allowed  to  evaporate. — (Frerichs.) 

Fig.  114.  Pure  tyrozin  from  the  same  urinary  sediment. — (Frerichs).  200  diam. 


USE  OF  THE  MICROSCOPE. 


lor 


In  addition  to  the  elements  now  and  previousl}’-  described  as  occa* 
sionally  met  with  in  urine,  there  should  not  be  overlooked  two  products, 
viz.,  Tyruzin  and  Leucin.  According  to  Frerichs,*  they  occur  in  that 
fluid  in  certain  diseases  of  the  liver,  and  especially  in  acute  atrophy  of 
that  organ.  Hitherto  they  have  not  been  much  studied,  having  com- 
monly been  mistaken  for  fatty,  starchy,  or  mineral  bodies.  But  their 
clinical  history,  in  relation  to  hepatic  and  renal  disease,  having  been 
commenced  by  so  able  an  investigator  as  Frerichs,  justifies  my  placing  be- 
fore you  the  forms  which  they  assume  (Figs.  112,  113,  114j. 

Cutaneous  Eruptions  and  Ulcers. 

An  examination  of  the  various  products  thrown  out  upon  the  skin  in 
the  different  forms  of  eruption,  ulcer,  and  morbid  growth,  may  in  many 
cases  be  of  high  diagnostic  value.  Of  these  we  shall  speak  separately. 

1.  Cutaneous  Eruptions. — In  the  vesicular  and  pustular  diseases, 
there  may  be  observed  below  the  epidermis  all  the  stages  of  pus  forma- 
tion, commencing  in  exudation  of  the  liquor  sanguinis,  gradual  deposi- 
tion of  molecular  and  granular  matter,  and  formation  around  them  of 
cell  walls.  The  eruption  produced  artificially  by  tartar  emetic  ointment 
ofliers  the  best  opportunity  of  examining  the  gradual  formation  of  these 
bodies  under  the  microscope.  Pus  taken  from  all  kinds  of  eruptions 
and  sores  presents  the  same  characters,  there  being  no  difference  between 
the  pus  in  impetigo  and  that  in  variola.  When  a scab  is  formed,  as  in 
eczema  or  impetigo,  a small  portion  of  it  broken  down,  mixed  with  water 
and  examined  under  a microscope,  presents  an  amorphous  collection  of 
granules,  oil  globules,  and  epithelial  scales. 

The  squamous  eruptions  of  the  skin  are  three  in  number — namely, 
psoriasis,  pityriasis,  and  ichthyosis.  The  dry  incrustations  which  form 

on  the  surface  in  these  diseases,  es- 
sentially consist  of  epidermic  scales 
more  or  less  aggregated  together. 
They  are  very  loose  in  pityriasis, 
and  occasionally  mingled  with  de- 
bris of  vegetable  confervse,  similar 
to  what  grows  on  the  mucous  mem- 
brane of  the  mouth  (Figs.  52  and 
53).  The  scales  are  more  aggre- 

occa- 


Fig.  115. 


gated  together  in  psoriasis,  and  greatly  condensed  in  ichthyosis- 
sionally  in  the  latter  disease  presenting  the  hardness  and  structure  of  horn. 

The  epidermic  tumors  of  the  skin  assume  the  form  of  corns,  callosi- 
ties, condylomatous  warts,  and  what  has  been  called  Verruca  achrocor- 
don.  They  all  consist,  in  like  manner,  of  epidermic  scales  more  or  less 
condensed  together ; in  the  latter  growth  they  surround  a canal  fur- 
nished with  blood-vessels.  Sometimes  they  assume  a regular  form,  their 
interior  being  more  or  less  hard,  fibrous,  and  vascular — in  short,  a pro- 
longation of  the  epidermis  (Fig.  115).  At  other  times  they  soften  on 
*Atlas  zur  Klinik  der  Leberkrankheiten.  Taf.  iii. 


Fig.  115.  Epidermic  cells  from  crust  of  Psoriasis. 


250  diam. 


108 


EXAMINATION  OF  THE  PATIENT. 


their  summits,  and  assume  the  structural  peculiarities  of  the  epithelial 
ulcer  afterwards  to  be  described. 


Fig.  116.  * 


The  favus  crust  is  composed  of  a capsule  of  epidemic  scales,  lined 
by  a finely  griinular  mass,  from  which  millions  of  cryptogamic  plants 
spring  up  and  fructify.  The  presence  of  these  parasitic  vegetations 
constitutes  the  pathognomonic  character  of  the  disease  (see  Favus). 
Other  forms  of  vegetable  parasite  are  occasionally  found  in  connection 
with  the  skin,  of  which  that  described  by  Mayer  and  Grove,  in  the 
meatus  of  the  ear,  is  a good  example.  The  latter,  as  figured  by  Beale, 
is  given  Fig.  11<5. 

The  skill  is  also  attacked  by  certain  animal  parasites.  Of  these  the 
pediculi,  or  lice,  are  too  well  known  to  need  description.  The  Acarus 
scabiei  and  the  Entozoon  folliculorum  are  described  and  figured  in  the 
section  on  skin  diseases. 

2.  Cutaneous  Ulcers. — In  healthy  granulating  sores,  whilst  the  sur- 
..  . . face  is  covered  with  normal  pus  cor- 

\ ^ puscles  (Fig.  66),  the  granulations 

themselves  present  fibre-cells  in  all 
y stages  of  development  passing  into 
© \\  fibres.  In  scrofulous  and  unhealthy 

® is  more  or  less  broken 

down,  or  resembles  tubercle  corpus- 
(O)  \0{.\  ^ cles  (Fig.  69). 

J Q ] 0 ' '?  The  epithelial  ulcer  is  very  common 

on  the  under  lip,  commencing  in  the 
^ form  of  a small  induration  or  wart, 
but,  rapidly  softening  in  the  centre,  it 


‘.T'O  .o" 

Fig.  119. 


Fig  120. 


assumes  a cup-shaped  depression,  with  indurated  margins,  which  extend 


Fig.  116.  Thalli  of  the  fungus  found  in  the  ear  by  Mr.  Grove  {Beale).  See  also 
Trans,  of  the  Microscopical  Society,  vol.  v.  p.  161,  and  plate  vii. 

Fig.  1 1 Y.  The  fungus  {Achorion  Schonleini)  from  a favus  crust. 

Fig.  118.  The  same,  magnified  600  diameters  linear. 

Fig.  119.  Epithelial  cells,  from  the  surface  of  an  ulcer  of  the  lip. 

Fig.  120.  The  same,  after  the  addition  of  acetic  acid. 


250  diam. 


USE  OF  THE  MICROSCOPE. 


109 


in  a circular  form  more  or  less  over  the  cheek  and  chin.  An  examina- 
tion of  the  softened  matter  sometimes  exhibits  epithelial  cells,  in  various 
stao-es  of  development,  as  in  Fig.  119.  At  other  times  the  cells  are 


Fig.  121.  F:g.  122 


enlarged,  flattened  out,  and  more  or  less  loaded  with  fat  molecules  and 
granules,  or  compressed  concentrically  round  a centre,  forming  what  have 
been  called  nest  cells.  These  growths,  though  generally  denominated 
cancer,  are  at  once  distinguished  by  a microscopic  examination.  The 
so-called  chimney-sweep’s  cancer  of  the  scrotum  is  essentially  a similar 
formation  (see  Epithelioma). 

The  cancerous  ulcer  of  the  skin  is  often  difl&cult  to  distinguish 
microscopically  from  the  epithelial  ulcer,  because  the  external  layer,  like 
it,  is  often  composed  of  softened  epidermis.  When,  however,  a drop  of 
cancerous  juice  can  be  squeezed  from  the  surface,  it  is  found  to  contain 
groups  of  cancer  cells,  which,  from  their  general  appearance,  may  for  the 
most  part  be  easily  distinguished.  Considerable  experience,  however  in 


0 o d 


the  knowledge,  and  skill  in  the  demonstration,  of  cancerous  and  cancroid 
growths,  are  necessary  in  order  to  pronounce  confidently  on  this  point, 
and  to  this  end  an  acquaintance  with  the  whole  subject  of  the  histology 
of  morbid  growths  is  essential.* 

* See  the  Author’s  Treatise  on  Cancerous  and  Cancroid  Growths.  Edin.  1849. 


Fig.  121.  Epidermic  cells  from  the  edge  of  a softened  epithelioma. 

Fig.  122.  Other  cells  from  the  centre  of  the  softened  portion. 

Fig.  123.  Appearance  of  section  of  cancerous  ulcer  of  the  skin. — a,  Epidermic 
scales  and  fusiform  corpuscles  on  the  external  surface.  6,  Group  of  epidermic  scales, 
c.  Fibrous  tissue  of  the  dermis.  <7,  Cancer-cells  iuflhrated  into  the  fibrous  tissue,  and 
filling  up  the  loculi  of  the  dermis.  250  diam. 


-110 


EXAMINATION  OF  THE  PATIENT. 


USE  OF  CHEMICAL  TESTS. 

The  chemical  examination  of  urine,  blood,  milk,  and  other  animal 
fluids,  as  well  as  the  detection  of  poison  in  vomited  matters,  or  other 
organic  mixtures  and  tissues,  constitutes  an  extensive  field  of  inquiry, — 
for  a description  of  which  I must  refer  to  works  on  chemistry  and 
medical  jurisprudence.  At  the  bed-side  much  of  this  kind  of  investi- 
gation is  now  superseded  by  the  use  of  the  microscope,  which  at  a glance 
enables  us  to  detect  the  poverty  and  adulterations  of  milk,  the  spissitude 
and  altered  conditions  of  blood,  the  nature  of  various  salts  and  precipi- 
tates in  urine,  etc.  The  action  of  chemical  reagents  on  the  corpuscles, 
made  visible  by  this  instrument  has  been  already  alluded  to.  Chemical 
tests  are  most  valuable  at  the  bed-side,  to  determine  the  presence  of 
albumen,  bile,  sugar,  or  chlorides  in  the  urine,  to  which  points  alone  I 
shall  in  this  place  direct  your  attention.  All  quantitative  analyses  of 
urine  should  only  be  taken  by  skilful  analytical  chemists. 

Before  proceeding  to  test  the  urine  for  particular  substances,  notice 
should  be  taken  of  its  general  properties ; such  as  its  average  daily 
quantity,  its  color,  odor,  density,  and  reaction.  The  naked-eye  cha- 
racters of  the  cloud  or  precipitate  which  appears  in  almost  every  kind 
of  urine,  when  allowed  to  remain  at  rest  for  some  time  after  emission, 
should  also  be  observed,  and  its  morphological  constituents  determined 
by  means  of  the  microscope.  The  observation  of  one  or  more  such 
properties  may  lead  at  once  to  the  establishment  of  a correct  diagnosis, 
and  wdll  certainly  direct  the  path  we  should  take  in  the  subsequent 
chemical  investigation  of  the  fluid. 

The  B'pecfic  Gravity  of  the  Urine  is  at  once  obtained  by  means  of  a 
urinometer,  and  should  always  be  noted  at  the  commencement  of  the 
examination  of  this  fluid,  as  it  furnishes  important  indications  for  further 
proceedings.  Thus  the  specific  gravity  is  generally  diminished  in  chronic 
cases  of  Bright’s  disease,  and  increased  in  cases  of  Diabetes. 

To  detect  Albumen  in  the  Urine. — Boil  a portion  of  urine  in  a test- 
tube  over  the  flame  of  a spirit-lamp,  and  observe  the  result.  If  the  urine, 
which  has  in  the  preliminary  examination  proved  to  be  acid,  become 
hazy  or  coagulate,  the  presence  of  albumen  is  certain  ; but  if  it  be  neutral 
or  alkaline  in  its  reaction,  the  cloudiness  may  be  occasioned  by  the 
deposition  of  earthy  phosphates.  One  drop  of  nitric  acid  should  there- 
fore, in  the  latter  instance,  be  added,  which  will  immediately  clear  up 
the  opacity  of  the  fluid  if  due  to  phosphates,  but  serve  to  increase  its 
turbidity  if  depending  solely  on  coagulated  albumen. 

To  detect  Bile  in  the  Urine. — The  test  for  bile-pigment  is  nitric  acid, 
which  changes  the  fluid  containing  it  in  any  quantity,  first  into  a grass 
green,  and  then,  if  the  test  be  added  in  excess,  into  a ruby-red  or  reddish 
brown  tint.  If  the  urine  be  very  much  loaded  with  bile,  as  sometimes 
Iiappens  in  cases  of  jaundice,  so  that  it  resembles  porter  in  appearance, 


USE  OF  CHEMICAL  TESTS. 


Ill 


it  is  better  to  dilute  it  with  water  before  adding  the  acid.  If  the  test  be 
applied  to  the  urine,  placed  in  a clean  white  plate,  so  as  to  form  a thin 
layer  over  the  surface,  the  play  of  colors  may  often  be  distinctly  seen 
assuming  green,  violet,  pink,  and  yellow  hues.  The  same  succession  of 
tints  may  be  induced  by  nitric  acid  acting  upon  urine  containing  an 
excess  of  indican  (Schunck),  in  consequence  of  this  substance  being 
resolved  into  blue  and  red  indigo,  which  are  subsequently  destroyed  by 
the  continued  action  of  the  acid.  There  is,  however,  little  chance  of 
fallacy  arising  from  this  source,  as  a marked  excess  of  indican  has 
hitherto  only  been  observed  in  two  cases  (Carter),  and  never  in  connec- 
tion with  urine  presenting  a bilious  appearance. 

To  detect  Bile  Acids  in  the  Urine. — Pettenkofer’s  test  for  the  biliary 
acids  is  applied  in  the  following  manner.  A few  drops  of  simple  syrup 
are  mixed  with  a small  quantity  of  urine  contained  in  a test-tube,  or 
still  bett  u',  in  a porcelain  capsule ; concentrated  sulphuric  acid  is  then 
gradually  added  in  considerable  quantity.  If  choleic  acid  be  present, 
tire  mixture  will  exhibit  a most  intense  and  beautiful  purple  or  violet 
color.  The  vessel  employed  should  be  placed  in  cold  water  before  the 
acid  is  added,  in  order  to  prevent  the  sugar  being  decomposed  into 
certain  brown  compounds,  which  would  tend  to  obscure  the  development 
of  the  reaction  which  has  been  described.  True  bile  is  seldom  found  in 
urine,  even  when  large  quantities  of  the  coloring  matters  exist. 

To  detect  Leucin  and  Tyrozin  in  the  Urine. — They  may  be  deposited 
spontaneously,  if  not  the  urine  should  be  evaporated  on  a sand  or  water 
bath  to  a syrupy  consistence  and  set  aside  for  24  hours  to  allow  of  depo- 
sition. The  characteristic  forms  if  present  are  detected  with  the  micro- 
scope (see  Figs.  112  to  114). 

To  detect  Sujar  m the  Urine. — The  three  best  tests  for  sugar  in  urine 
are  those  known  as  Moore’s  test,  Trommcr’s  test,  and  the  Fermentation 
test.  Moore's  test  consists  in  boiling  urine  for  five  minutes,  in  a tube, 
with  half  its  bulk  of  liquor  potassae.  If  sugar  be  present  the  liquid 
assumes  a brownish  bistre  color.  TrommeBs  test  consists  in  adding  a 
few  drops  of  a solution  of  sulphate  of  copper,  so  as  to  give  the  urine  a 
pale  blue  color ; liquor  potassae  is  then  added  until  the  hydrated  oxide 
of  copper  thrown  down  is  again  dissolved,  which  will  happen  if  the  urine 
be  saccharine.  The  clear  deep  blue  solution  which  is  formed  must  now 
be  boiled  ; when,  if  sugar  be  present  in  very  minute  quantity,  it  will  be 
indicated  by  the  mixture  assuming  a yellowish-red  opalescent  tint ; but 
if  in  large  amount,  by  its  becoming  perfectly  opaque  from  the  formation 
and  precipitation  of  the  yellow  sub-oxide  of  copper.  If  the  urine  con- 
tain no  sugar,  a dark-green  precipitate  only  is  formed  on  ebullition. 
Fermentation  test. — A few  drops  of  yeast  should  be  added  to  urine  and 
a test-tube  completely  filled  with  the  mixture  inverted  and  allowed  to 
remain  in  a saucer,  containing  a little  more  of  the  urine.  The  whole 
should  then  be  put  in  a warm  place,  of  about  70  or  80  degrees,  for  24 
hours.  Fermentation  ensues,  and  carbonic  acid  is  formed,  which  collects 
at  the  top  of  the  tube,  displacing  the  fluid.  The  test  is  now  but  seldom 


112 


EXAMINATION  OF  THE  PATIENT. 


employed,  being  tedious  of  application,  and  not  giving  such  accurate 
results  as  was  at  one  time  supposed. 

Barreswil’s  solution  is  very  useful  when  many  observations  are  to  be 
made  for  the  detection  of  grape  sugar  in  the  urine.  Take  of  bitartrate  of 
potash  and  crystallized  carbonate  of  soda,  of  each  150  parts,  of  caustic 
potash  80  parts,  of  sulphate  of  copper  50  parts,  and  of  water  1000  parts  ; 
dissolve  the  carbonate  of  soda  and  potash  in  part  of  the  water  boiling, 
then  add  the  sulphate  of  copper  powdered.  When  all  the  bitartrate  is 
dissolved,  add  the  rest  of  the  water,  and  filter.  A few  drops  of  this 
solution  added  to  a little  urine  in  the  test-tube  will,  under  the  action  of 
heat,  throw  down  a dirty  green  or  yellow  precipitate  of  sub-oxide  of 
copper,  if  sugar  be  present. 

To  detect  Chlorides  in  the  Urine. — Add  to  urine  in  a test-tube  about 
a sixth  part  of  its  bulk  of  strong  nitric  acid,  and  then  a few  drops  of  a 
solution  of  nitrate  of  silver.  If  any  soluble  chloride  be  present,  the 
chlorine  will  be  thrown  down  in  combination  with  the  silver,  as  a white 
precipitate;  but  if  none  exist  the  fluid  will  remain  clear.  From  the 
degree  of  turbidity  or  haziness  occasioned  by  the  addition  of  the  silver 
solution,  a rough  estimate  may  be  made  of  the  amount  of  chlorides  con- 
tained in  the  urine. 

A small  case  I have  caused  to  be  arranged  will  be  found  useful  for 
examining  urine  by  the  practitioner,  as  it  is  readily  carried  in  the  pocket. 


paper,  matches,  and  a file  for  striking  fire.  (See  Fig.  124.) 

In  concluding  this  subject,  allow  me  to  impress  upon  you  the  great 
importance  of  making  yourselves  acquainted  with  all  the  modes  of  ex- 
amination I have  brought  before  you,  rather  than  one  or  more  of  them. 
It  too  frequently  happens  that  exclusive  attention  to  a particular  method 
of  exploration  has  rendered  some  medical  men  good  observers  of  symp- 

Fig.  124.  A pocket  case,  containing  a spirit-lamp,  two  stoppered  bottles,  test-tube, 
test-paper,  with  matches  and  file  for  obtaining  a light.  Half  the  real  size.  Sold  by 
Kemp,  Infirmary  Street. 


EXAMINATION  OF  THE  PATIENT. 


113 


toms,  whilst  they  are  unacquainted  with  physical  diagnosis ; and  again, 
among  those  who  have  cultivated  the  latter,  there  are  some  who  can 
percuss  and  use  the  stethoscope  with  skill,  who  are  ignorant  of  the  use  of 
the  microscope.  Now,  you  should  regard  all  instruments  only  as  means 
to  an  end.  In  themselves  they  are  nothing,  and  can  no  more  confer  the 
power  of  observing,  reflecting,  or  of  advancing  knowledge,  than  a cutting 
instrument  can  give  the  judgment  and  skill  necessary  for  performing  a 
great  operation.  We  should  learn  to  distinguish  between  the  mechanical 
means  necessary  for  arriving  at  truths,  and  those  powers  of  observation 
and  mental  processes  which  enable  us  to  recognise,  compare,  and  arrange, 
the  truths  themselves.  In  short,  rather  endeavor  to  observe  carefully 
and  reason  correctly  on  the  facts  presented  to  you,  than  waste  your  time 
in  altering  the  fashion  and  improving  the  physical  properties  of  the  means 
by  which  facts  are  ascertained.  At  the  same  time  these  means  are 
absolutely  necessary  in  order  to  arrive  at  the  facts  on  which  all  correct 
reasoning  is. based;  and  perhaps  no  kind  of  knowledge  has  been  so  much 
advanced  in  modern  times  by  the  introduction  of  instruments,  and  by 
physical  means  of  investigation,  as  that  of  medicine.  These  enable  the 
practitioner  to  extend  the  limits  to  which  otherwise  his  senses  would  be 
confined.  Chest-measurers,  pleximeters,  stethoscopes,  microscopes,  specu- 
la, probes,  etc.  etc.,  are  all  useful,  and  in  particular  cases  indispensable. 
I do  not  say  employ  one  to  the  exclusion  of  the  other,  but  bo  equally 
dexterous  in  the  use  of  each.  Do  not  endeavor  to  gain  a roputatioa  as 
a microscopist,  as  a stethoscopist,  or  as  a chemist ; but  by  the  appropriate 
application  of  every  instrument  and  means  of  research,  seek  to  arrive  at 
the  most  exact  diagnosis  and  knowledge  of  disease,  so  as  to  earn  for  your- 
selves the  title  of  enlightened  medical  practitioners.  Above  all,  do  not  be 
led  away  by  the  notion  that  any  kind  of  reasoning  or  theory  will  enable 
you  to  dispense  with  the  careful  observation  of  facts.  What  is  called 
tact  and  skill  is  not  a peculiar  intuition,  or  a superior  power  of  intelli- 
gence possessed  by  certain  persons,  but  is  always  the  result  of  constant 
and  laborious  examination  of  symptoms  and  signs  in  the  living,  combined 
with  careful  research  into  the  nature  of  morbid  changes  discovered  in. 
the  dead. 


8 


SECTION  II 


PRINCIPLES  OF  MEDICINE. 

Every  animated  being  has  a limited  period  of  existence,  during  which  it 
is  constantly  undergoing  a change.  So  long,  however,  as  this  change 
takes  place  uniformly  in  the  different  parts  of  which  it  is  composed,  its 
physiological  or  healthy  condition  is  preserved.  But  immediately  the 
action  of  one  organ  becomes  excessive  or  weak  in  proportion  to  the  others, 
disease,  or  a pathological  state,  is  occasioned.  This  state  may  be  induced 
by  direct  mechanical  violence,  but  may  also  occur  from  the  continued  or 
irregular  influence  of  several  physical  agents  upon  the  body,  such  as 
temperature,  moisture  or  dryness,  certain  qualities  of  the  atmosphere, 
kinds  of  food,  etc.  etc.  These  are  always  acting  upon  the  vital  powers 
of  the  individual  as  a whole,  as  well  as  incessantly  stimulating  the 
various  organs  to  perform  their  functions.  Life,  then,  may  be  defined  in 
the  words  of  Bedard — “ organization  in  action.”  Health  is  the  regular 
or  normal,  and  disease  the  disturbed  or  abnormal  condition  of  that  action. 

While  such  may  be  assumed  to  be  our  notion  of  disease  in  the 
abstract,  what  constitutes  disease  in  particular  has  been  much  disputed. 
From  the  time  of  Hippocrates  to  that  of  Cullen  and  his  followers,  the 
external  manifestation  or  symptoms  constituted  the  only  means  of  recog- 
nizing diseased  action,  and  gradually  came  to  be  regarded  as  the  disease 
itself.  Then  these  symptoms  were  arranged  into  groups,  divided,  sub- 
divided, and  named,  according  to  the  preioniinance  of  one  or  more  of 
them,  or  the  mode  in  which  they  presented  themselves.  These  artificial 
arrangements  are  the  nosologies  of  former  writers.  All  philosophical 
physicians,  however,  have  recognised  that  the  true  end  of  medical  inquiry 
is,  if  possible,  to  determine  rather  the  altered  condition  of  the  organs 
which  produces  the  disordered  function,  than  to  be  contented  with  the 
study  of  the  effects  it  occasions.  But  the  difficulty  of  this  inquiry  has 
been  so  great,  and  a knowledge  of  the  means  of  prosecuting  it  so  limited, 
that  it  is  only  within  the  last  thirty  years  that  medicine  has  been  enabled 
to  build  up  for  herself  anything  like  a solid  scientific  foundation.  What 
has  hitherto  been  accomplished  in  this  way  has  been  brought  about  by 
the  conjoined  cultivation  of  morbid  anatomy,  pathology,  and  clinical 
observation,  greatly  assisted,  however,  by  the  advance  of  numerous 
collateral  branches  of  science,  and  especially  in  recent  times  by  chemical 
and  histological  investigation.  The  result  has  been  a complete  over- 
throw of  nosological  systems.  We  now  attempt  to  trace  all  maladies  to 
their  organic  cause,  and  just  in  proportion  as  this  has  been  successfully 
accomplished,  has  medicine  become  less  empirical  and  more  exact.  The 


MOLECULAR  AXD  CELL  THEORIES  OF  ORGANIZATION. 


115 


cro-niic  cliauges,  however,  which  produce  or  accompauy  many  diseases 
have  not  yet  been  discovered,  and  consequently  a classification  of  all  - 
maladies  on  this  basis  cannot  be  strictly  carried  out.  The  organic  cause 
of  epilepsy,  hydi-ophobia,  and  of  many  fevers,  for  example,  is  as  yet  un- 
kuo.vii.  In  the  present  state  of  medicine,  therefore,  when  the  morbid 
c.iange  in  an  organ  is  unequivocally  the  origin  of  the  symptoms,  we 
employ  the  name  of  the  lesion  to  designate  the  disease;  but  when  there 
is  disturbance  of  function,  without  any  obvious  lesion  of  a part,  we  still 
make  use  of  the  principal  derangement  to  characterize  the  malady. 
Thus  as  regards  the  stomach  we  say  a cancer  or  an  ulcer  of  that  viscus, 
and  thereby  express  all  the  phenomena  occasioned.  But  if  we  are  un- 
able to  detect  such  cancer  or  ulcer,  we  denominate  the  affection  after  its 
leading  symptom,  dyspepsia,  or  difficulty  of  digestion. 

In  endeavoring  to  carry  out  this  distinction,  however,  modern  physi- 
cians have  fallen  into  a great  error,  inasmuch  as  they  have  continued  to 
employ  the  nomenclature  of  our  forefathers,  and  use  words  simply  ex- 
pressive of  the  presence  of  symptoms  to  indicate  the  altered  condition 
of  organs  which  are  the  cause  of  those  symptoms.  Formerly  the  term 
iiiflanunation  meant  the  existence  of  pain,  heat,  redness,  and  swelling;  it 
now  represents  to  us  certain  changes  in  the  nervous,  vascular,  and  paren- 
chymatous tissues  of  a part.  Formerly,  apoplexy  meant  sudden  uncon- 
sciousness originating  in  the  brain ; now  it  is  frequently  used  to  express 
haemorrhage  into  an  organ,  and  hence  the  term  apoplexy  of  the  lung  and 
of  the  spinal  cord.  The  two  ideas  are  essentially  distinct,  and  bear  no 
reference  to  each  other,  because  the  same  word  may  be,  and  often  is, 
employed  under  circumstances  where  its  original  meaning  is  altogether 
inapplicable.  Hence  it  is  incumbent  on  every  one  who  applies  to  organic 
changes  terms  which  have  been  long  employed  in  medicine,  to  define 
exactly  what  he  means  by  them.  In  this  way  old  indefinite  expressions, 
though  still  retained,  will  have  a more  precise  meaning  attached  to 
them.  If,  for  instance,  it  be  asserted  that  bleeding  cut  short  an  in- 
flammation, let  it  be  explained  what  is  cut  short — whether  the  symp- 
toms, the  physical  signs,  a congestion  of  the  vessels,  or  an  exudation  of 
the  liquor  sanguinis. 

But  notwithstanding  the  confusion  in  our  nosological  systems,  and 
the  frequent  change  of  ideas  with  regard  to  the  nature  of  morbid  actions, 
which  have  necessarily  resulted  from  the  rapid  advance  of  medicine  in 
late  years,  it  still  follows  that  disease  is  only  an  alteration  in  the  healthy 
function  of  organs.  Hence  all  scientific  classification  of  maladies  must 
be  founded  on  physiology,  which  teaches  us  the  laws  that  regulate  those 
functions.  A condensed  account  of  our  existing  knowledge  of  physiolo- 
gical pathology  is  therefore  a necessary  preliminary  to  the  clinical  study 
of  disease. 


MOLECULAR  AND  CELL  THEORIES  OF  ORGANIZATION. 

It  has  been  a favorite  speculation  with  philosophers  in  all  ages  that 
the  infinite  variety  of  matter  we  see  around  us  is  merely  the  result  of  a 
definite  combination  of  atoms.  The  hypothetical  doctrines  of  Democritus, 


116 


PRINCIPLES  OF  MEDICINE. 


Anaxagoras,  and  Empedocles  appear,  after  many  centuries  of  discussion, 
to  have  converged  into  a fixed  law  about  fifty  years  ago,  which  was 
formularized  by  Dalton  under  the  denomination  of  the  Atomic  Theory. 
This  theory  has  unquestionably  given  a great  impulse  to  chemical  science, 
but  has  done  little  for  the  science  of  organization.  It  has  facilitated  the 
calculation,  and  thrown  light  on  the  proportional  combinations  of  chem- 
ical elements,  hut  has  taught  us  nothing  whatever  as  to  the  develop- 
ment and  growth  of  plants  and  animals.  Gradual  improvement  in  optical 
instruments,  however,  has  now  enabled  us  to  resolve  the  ultimate  elements 
of  living  bodies  into  minute  particles,  and  convinced  us  that  it  is  upon 
our  knowledge  of  their  physical  and  vital  properties  that  our  acquaintance 
with  physiological  and  pathological  processes  must  essentially  depend. 
The  theory  of  Schleiden  and  Schwann  was  that  all  the  tissues  are  derived 
from  minute  bodies  called  cells,  and  that  the  cause  of  nutrition  and 
growth  resides  in  these,  and  not  in  the  organism  as  a whole.  This  doc- 
trine has  led  din  ing  the  last  twenty-five  years  to  the  exploration  of  the 
tissues  with  the  aid  of  high  magnifying  powers,  and  to  the  discovery  of 
facts  and  theories  which,  during  that  period,  have  greatly  advanced  our 
knowledge,  and  tended  to  revolutionize  the  practice  of  medicine.  But  as 
this  knowledge  progressed,  it  became  evident  that  even  the  cell  doctrine 
did  not  embrace  all  the  facts  of  organization,  and  that  we  required  a still 
wider  generalization.  Hence  it  appears  to  me  evident  that  with  a view 
to  making  further  progress,  and  stimulating  to  fresh  investigation,  we 
must  substitute  for  the  hypothetical  atoms  of  the  chemist  the  visible 
molecules  of  the  histologist,  and  demonstrate  how  all  research  and  dis- 
covery in  recent  times  tend  to  support  a molecular  rather  than  a cell 
theory  of  organization.  It  will  be  my  object,  therefore,  as  the  essential 
foundation  for  correct  principles  in  medicine,  to  develop  what  I consider 
to  be  the  true  law  of  organic  formation — to  blend  the  well-known  doc- 
trine of  Schleiden  and  Schwann  into  a theory  of  wider  application — to 
show  how  the  known  facts  in  physiology  and  pathology  give  it  the  most 
unequivocal  support — and,  lastly,  indicate  the  manner  in  which  it  must 
constitute  the  basis  of  a sound  therapeutics. 

Passing  over  the  views  of  the  older  observers,  including  those  of  Wolff, 
Von  Baer,  Baspail,  and  others,  in  which  there  is  much  that  invites  atten- 
tion, the  chief  theories  advanced  on  this  subject  may  be  limited  to  four. 

1.  Ihe  Theory  of  Schleiden  and  Schwann  (1839). — In  a cytoblas- 
tema  or  amorphous  substance,  found  either  contained  within  cells  already 
existing,  or  else  between  them  in  the  form  of  intercellular  substance, 
round  corpuscles  make  their  appearance,  which  are  at  first  structureless 
or  minutely  granular.  These  enlarge  and  constitute  the  nuclei,  around 
which  a cell  wall  is  formed  by  molecular  deposition,  and  gradually  ex- 
pands by  the  progressive  reception  of  new  molecules  between  the  existing 
ones.  The  interspace  between  the  cell  membrane  and  the  cell  nucleus  is 
at  the  same  time  filled  with  fluid,  and  thus  a nucleated  cell  is  produced. 
Cells  so  formed  may  remain  isolated,  or,  by  subsequent  development  and 
coalescence  of  their  walls  in  different  ways,  produce  all  the  various  tex- 
tures.^ Thus  all  tissues  are  derived  from  cells,  and  “ the  cause  of  nutri- 

* Schwann  & Schleiden’s  Researches,  translated  by  the  Sydenham  Society,  p.  172,  et  scq. 


MOLECULAR  AND  CELL  THEORIES  OF  ORGANIZATION.  117 


tion  and  growtli  resides,  not  in  the  organism  as  a whole,  but  in  the  sep- 
arate elementary  parts — the  cells.’'^^ 

2.  The  Theory  of  Gooddr  (1845). — It  is  not  so  much  the  cells  as 
the  nuclei  of  the  textures  which  are  the  potential  elementary  parts  of  the 
organisin,and  wdiicdi  therefore  may  be  called  centres  ofnutriiion  or  centres 
of  germination.  “ As  the  entire  organism  is  formed  at  first,  not  by 
simultaneous  formation  of  its  parts,  but  by  the  successive  development  of 
these  from  one  centre  ” (the  germinal  S[)Otof  the  ovum),  “so  the  various 
parts  arise  each  from  its  own  centre,  this  being  the  original  source  of  all 
the  centres  from  which  the  part  is  ultimately  supplied.  From  this  it 
follows,  not  only  that  the  entire  organism,  as  has  been  stated  by  the 
authors  of  the  cellular  theory,  consists  of  simple  or  developed  cells,  each 
having  a peculiar  independent  vitality,  but  there  is  in  addition  a divi- 
sion of  the  whole  into  departments,  each  containing  a certain  number  of 
simple  or  developed  cells,  all  of  which  hold  certain  relations  to  one  cen- 
tral or  capital  cell,  around  which  they  are  grouped.  It  would  appear 
from  this  central  cell  all  the  other  cells  of  its  department  derive  their 
origin.  It  is  the  mother  of  all  those  within  its  own  territory.”! 

3.  The  Theory  of  Huxley  (1853). — A homogeneous  plasma  first 
exists,  in  which  spaces  {vacuoles)  are  formed,  and  these  contain  the  cell 
wall,  contents,  and  nucleus.  The  walls  of  these  spaces  are  called 
plast,  the  nucleus  endoplast.  This  last  he  considers  comparatively  an 
unimportant  element.  “ The  periplast,  on  the  other  hand,  which  has 
hitherto  passed  under  the  names  of  cell  wall,  contents,  and  intercellular 
substance,  is  the  subject  of  all  the  most  important  metamorphic  processes, 
whether  morphological  or  chemical,  in  the  animal  and  in  the  plant.  By 
its  diiferentiation  every  variety  of  tissue  is  produced  ; and  this  differen- 
tiation is  the  result  not  of  any  metabolic  action  of  the  endoplast,  which 
has  frequently  disappeared  before  the  metamorphosis  begins,  but  of  in- 
timate molecular  changes  in  its  substance,  which  take  place  under  the 
guidance  of  the  ‘ vis  essentialis,’  or,  to  use  a strictly  positive  phrase, 
occur  in  a definite  order,  we  know  not  why.”! 

Whilst  each  of  these  theories  has  numerous  facts  in  its  support,  no 
one  of  them  is  capable  of  embracing  all  the  facts  of  organization.  Thus 
there  are  several  tissues  which  have  never  been  known  to  contain,  or  to 
originate  from  cells,  such  as  the  sarcolemma,  vitelline  membrane,  ante- 
rior and  posterior  layers  of  the  cornea,  and  capsule  of  the  crystalline 
lens.  The  blood  corpuscles  of  mammals  are  not  cells,  but  nuclei.  The 
striated  muscular  fibre  has  been  shown  by  the  researches  of  Savory  and 
Lockhart  Clarke  to  be  formed  from  the  molecular  mass  outside  the  em- 
bryonic cells,  while  the  mineral  matter  of  bone  is  first  deposited  in  the 
intercellular  substance,  outside  and  often  at  a distance  from  the  cartilage 
cells.  These  facts  are  opposed  to  an  exclusive  cell  theory,  as  thej  are 
i.lso  to  a nuclear  or  germinal  centre  theory.  It  is  true  the  originator 
of  this  last  doctrine  was  obliged  by  them  to  extend  the  influence  of  his 
centre  over  a certain  distance  or  territory  external  to  it,  whereby  he  hoped 

* Schwann  and  Schleiden’s  Researches,  translated  by  the  Sydenham  Society,  p.  192. 

f Goodsir’s  Anatomical  and  Pathological  Observations,  pp.  1 and  2. 

X Brit,  and  For.  Med.-Chir.  Review,  vol.  xii.  p.  306. 


118 


PRINCIPLES  OF  MEDICINE. 


to  embrace  tlie  actions  which  are  carried  on  in  the  intercellular  sub- 
stance. But,  as  pointed  out  by  the  supporter  of  the  third  theory,  the 
centre  often  disappears  while  development  in  the  matter  outside  it  is 
active.  A study  of  the  development  of  the  skeleton  proves  that  mineral 
matter  is  first  deposited  outside  cells  and  their  nuclei,  and  proceeds  not 
from,  but  towards  them ; while  the  earthy  matter  often  assumes  forms 
that  no  known  combination  of  cells  can  be  supposed  to  produce.  On  the 
other  hand,  there  can  be  no  doubt  that  in  many  cases  development  does 
proceed  from  the  centre,  by  proliferation  both  of  the  nucleus  and  of  the 
cell ; so  that  the  difficulties  imposed  upon  us  by  each  of  these  theories 
simply  depend  upon  their  exclusive  character. 

4.  The  Molecular  Theory  of  ihe  Author. — It  was  at  the  meeting 
of  the  British  Association  in  Edinburgh  (1850)  that  I pointed  out  to  the 
Physiological  sub-section  the  defects  of  the  cell  theory,  as  explanatory 
of  the  formation  of  various  textures.  In  1852  I read  another  paper  on 
this  subject  to  the  Physiological  Society  of  Edinburgh."^  But  it  was  at 
the  Glasgow  meeting  of  the  British  Association  in  1855  I brought  for- 
ward the  molecular  theory  of  organization,!  which  may  shortly  be  stated 
as  follows : — The  ultimate  parts  of  the  organization  are  not  cells  nor 
nuclei,  but  the  minute  molecules  from  which  these  are  formed.  They 
possess  independent  physical  and  vital  properties,  which  enable  them  to 
unite  and  arrange  themselves  so  as  to  produce  higher  forms.  Among 
these  are  nuclei,  cells,  fibres,  and  membranes,  all  of  which  may  be  pro- 
duced directly  from  nmlecules.  The  development  and  growth  of  organic 
tissues  is  owing  to  the  successive  formation  of  histogenetic  and  histolytic 
molecules.  The  breaking  down  of  one  substance  is  often  the  necessary 
step  to  the  formation  of  another ; so  that  the  hystoiytic  or  disintegrative 
molecules  of  one  period  become  the  histogenetic  or  formative  molecules 
of  another. ! 

This  theory  appears  to  me  to  comprehend  all  known  facts;  to  unite 
the  views  of  Schwann,  Goodsir,  and  Huxley;  and  explain  the  otherwise 
irreconcilable  ideas  concerning  development  sometimes  proceeding  from 
the  nucleus,  at  others  from  the  cell,  and  at  others  from  the  intercellular 
substance. 

Two  leading  ideas  have  governed  histologists  in  their  attempts  to 
discover  the  law  of  development ; the  one,  that  there  is  an  evolution  of 
matter  from  within ; the  other,  that  there  is  a superposition  of  matter 
from  without.  Facts  indicate  that,  as  regards  cells  and  nuclei,  both 
notions  are  correct ; nature,  more  especially  during  embryonic  life, 
adopting  the  first  method,  and  during  adult  life,  the  second.  But  the 
differences  between  these  notions  are  more  apparent  than  real,  because 
the  molecular  theory  of  organization  reconciles  the  two.  It  inculcates 
that  it  is  not  a cell  or  a nucleus  only  which  acts  as  a centre,  but  that 
every  molecule  is  a centre,  and  is  endowed  with  physical  or  vital  proper- 
ties which  enable  it  sometimes  to  act  in  the  one  way,  sometimes  in  the 
other — here  within,  and  there  outside  cells. 

* Edinburgh  Monthly  Journal,  May  1862,  p.  476. 

\ Report  of  the  British  Association  for  the  Advancement  of  Science,  1856,  p.  119. 

f Proceedings  of  the  Royal  Society  of  Edinburgh,  April  1st,  1861,  and  my  Leo 
tures  on  Molecular  Physiology,  etc.,  in  the  Lancet^  186^ 


MOLECULAR  AND  CELL  THEORIES  OF  ORGANIZATION. 


119 


The  accompanyiag  figures  will  serve  to  illustrate  the  agency  of  mole- 
cules in  the  production  of  vibriones  under  circumstances,  where  by  no 
possibility  can  they  be  attributed  to  the  existence  of  pre-existing  cells. 


Fig.  125.  Fig.  126.  Fig.  127.  Fig.  12S.  Fig.  129. 

If  we  take  a general  view  of  the  structural  relations  of  the  tissues, 
we  observe  that  the  molecuiar,  cellular,  fibrous,  and  tubular  elements  are 
more  or  less  mingled  together,  but  that  some  tissues  abound  in  one,  and 
others  in  another.  Thus  the  molecular  element  abounds  in  the  nutritive 
fluids,  in  voluntary  muscle,  and  in  the  grey  substance  of  the  cerebral  con- 
volutions; the  cellular  element  abounds  in  adipose,  in  glandular,  and  in 
epithelial  tissues;  the  fibrous  element  in  areolar  texture,  ligament,  ten- 
don, and  muscular  tissues;  and  the  tubular  element  in  brain,  spinal 
cord,  bone,  tooth,  and  throughout,  the  body  in  the  form  of  minute  ducts, 
nerves,  and  blood-vessels.  They  ail,  as  we  have  seen,  serve  general  pur- 
poses in  the  economy.  The  molecular  may  be  regarded  as  nutritive,  or 
as  Dr.  Beale  has  called  it,  germinal  matter.  The  cells  serve  to  elaborate 
this  matter  for  secretion,  excretion,  and  certain  kinds  of  growth.  The 
fibres  connect  parts  together,  and  in  the  molecular  form  of  muscular 
fibre  present  the  highest  degree  of  contractility.  The  tubes  conduct 
nutritive  fluid.s,  and  the  nerve- tubes  that  influence,  which  is  capable  of 
exciting  action  in  brain,  voluntary  muscle,  glands,  and  vessels,  by  bring- 
ing each  texture  in  connection  with,  or  under  the  control  of,  thought. 

We  perceive  further  that  those  actions  which  are  peculiarly  vital — 
such  as  growth  in  certain  directions,  the  power  of  contractility,  and  the 
existence  of  sensibility — are  not,  as  some  have  suppo.sed,  the  peculiar 
attribute  of  any  one  peculiar  element  of  the  textures,  such  as  of  cells 
or  nuclei.  I regard  one  and  all  as  possessing  powers  which  are  necessary 
for  the  well-being  of  the  economy,  and  each  as  reacting  for  the  common 
welfare  on  one  another.  Thus  growth  may  be  molecular,  cellular,  fibrous, 
or  tubular.  ’ Contractility  and  spontaneous  movements  may  be  present  in 
each  of  these  elementary  forms  ; and  sensibility  unquestionably  is  shared 
by  nervous  matter,  at  least  in  its  molecular,  cell,  and  tubular  forms. 

As  to  development,  the  molecular  is  the  basis  of  all  the  tissues.  The 
first,  step  in  the  process  of  organic  formation  is  the  production  of  an 
organic  fluid ; the  second,  the  precipitation  in  it  of  organic  molecules, 
from  which,  according  to  the  molecular  law  of  growth,  all  other  textures 
are  derived,  either  directly  or  indirectly. 

When  we  investigate  the  functions  of  plants  and  animals — for  ex- 
ample, generation,  nutrition,  secretion,  motion,  and  sensation — we  find 


Fig.  125.  Molecular  structure  of  the  scum  on  its  first  appearance  on  a clear  animal 
infusion.  Fig.  126.  Molecular  structure  of  the  same  six  hours  afterwards.  The 
molecules  are  separated  and  the  long  ones  (so-called  Vibriones)  in  active  movement. 
Fig.  127.  The  same  on  the  second  day.  Fig.  128.  The  same  separated.  The  molecules 
uniting  in  rows  which  are  moving  rapidly  across  the  field  of  the  microL cope.  Fig.  129. 
Filaments  (so-called  Spirilla)  formed  by  aggregation  of  the  molecules,  in  the  same  scum 
on  the  third  and  fourth  days,  all  in  rapid  motion.  800  diam.  linear. 


120 


PRINCIPLES  OF  MEDICINE. 


them  all  necessarily  dependent  on  the  permanent  existence  and  constant 
formation  of  molecules.  Thus  generation,  both  in  plants  and  animals, 
is  accomplished  by  the  union  of  certain  molecular  particles  called  the 
male  and  female  elements  of  reproduction.  Among  the  Protophyta,  the 
conjugation  of  two  cells  enables  their  contents,  or  the  endochrome,  to 
mix  together.  This  endochrome  is  a mass  of  colored  molecules,  and  the 
union  of  two  such  masses  constitutes  the  essential  part  of  the  genera- 
tive act.  In  the  Cryptogamia,  a vibratile  antheroid  particle  enters  a 
germ  cell,  and  finds  this  last  filled  with  a mass  of  molecules  which,  on 
receiving  the  stimulus  it  imparts,  assumes  the  power  of  growth.  It  is 
the  same  among  the  Phanerogamia,  when  the  germ  cell  is  impregnated 
by  the  pollen  tube.  In  all  these  cases  it  is  necessary  to  remember  that 
the  protoplasm  is  a mass  of  molecules ; that  a spore  is  another  mass  of 
molecules  ; that  sporules  are  molecules  ; the  antherozoids  are  only  mole- 
cules with  vibratile  appendages;  and  that  the  so-called  germinal  matter 
of  the  ovule  is  also  nothing  but  a mass  of  molecules.  Cell  forms  are 
subsequent  processes,  and  once  produced  may  multiply  endogenously,  by 
gemmation  or  cleavage.  All  that  is  here  contended  for  is,  that  the 
primary  form  is  molecular,  and  that  the  force-producing  action  in  it  is  a 
molecular  force. 

In  animals,  as  in  vegetables,  every  primary  act  of  generation  is 
brought  about  by  the  agency  of  molecules.  The  Protozoa  entirely  con- 
sist of  mere  molecular  gelatiniforni  masses,  in  which  no  cell-wall  or 
central  cell  exists.  And  yet  such  masses  have  the  power  of  independ- 
ent motion,  and  of  multiplying  by  gemmation.  Considerable  discussion 
has  occurred  as  to  whether,  among  Infusorians,  there  is  a union  of  sexes 
cr  a conjugation  similar  to  what  occurs  among  the  Protophyta  ; but  in 
either  case  it  is  by  molecular  fusion  that  the  end  is  accomplished.  In 
the  higher  classes  of  animals  there  are  male  elements,  consisting  of  mole- 
cules, generally  with,  but  sometimes  destitute  of,  vibratile  filaments; 
and  female  elements,  composed  of  the  yelk  within  the  ovum,  containing 
a germinal  vesicle  or  included  cell.  Both  spermatozoid  and  germinal 
vesicle  are  dissolved  in  the  molecules  of  the  yelk,  which  then,  either 
wholly  or  in  part,  by  successive  divisions  and  transformations*  constitute 
a germinal  mass  out  of  which  the  embryo  is  formed.  Here,  as  in  plants, 
it  is  necessary  to  remember  that  the  spermatozoids,  the  yelk,  and  the 
germinal  mass,  are  all  composed  of  molecules;  and  that  these,  combining 
together,  form  the  nuclei,  cells,  fibres,  and  membranes,  which  build  up 
the  tissues  and  organs  of  the  organism.  It  is  not  from  either  the  male 
or  the  female  element  that  the  embryo  is  formed.  The  supporters  of  an 
exclusive  cell  doctrine  have  endeavored  to  show  that  there  is  always  a 
direct  descent  either  from  the  wall  of  the  ovum  or  from  the  germinal 
vesicle  as  its  nucleus.  Thus  some  consider  that  the  vitelline  membrane 
sends  in  partitions  to  divide  the  yelk  mechanically.  Others  have  formed 
the  idea  that  the  germinal  vesicle  bursts,  and  that  its  included  granules 
constitute  the  germs  of  those  cells  which  subsequently  form  in  the  germ- 
inal mass.  Others,  again,  suppose  that  on  impregnation  the  germinal 
vesicle  divides  first,  and  that  the  molecules  of  the  yelk  are  attracted 
round  the  two  centres  so  formed.  But  numerous  observations  have 
satisfied  me  that  both  spermatozoid  and  germinal  vesicles  are  simply  dis- 


MOLECULAR  A^B  CELL  THEORIES  OF  ORGANIZATION.  121 


solved  among  the  molecules  of  the  yelk,  from  the  substance  of  which 
stimulated  and  modified  by  the  mixture  so  occasioned,  the  embryo  is 
formed — a view  which  has  further  the  merit  of  explaining  what  is  known 
of  the  qualities  of  both  parents  observable  in  the  offspring.  The  truth 
appears  to  be,  that  in  an  analogous  manner  to  that  in  which  the 
pigment  molecules  of  the  skin  are  stimulated  by  the  access  of  light  to 
enter  into  certain  vital  combinations  with  one  another,  so  are  the  mole- 
cules of  the  yelk  stimulated  by  the  access  of  the  spermatozoid  to  produce 
those  other  vital  combinations  that  result  in  a new  being.  The  essential 
action  is  not  so  mncii  connected,  as  has  hitherto  been  supposed,  with  the 
cell-wall  or  nucleus  as  with  the  molecular  element  of  the  ovum. 

With  regard  to  nutrition,  food  and  all  assimilable  material  must  be 
reduced,  in  the  first  instance,  to  the  molecular  form  ; while  the  fluid  from 
which  the  blood  is  prepa’.’ed — namely,  chyle — is  essentially  molecular. 
Most  of  the  secretions  originate  in  the  effusion  of  a fluid  into  the  gland 
follicle,  which  becomes  molecular,  and  gives  rise  to  cell  formation.  In 
muscle,  the  power  of  contractility  is  inherently  associated  with  the  ulti- 
mate molecules  of  which  the  fasciculus  is  composed.  And  lastly,  the 
grey  matter  of  the  sensory  ganglia  and  of  the  brain,  which  furnish  the 
conditions  necessary  for  the  exercise  of  sensation  and  of  even  intellect 
itself,  is  associated  with  layers  of  molecules  which  are  unquestionably 
active  in  producing  the  various  modifications  of  nervous  force.  These 
molecules  are  constant  and  permanent  as  an  integral  part  of  these  tissues, 
as  much  as  cells  or  fibres  are  essential  parts  of  others ; and  their  presence 
is  not  transitory,  but  essential  to  the  functions  of  the  organs  to  which 
they  belong. 

All  morbid  growths  may  easily  be  shown  to  originate  either  in  a 
molecular  blastema,  or  in  pre-existing  cells.  The  coagulated  exudation 
infiltrated  into  the  lung,  or  on  the  serous  membranes,  and  from  which  pus 
and  fibre  ceils  originate,  are  excellent  examples  of  the  former;  while  the 
hypertrophy  of  glands,  and  formation  of  certain  carcerous  and  cancroid 
growths,  are  good  illustrations  of  the  latter.  In  morbid  alterations  of 
texture,  also,  we  shall  have  abundant  opportunities  of  pointing  out  that 
the  molecular  law  of  development  prevails,  and  that  histogenetic  and 
histolytic  groups  constitute  the  numerous  alterations  of  texture  con- 
stantly brought  under  the  observation  of  the  pathologist. 


Fig.  130.  Fig.  131.  Fig.  132.  Fig.  133. 

All  these  facts  point  to  the  conclusion  that  vital  action,  so  far  from 
being  exclusively  seated  in  the  cells,  is  also  intimately  associated  with 
the  elementary  molecules  of  the  organism. 

This  molecular  theory  of  organization  is  opposed  to  the  views  of 

Fig.  130.  Nuclei  imbedded  in  a molecular  blastema.  Fig.  131.  Young  fibre  cells 
formed  by  aggregation  of  molecules  around  the  nuclei,  Fig.  130.  Fig.  132.  Cancer 
cells,  one  with  a double  nucleus.  Fig.  133.  Histolytic,  or  so-called  granule  cells,  break- 
ing down  from  fatty  degeneration.  250  dlam.  linear. 


122 


PRIXCIPLES  OF  MEDICINE. 


tliose  who  support  an  exclusive  origin  for  the  tissues  in  cells  alone.  The 
fallacy  of  such  a cell  theory  will,  however,  he  manifest  by  considering 
for  a moment  what  it  imposes  upon  us.  Not  the  fact,  wliich  has  been 
long  recognized,  that  cell  may  be  formed  within  cell,  or  that  proliferation 
of  cells  constitutes  an  important  and  a common  method  of  cell  multipli- 
cation ; but  that  in  no  other  possible  way  can  a cell  or  a living  particle 
be  produced.  It  asserts  that  all  embryonic  textures  in  the  ovum,  all 
adult  tissues  during  life,  and  every  kind  of  morbid  formation,  are  to  be 
traced  to  the  cell,  and  can  originate  in  it  alone.  In  short,  parodying 
the  celebrated  saying  of  Harvey,  “ omne  animal  ex  it  has  been 

attempted  by  Virchow  to  establish  the  law  of  “ omnis  cellula  e cellula^'^ 
and  to  maintain  that  “ the  cell  is  really  the  ultimate  morphological 
element  in  which  there  is  any  manifestation  of  life,  and  that  we  must 
not  transfer  the  seat  of  any  real  action  to  any  point  beyond  the  cell.”  * 
Now,  I have  pointed  out  to  you  that  such  a doctrine  is  inconsistent  with 
numerous  facts,  and  we  shall  see  that  histologists  (including  Virchow 
himself)  have  been  so  unsuccessful  in  tracing  all  tissues  back  to  cells, 
that  they  have  universally  recognised  that  cells  must  originate  in  the 
first  instance,  from  a formless  or  molecular  fluid  or  material,  called  by 
Schwann  a blastema.  Besides,  no  attempt  has  been  made  (even  by 
Virchow)  to  show  that  muscle,  nervous  matter,  the  vascular  system,  and 
the  blood,  only  originate  in  cells.  He  himself  admits,!  that  this  cannot 
be  established.  Several  tissues  are  absolutely  structureless,  such  as  the 
sarcolemma,  the  neurilemma  of  the  nerve  tube,  the  vitellire  membrane, 
the  anterior  and  posterior  layers  of  the  cornea,  and  the  capsule  of  the 
crystalline  lens.  They  are  apparently  the  result  of  simple  coagulation  and 
the  subsequent  union  of  minute  molecules,  such  as  occurs  in  the  haptogen 
membrane.  The  blood  of  mammals  is  for  the  most  part  not  cellular  but 
nuclear,  and  we  shall  subsequently  see  that  the  nuclei  in  the  adult  are 
more  probably  the  result  of  molecular  than  of  cell  formation.  The 
development  of  bone  and  the  various  forms  mineral  matter  assumes  in 
the  integumentary  skeletons  of  many  animals,  such  as  the  Holotlmria, 
Sinaptae,  etc.,  are  wholly  opposed  to  this  cell  theory,  the  mineral  matter 
being  deposited  outside  the  cells,  and  often  assuming  the  form  of  spicules, 
hooks,  anchors,  etc.,  which  can  have  no  possible  reference  to  cell  growth. 
Then,  so  far  from  it  being  correct,  “ that  we  must  not  transfer  the  seat 
of  real  action  to  any  point  beyond  the  cell,”  which  is  another  fundamental 
part  of  this  cell  theory,  you  will  find  that  Virchow  admits  | that  the 
contractile  action  of  a muscle  is  seated  in  its  ultimate  granules ; and  he 
adopts  ^ Du  Bois-Beymond’s  theory  of  electrical  action  in  nerve  as  being 
dependent  on  “ a change  in  the  position  which  the  individual  molecules 
assume  to  one  another^  If,  therefore,  it  cannot  be  shown  by  the  chief 
supporter  of  this  theory  that  many  important  tissues  are  formed  directly 
from  cells,  and  if  it  be  admitted  that  the  vital  actions  of  these  same 
tissues  are  inherent  in  their  ultimate  molecules — elements  in  no  way 
connected  with  and  quite  distinct  from  cells — what  becomes  of  the 
formula  omnis  cellula  e cellula^  and  of  the  doctrine  that  “ we  must  not 
transfer  the  seat  of  real  action  to  any  point  beyond  the  cell  ? ” 

* Cellular  Pathology,  by  Chance,  p.  3. 

! Ihid.^  p.  54.  § Ihid.^  p.  290. 


f 75'ic/.,  p.  60. 


MOLECULAR  AND  CELL  THEORIES  OF  ORGANIZATION. 


123 


On  the  other  hand,  the  molecular  theory  of  organization  does  not 
appear  to  me  chargeable  with  any  such  defects.  It  is  consistent  as  a 
whole,  and  embraces  all  known  facts.  As  investigations  are  multiplied, 
the  more  it  becomes  evident  that  the  ultimate  vital  elements  of  the  tissues 
are  their  molecular,  and  not  their  cell,  constituents.  Indeed,  it  is  now 
agreed  by  many  upholders  of  a cell  theory,  that  the  potential  part  of  the 
cell  is  not  the  wall  nor  the  nucleus,  but  the  contents.  Now  these  con- 
tents are  for  the  most  part  molecular  ; and  if  we  must  have  a doctrine  of 
unities,  it  is  evidently  more  reasonable  to  adopt  a view  of  simple  unities 
like  molecules,  than  of  composite  advanced  formations  like  cells.  As  a 
whole,  the  molecular  theory  appears  to  me  to  possess  all  the  attributes  of 
a true  theory,  and  as  such  I have  no  hesitation  in  recommending  it  to 
your  adoption,  not  only  as  a basis  on  which  the  formation  of  healthy 
structure  may  be  explained,  but  as  one  eminently  valuable  when  applied 
to  morbid  formations,  and,  above  all,  in  assisting  us  to  reach  (as  we  shall 
subsequently  endeavor  to  show)  correct  modes  of  treating  disease  and  a 
true  therapeutics. 

From  what  has  been  said,  it  will  be  apparent  that  it  has  not  been  my 
object,  in  directing  attention  to  a molecular  theory  of  organization,  to  in- 
terfere in  any  way  with  the  well-observed  facts  on  which  physiologists 
have  based  what  has  been  called  the  cell-theory  of  growth.  True,  this 
last  will  require  modification,  in  so  far  as  unknown  processes  of  growth 
have  been  hypothetically  ascribed  to  the  direct  metamorphosis  of  cell 
elements.  But  a cell  once  formed  may  produce  other  cells  by  buds,  by 
division,  or  by  proliferation  without  a new  act  of  generation,  in  the  same 
manner  that  many  animals  and  plants  do,  and  this  fact  comprehends  most 
of  the  admitted  observations  having  reference  to  the  cell  doctrine.  The 
molecular,  therefore,  is  in  no  way  opposed  to  a true  cell-theory  of  growth, 
but  constitutes  a wider  generalization  and  a broader  basis  for  its  opera- 
tions. Neither  does  it  give  any  countenance  to  the  doctrines  of  equivocal 
or  spontaneous  generation.  It  is  not  a fortuitous  concourse  of  molecules 
that  can  give  rise  to  a plant  or  animal,  but  only  such  a molecular  mass  as 
is  formed  from  organic  substances,  and  receives  the  appropriate  stimulus 
to  act  in  certain  directions.^ 

The  molecular  theory  of  organization  must  ultimately  constitute  the  ba- 
sisfor  the  arts  of  horticulture,  agriculture,  and  medicine.  Thus  vegetables 
and  animals  grow  by  the  juxtaposition  of  molecules  which  are  introduced 
into  the  economy  in  the  fluid  form.  This  fluid  holds  in  solution  the  particles 
of  which  the  different  textures  consist.  These  are  deposited,  and  so  increase 
of  bulk  takes  place.  Any  interruption  to  this  process,  or  any  violent 
disturbance  in  their  statical,  chemical,  or  dynamical  arrangements  when 
formed,  is  the  fruitful  cause  of  disease.  If  this  occurs  in  nervous  matter, 
it  causes  pain,  convulsions,  and  spasms;  if  in  muscle,  paralysis ; if  in 
the  blood,  alterations  in  growth,  secretion,  excretion,  etc.  In  cases  of 
faulty  nutrition,  it  is  reasonable  to  conclude  that  if  we  could  add  to,  or 
subtract  from,  the  particular  molecular  elements  which  are  essential  to 
that  process,  we  could  accelerate  or  retard  it ; and  this  is  within  the  reach 

* For  an  account  of  the  numerous  facts  which  support  this  doctrine,  see  the 
author’s  lectures  on  Molecular  Physiology,  Pathology,  and  Therapeutics,  in  the  Lancet 


124 


PRINCIPLES  OF  MEDICINE. 


of  the  medical  practitioner.  For  example,  cod-liver  oil,  in  scrofulous  and 
phthisical  cases  operates,  not  because  of  any  vague  specific  virtue  it  has 
been  supposed  to  possess,  but  on  account  of  its  power  of  adding  to  the 
molecular  constitution  of  the  chyle,  and  thus  favoring  the  building-up 
function  of  the  blood  and  tissues.  There  can  be  no  doubt  that  iron, 
lead,  opium,  strychnine,  and  other  of  our  remedial  agents,  must  operate 
on  tins  or  that  tissue  in  virtue  of  the  affinities  between  them  and  the 
ultimate  molecules  of  such  textures.  Again  the  law  of  successive  mole- 
cular evolutions  and  disintegrations,  to  which  I have  directed  your  atten- 
tion, points  out  that  in  the  chain  of  processes  each  step  is  dependent  on 
the  one  that  precedes  it;  and  that,  inasmuch  as  regards  form,  we  cannot 
go  farther  back  than  the  molecular  form,  so  a knowledge  of  it  and  the 
manner  in  which  it  is  produced  from  fluids  holding  proximate  principles 
in  solution,  is  not  only  the  first  step  to  an  acquaintance  with  organization, 
but  is  the  one  which  should  best  inform  us  how  to  repair  that  organization 
when  so  altered  as  to  constitute  disease. 

ON  THE  GENERAL  LAWS  OF  NUTRITION  IN  HEALTH 
AND  DISEASE. 

There  have  not  been  wanting  some  pathologists  who  have  ascribed 
the  origin  of  all  diseases  to  an  altered  condition  of  nutrition  and  of  the 
blood,  whilst  others  have  regarded  even  this  function  as  subservient  to 
that  of  innervation.  In  man,  it  is  true,  we  find  them  inextricably  united, 
and  it  becomes  exceedingly  difficult  at  all  times  to  separate  with  exacti- 
tude what  are  the  purely  nutritive,  and  what  the  purely  nervous  pheno- 
mena. But  a consideration  of  animated  nature  at  large  must  satisfy  us, 
that  in  the  vegetable  world,  as  well  as  in  some  forms  of  animal  life,  nutri- 
tion may  proceed  independently  of  a nervous  system.  We  also  feel 
satisfied  that,  in  theory  as  well  as  in  fact,  the  function  of  nutrition  is 
capable  of  being  separated  from  that  of  innervation.  Doubtless  there  is 
no  lesion  whatever  which  does  not  in  the  higher  class  of  animals  involve 
both  nutritive  and  nervous  changes ; but  the  only  method  of  arriving  at 
a knowledge  of  their  conjoint  action,  of  their  mutual  influence,  or  the 
manner  in  which  sometimes  one  predominates  over  or  mingles  with  the 
other,  is  by  studying  in  the  first  instance  the  laws  by  which  each  seems 
to  be  governed. 

Function  of  Nutrition. 

The  various  modes  in  which  nutrition  becomes  impaired,  and  the  blood 
diseased,  can  only  be  understood  by  passing  in  review  the  dififerent  steps 
of  the  nutritive  process.  We  have  already  pointed  out  how  pathology 
and  practical  medicine  must  be  based  upon  anatomy  and  physiology,  and 
there  is  no  one  subject  perhaps  wffiich  is  so  well  capable  of  illustrating 
this  proposition  as  the  one  we  are  about  to  consider.  For  ages  medical 
men  have  been  in  the  habit  of  considering  the  blood  to  be  the  primary 
source  of  numerous  maladies.  It  will  be  our  endeavor  to  show,  by  an 
analysis  of  the  process  of  nutrition,  that  the  changes  of  the  blood  and  the 
diseases  which  accompany  them,  are  for  the  most  part  not  primary,  but 


HEALTHY  AND  DISEASED  NUTEITION. 


125 


secondary — that  is  to  say,  they  are  dependent  on  previously  existing  cir- 
cumstances, to  the  removal  of  which  the  medical  practitioner  must  look 
for  the  means  of  curing  his  patient. 

For  the  sake  of  convenience  of  description  and  reference,  we  shall 
divide  the  process  of  nutrition  in  man  into  five  stages.  1.  The  introduc- 
tion into  the  stomach  and  intestinal  canal  of  appropriate  alimentary  mat- 
ters. 2.  The  formation  from  these  of  a nutritive  fluid,  the  blood,  and  the 
changes  it  undergoes  in  the  lungs.  3.  Passage  of  fluid  from  the  blood  to 
be  transformed  into  the  tissues.  4.  The  disappearance  of  the  transformed 
tissues  and  their  re-abgorption  into  the  blood.  5.  The  excretion  of  these 
effete  matters  from  the  body,  in  various  forms  and  by  different  channels. 

These  different  stages  comprehend  not  only  growth,  but  the  processes 
of  assimilation,  absorption,  secretion,  and  excretion  ; and  we  believe  that 
it  is  only  by  understanding  the  function  in  this  enlarged  sense  that  we 
can  obtain  a correct  explanation  of  those  important  affections,  which  may 
appropriately  be  called  diseases  of  nutrition.  We  shall  first,  however, 
consider  each  of  these  stages  separately. 

1.  'I7ie  Introduction  into  the  Stomach  and  Intestinal  Canal  of  Appro- 
priate Alimentary  Matters. 

Aliment. — All  the  various  kinds  of  food  are  resolvable  into  the  four 
elements — Carbon,  Hydrogen,  Oxygen,  and  Nitrogen,  combined  with 
certain  mineral  bases.  The  chemical  constitution  of  plants  and  animals 
is  nearly  the  same ; and  hence  food  derived  from  one  kingdom  of  nature 
must  contain  those  substances  of  which  the  bodies  to  be  nourished  in  the 
other  kingdom  are  themselves  made  up.  The  quantity  required  is  prin- 
cipally regulated  by  the  amount  of  air  we  breathe,  its  oxygen  uniting  with 
the  carbon  and  hydrogen  of  the  tissues  to  produce  carbonic  acid  and 
water,  and  to  evolve  the  heat  of  the  body.  In  endeavoring,  therefore, 
to  ascertain  what  are  the  best  kinds  of  food  requisite  for  meeting  the 
demands  of  supply,  we  must  pay  attention,  in  the  first  place,  to  the 
chemical  principles  which  enter  into  the  constitution  of  the  living  being 
to  be  nourished ; secondly,  to  the  mode  in  which  these  are  combined 
to  form  tissues  and  organs ; thirdly,  to  the  atmosphere  which  surrounds 
it ; fourthly,  to  the  amount  of  waste  it  undergoes ; and  fifthly,  to  the 
structure  of  the  animal. 

The  results  of  numerous  investigations,  carried  on  with  the  view  of 
determining  these  points,  are  as  follows : — 

1st,  The  proximate  chemical  principles  required  for  the  nourishment 
of  man  are  the  albuminous,  the  fatty,  and  the  mineral  principles.  The 
first  of  these  are  substances  rich  in  nitrogen — such  as  fibrin,  caseine,  and 
albumen,  which  occur  both  in  the  vegetable  and  animal  worlds.  The 
second  are  substances  devoid  of  nitrogen,  consisting  of  the  animal  and 
vegetable  fats,  together  with  starch,  sugar,  and  gum,  which  by  deoxida- 
tion are  readily  converted  into  fat.  The  third  are  mineral  salts,  more 
especially  phosphate  of  lime  and  chloride  of  sodium.  It  has  been  proved 
that  every  kind  of  nutritive  food  must  contain  all  three  principles ; and 
that  the  absence  of  any  one  of  these  induces  starvation  and  death. 
W ater  is  also  necessary  as  a diluent. 


126 


PRINCIPLES  OF  MEDICINE. 


2d,  It  is  not  mere  nitrogenous  or  non-nitrogenous  kinds  of  food  that 
will  serve  for  nourishment,  as  is  theoretically  supposed  by  chemists. 
To  form  tissue,  these  chemical  constituents  must  be  converted  into 
albumen  and  oil,  so  as  to  produce  those  elementary  molecules  of  the 
chyle  which  constitute  the  formative  substance  of  the  blood  cells;  while 
the  mineral  constituents  must  be  dissolved  in  the  fluid  in  which  these 
float.  All  three  elements  exist  in  every  tissue ; but  the  fibrous  tissues 
abound  in  albumen,  the  glandular  organs  in  fat,  and  the  bones  in  mineral 
matter. 

3d,  The  amount  of  oxygen  in  the  atmosphere  greatly  influences  the 
quantity  of  food  required.  If  cold  and  condensed,  more  oxygen  will 
unite  with  the  tissues,  and  more  nourishment  will  be  required  to  meet 
the  demand  and  prevent  waste.  If  warm  and  rarefied,  the  appetite 
diminishes,  and  less  nutritious  food  is  necessary. 

4th,  Bodily  and  mental  exercise  causes  waste  of  tissue,  and  active  • 
men  require  more  food  than  those  who  spend  idle  lives.  An  able-bodied 
laborer,  requires  at  least  thirty -five  ounces  of  dry  nutritious  food ; nor 
can  soundness  of  health  be  kept  up  for  any  length  of  time  under  thirty 
ounces.  Sedentary  people,  it  is  true,  exist  upon  much  less;  nut  they 
are  weak,  and  generally  valetudinarians.  Of  mixed  solid  and  fluid  food 
there  are  required  daily  between  six  and  seven  pounds,  of  which  about 
five  pounds  on  an  average  consist  of  water. 

5th,  Living  beings  are  governed  in  their  selection  of  food  by  laws 
which  the  chemist  cannot  elucidate,  and  which  are  essentially  connected 
with  structure.  It  may  be  true,  as  Mulder  pointed  out,  that  the  albumen 
of  vegetables  and  of  animals  is  the  same  ; but  some  animals  can  only  live 
upon  one,  and  some  on  the  other.  The  chemist  has  not  explained  to  us 
why  the  carnivora  reject  vegetable  and  the  graminivora  refuse  animal 
food,  or  why  the  substances  which  contain  least  nutritious  matter  for 
one  class  of  creatures  are  the  chief  means  of  support  for  others.  Hence, 
though  chemistry  may  teach  us  much,  the  laws  of  dietetics  can  only  be 
arrived  at  by  the  physiologist. 

It  is  unnecessary  to  dwell  at  any  length  upon  the  fact  that  of  all  the 
causes  of  disease,  irregularity  in  diet  is  the  most  common.  Neither  need 
I do  more  than  merely  allude  to  the  equally  well-known  circumstance, 
that  of  all  the  means  of  cure  at  our  disposal,  attention  to  the  quantity 
and  quality  of  the  ingesta  is  by  far  the  most  powerful.  The  peculiar 
kind  of  interference  with  the  aliment,  which  various  diseases  require,  will 
be  illustrated  as  we  proceed  further. 

Mastication  and  Insalivation. — The  various  kinds  of  solid  organic 
food  are,  in  the  first  place,  broken  down  by  the  action  of  the  teeth,  jaws, 
tongue,  lips,  and  cheeks,  and  thereby  prepared  for  the  solvent  and 
chemical  actions  to  which  they  are  subsequently  exposed.  In  the  mouth 
they  are  intimately  mingled  with  the  saliva,  a viscous  fluid,  which  is  not 
only  necessary  for  the  proper  trituration  of  the  food,  as  well  as  for  articu- 
lation and  deglutition,  but  which  contains  an  animal  principle — ptyaline 
— that  has  been  proved  to  possess  a peculiar  action  on  starch,  converting 
it  into  dextrine  and  glucose.  Buccal  saliva,  however,  is  a mixed  fluid, 
and,  according  to  Bernard,  originates  from  three  sources,  each  of  which 
communicates  special  properties  to  it.  Thus  the  parotid  glands  secrete  a 


HEALTHY  AND  DISEASED  NUTRITION. 


127 


clear  liquid  fluid  necessary  for  mastication;  the  suhinaxillary  glands 
secrete  a more  gelatinous  fluid,  which  is  connected  with  the  sense  of 
taste;  and  the  sublingual  and  palatine  glands  furnish  a viscous,  mucous 
matter,  which  surrounds  the  bolus  externally,  and  causes  it  to  slide  more 
easily  through  the  fauces  and  oesophagus.  The  peculiar  action  on  starch 
is  not  confined  to  the  saliva,  although  unquestionably  strong  in  that  fluid 
as  we  find  it  in  the  mouth.  According  to  Bidder  and  Schmidt,  about 
three  and  a half  pounds  of  it  are  secreted  daily. 

Digestion  in  the  stomach  and  intestines. — The  food  prepared  in  the 
mouth  is  conveyed  by  the  excito-niotory  act  of  deglutition  into  the 
stomach — a bag  in  which  it  is  further  subjected  to  gentle  trituration  and 
the  solvent  action  of  the  gastric  juice.  This  fluid,  according  to  Bidder 
and  Schmidt  secreted  to  the  extent  of  about  fourteen  pints  daily,  is 
slightly  acid,  and  contains  a peculiar  animal  principle,  pepsine.  It  has 
an  extraordinary  solvent  power  on  the  albuminous  constituents  of  the 
food,  as  well  as  gelatin,  chondrin,  and  gluten,  which  when  dissolved  in 
it  produce  a material  called  peptone.  It  has  no  further  effect  on  fatty 
substances  than  that  of  liquefying  them  ; so  that  the  albuminous  and 
fatty  constituents  of  the  food  pass  into  the  duodenum  in  a liipiid  state, 
mingled  with  broken-down  portions  of  animal  and  vegetable  substances, 
in  the  form  of  a pulp,  called  chyme.  In  the  duodenum  this  is  mingled 
with  the  bile  and  pancreatic  juice.  The  former  neutralizes  and  evidently 
checks  the  further  action  of  the  gastric  juice,  and  enables  the  alkaline 
and  albuminous  pancreatic  fluid  to  operate  on  the  fatty  substances,  which, 
previously  liquefied,  are  at  once  minutely  divided  and  emulsionized  by  it. 
The  pancreatic  juice  also  changes  amylaceous  matters  into  sugar  within 
the  intestine,  and  may  assist  in  disintegrating  the  bile,  and  rendering  it 
more  of  an  excretory  product.  The  intestinal  juice  secreted  by  the 
Brunerian  and  other  glands  of  the  intestine  has  been  shown  by  Bidder 
and  Schmidt  to  be  capable  of  dissolving  the  albuminous  constituents  of 
the  food  which  have  escaped  the  solvent  action  of  the  stomach.  The 
same  observer  tells  us  that  about  three  and  a half  pounds  of  bile  are 
secreted  within  the  twenty-four  hours,  and  about  half  a pound  each  of 
pancreatic  juice  and  of  the  intestinal  juice.  The  large  amount  of  digestive 
fluid  secreted,  amounting  in  all  to  twenty-two  pounds  daily,  contain  little 
solid  matter,  and  are  evidently  designed  to  dissolve  and  act  chemically 
on  the  aliment.  While  some  of  them  operate  more  especially  on  one 
kind  of  substance,  others  do  so  more  particularly  on  anotner,  at  the  same 
time  that  they  are  not  exclusively  directed  to  one  object.  Thus  the  pm- 
creatic  juice  may  do  other  things  besides  emulsionizing  fat,  and  the 
intestinal  juice  may  perform  lower  down  in  the  canal  what  the  stomach 
has  failed  to  accomplish.  Then  the  importance  of  the  peristaltic  move- 
ments of  the  intestines  must  not  be  overlooked,  which  intimately  mix  the 
food  with  the  different  secretions,  and  constantly  propel  the  mass  from 
above  odwnwards  along  the  tube.  Lastly  all  the  various  processes  are 
necessary  to,  and  assist  one  another.  The  saliva,  when  swallowed,  stimu- 
lates the  secretion  of  gastric  juice,  as  does  this  in  its  turn  the  flow  of 
bile,  the  pancreatic  and  the  intestinal  juices;  and  hence  why  indigestion 
may  arise  from  a permanent  excess,  diminution,  or  perversion  of  any  of 
the  actions  concerned  in  the  digestive  process. 


128 


PRINCIPLES  OF  MEDICINE. 


2.  The  Formation  from  Alimentary  Matters  of  Nutritive  Fluids  the 
Bloody  and  the  Changes  it  undergoes  in  the  Lungs. 

Chyl'f  cation  and  Sanguification. — The  food,  prepared  and  acted  upon 
in  the  maimer  described,  is  gently  propelled  by  the  peristaltic  contractions 
of  the  alimentary  canal  along  its  interior,  and  is  at  the  same  time  pressed 
against  the  numerous  villi  that  project  from  all  parts  of  the  small  intestine. 
These  organs,  covered  with  a layer  of  conical  or  cylindrical  epithelial  cells, 
imbibe  the  more  finely  molecular  particles  of  the  chyme,  which  pass 
through  the  delicate  walls  of  the  cells,  and  may  be  seen  shortly  after 
digestion  collected  in  them.  The  fluid  of  the  chyme  is  for  the  most  part 
absorbed  by  the  blood-vessels.  From  the  epithelial  cells  the  molecular 
material  passes  through  the  basement  membrane  of  the  villi,  and  finds 
its  way  into  the  chyle  ducts,  whence  it  is  conveyed  to  the  lymphatic 
glands.  The  passage  of  the  molecular  matter  from  the  chyme  into  the 
epithelial  cells  is  probably  owing  to  endosmose,  assisted  by  the  mechani- 
cal pressure  exercised  by  the  muscular  walls  of  the  intestine.  The 
mechanism  of  the  transmission  of  the  molecular  chyle  into  the  primary 
chyle  duct  is  unknown. 

A lymphatic  gland  consists  of  pouches  or  sacs,  surrounded  by  a firm 
fibrous  membrane,  which  is  richly  supplied  by  blood-vessels.  The  interior 
of  these  pouches  or  sacs  contains  a molecular  fluid,  in  which  numerous 
nuclei  and  a few  cells  may  be  found  in  all  stages  of  development.  The 
glands  of  Peyer  I agree  with  Brucke  in  considering  as  the  first  series  of 
lymphatic  glands.  These  are  succeeded  by  other  series  in  the  mesentery 
All  of  them  are  connected  with  one  another  by  lacteals,  which  ultimately 
terminate  in  the  thoracic  duct.  They  serve  to  subject  the  molecular 
chyle  as  it  is  first  derived  from  the  chyme  to  the  action  of  these  glands. 
There  the  onward  flow  of  the  fluid  is  somewhat  delayed ; an  exchange 
takes  place  between  it  and  the  surrounding  blood,  and  nuclei  and  cells 
are  formed — more  especially,  however,  nuclei — by  molecular  aggregation. 
Hence  why,  on  cutting  into  these  glands  shortly  after  digestion,  and 
examining  microscopically  the  fluid  they  contain,  it  may  be  seen  that  a 
molecular  fluid  (first  described  by  Gulliver)  is  more  or  less  crowded  with 
naked  nuclei  which  resist  the  action  of  acetic  acid.  On  repeating  the 
observation  on  fluid  taken  from  the  thoracic  duct,  the  same  thing  is 
noticeable,  only  several  of  the  nuclei  are  now  flattened,  and  in  every 
point,  except  color,  closely  resemble  the  blood  corpuscles.  It  is  clear, 
therefore,  that  chylification  and  sanguification  are  perfected  through  the 
aetion  of  the  lymphatic  glands  upon  the  molecular  chyle ; that  in  them 
the  blood  corpuscles  are  formed,  and  conveyed  by  the  thoracic  duct  into 
the  circulation  at  a point  not  far  from  the  right  side  of  the  heart ; from 
thence  they  are  rapidly  propelled  into  the  lungs,  where,  on  being  exposed 
to  the  oxygen  of  the  atmosphere,  they  assume  color,  and  thereby  become 
the  colored  corpuscles  of  the  blood  (Fig.  57). 

There  are  other  glands  which  are  supplementary  to  this  funetion  of 
sanguification,  and  which  in  consequence  were  first  called  by  Hewson 
lymphatic  glands.  They  are  the  spleen,  thymus,  thyroid,  and  supra-renal 
bodies.  These  organs  also  contain  pouches  or  shut  sacs,  rich  in  a mole- 


HEALTHY  AND  DISEASED  NUTRITION. 


129 


cular  fluid,  and  multitudes  of  naked  nuclei.  Like  the  lymphatic  glands, 
also,  they  are  very  vascular,  and  are  connected  with  the  thoracic  duct  by 
numerous  minute  channels  or  lymphatics.  No  difference  whatever  can 
be  distinguished  between  the  glandular  contents  of  these  organs  and 
those  of  the  lymphatic  glands;  and  other  facts  connected  with  their 
morbid  states — more  especially  the  production  of  leucocytheinia — serve 
to  convince  us  that,  like  them,  they  are  connected  with  sanguification ; 
hence  their  modern  name  of  blood  glands.  The  whole  system  of  lym- 
phatic glands  may  be  said  to  secrete  or  form  the  blood  corpuscles, 
although  the  nature  of  the  blood,  as  a whole,  being  very  complex,  can- 
not be  clearly  understood  until  we  study  the  results  of  the  secondary 
digestion.  (See  Leucocythemia.) 

Respiration  and  Circulation. — The  lungs  are  organs  so  constructed 
as  to  expose  a large  surface,  covered  with  capillaries,  to  the  action  of  the 
atmosphere.  In  man,  the  air,  by  going  into  and  coming  out  of  the  lungs, 
loses  its  oxygen,  and  has  substituted  for  it  carbonic  acid,  which  is  given, 
off  in  the  proportion  of  1000  of  the  latter  to  1174  of  the  former  gas. 
The  excess  unites  with  the  hydrogen,  phosphorus,  sulphur,  and  other 
elements  of  the  tissues,  giving  rise  to  various  chemical  compounds,  and 
serving,  in  the  act  of  combination,  to  produce  much  of  the  animal  heat 
of  our  bodies.  The  amount  of  carbonic  acid  gas  given  off  by  the  lungs 
varies  according  to  circumstances.  Under  ordinary  circumstances,  the 
amount  would  yield  eight  ounces  of  solid  carbon  daily;  during  hard 
labor,  twelve  ounces ; and  during  sleep,  four  ounces. 

The  most  important  experiments  in  recent  times,  as  to  the  excretion 
of  carbonic  acid  by  the  lungs,  have  been  made  by  Dr.  E.  Smith  of 
London.  In  determining  the  influence  of  food,  he  made  numerous 
careful  experiments;  and  of  the  many  conclusions  he  arrived  at  on  this 
subject  I may  quote  the  following: — 1.  That  the  influence  of  food  is 
evident  soon  after  its  introduction  into  the  sj^stem,  and  attains  its  maxi- 
mum within  about  two  hours.  2.  Pure  starch  and  fat  do  not  increase 
the  quantity  of  carbonic  acid  evolved,  but  on  the  contrary,  the  latter 
somewhat  lessens  it.  3.  The  cereals,  however,  which  contain,  besides 
starch,  albuminous  products,  gluten  and  sugar,  increase  the  excretion  of 
carbonic  acid  to  the  extent  of  two  grains  per  minute.  4.  Milk,  sugar, 
tea  and  coflee  do  the  same.  5.  Alcohol,  rum,  and  malt  liquors  increase 
it  to  the  extent  of  one  grain  per  minute ; but  brandy  and  gin,  especially 
the  latter  lessen  it.  6.  Foods  may  be  classified  into  non-excitants  and 
excitants  as  regards  the  excretion  of  carbonic  acid  gas.  The  non-excitants 
are — starch,  fat,  some  alcohols,  and  coffee-berries.  The  excitants  are — 
sugar,  milk,  cereals,  potatoes,  gluten,  gelatin,  fibrin,  albumen,  tea,  coffee, 
cocoa,  chicory,  alcohol,  rum,  and  some  wines. 

These  results  are  remarkable  as  distinguishing  starch  and  fat  as  non- 
excitors  of  increased  carbonic  acid  in  expiration,  thus  confirming  what  I 
have  long  maintained  on  histological  grounds — viz.,  that  fats  and  oils 
serve  largely  to  build  up  the  tissues,  and  are  not,  as  Liebig  endeavored 
to  show,  merely  respiratory  food.  They  are  further  remarkable  in 
showing  that  alcohol  and  rum  increase,  while  brandy  and  gin  diminish, 
the  carbonic  acid — effects  which,  if  correct,  are  wholly  inexplicable. 

The  effect  of  respiration  on  the  blood  is  to  give  color  to  the  free 
9 


1.30 


PRINCIPLES  OF  MEDICINE. 


nuclei  in  mammals,  and  to  the  cells  in  the  other  vertebrata  which  join 
the  blood  from  the  chyliferous  system.  It  also  produces  those  differences 
which  characterise  arterial  from  venous  blood.  The  only  novel  point  I 
may  allude  to  is  the  fact  shown  by  Bernard,  that  venous  blood  coming 
from  glands  in  action,  is  red  like  arterial  blood,  and  like  it,  owes  its  color 
to  excess  of  oxygen.  A perfect  chemical  theory  of  respiration  is  still  a 
desideratum. 

Hie  circulation  of  the  blood  is  kept  up  by  the  various  motor  powers 
of  the  heart,  arteries,  capillaries,  veins,  and  lungs,  the  nature  and  amount 
of  which  we  cannot  here  dwell  upon  at  length. 

The  most  careful  investigations  made  in  modern  times  by  Poissieulle, 
Valentin,  and  Ludwig,  as  to  the  static  force  of  the  heart  and  arteries, 
show  that  it  is  equal  to  about  four  pounds  on  the  square  inch.  Assum- 
ing the  internal  superficies  of  the  left  ventricle  to  be  about  thirteen  inches, 
this  would  give  fifty-two  pounds  as  the  force  it  exerts.  Now,  Hales, 
more  than  a hundred  years  ago,  calculated  it  to  be  fifty- one  and  a half 
pounds,  which  must  not  only  satisfy  us  of  his  accuracy  as  an  observer, 
but  convince  us  that  no  change  has  occurred  in  the  force  of  the  pulse, 
either  in  man  or  animals,  during  that  time.  The  importance  of  this  fact 
I shall  allude  to  subsequently.  The  experiments  of  Marey  indicate  that 
there  are  two  forces  propelling  the  fluid — one,  direct,  dependent  on  the 
heart  or  pump;  the  other  secondary,  caused  by  the  recoil  of  the  dis- 
tended blood-tube.  The  intensity  of  the  latter  force,  however,  gradually 
diminishes  as  the  wave  of  fluid  recedes  from  the  source  of  afflux,  while 
the  time  of  the  pulse  remains  the  same. 

What  has  most  attracted  attention  in  recent  times  is  a more  correct 
explanation  of  the  phenomena  formerly  called  determination  of  blood. 
This  afflux  of  the  blood  to  different  parts  of  the  system,  instead  of  being 
sent  by  a vis  a tergo,  is  in  truth  drawn  or  attracted  there  by  a vis  a fronte. 
This  force  originates  in  the  chemical  and  vital  changes  which  go  on  in 
the  ultimate  molecules  of  the  part.  Stimulation  or  irritation  of  texture 
is  the  exciting  cause,  and  the  result  is  a flow  of  fluid  towards  the  tissues 
or  organs  requiring  it.  Examples  are  seen  in  the  ascent  of  sap  in  plants, 
in  the  turgid  mamma  during  lactation,  in  the  gums  of  the  infant  when 
teething,  in  the  integuments  surrounding  the  annual  growth  of  the  stag’s 
horn,  in  the  circulation  of  the  acardiac  foetus,  in  the  female  sexual  organs 
during  menstruation,  in  the  portal  circulation  of  the  liver,  and  in  the 
congestion  of  irritated  texture  preeeding  inflammation.  In  all  these 
cases,  there  is  no  heart,  pulsatile  vessel,  or  pumping  apparatus  which  can 
especially  force  the  fluid  into  the  parts  referred  to,  and  therefore  they 
must  draw  or  attract  it  by  a force  the  result  of  molecular  action. 

.3.  The  Passage  of  Fluid  from  the  Blood  to  he  transformed  into  the  Tissues. 

From  the  blood  so  formed  and  elaborated  there  are  constantly 
passing  off,  through  the  capillaries,  matters  which  are  transformed  into 
the  tissues  and  secretions.  It  is  necessary  that  this  should  take  place  to 
an  amount  proportionate  to  the  matter  supplied  to  the  blood  by  assimila- 
tion on  the  one  hand,  and  that  dissipated  by  waste  on  the  other.  If  more 
or  less  be  given  off,  a morbid  condition  is  occasioned.  Thus,  an  increased 


HEALTHY  AND  DISEASED  NUTRITION. 


131 


amount  in  a part  gives  rise  to  hypertrophies,  a diminished  amount  pro- 
duces atrophy. 

When  we  endeavor  to  ascertain  in  what  way  this  is  accomplished, 
it  is  clear  it  cannot  be  attributed  to  any  power  in  the  blood  or  blood- 
vessels, as  these  are  the  same  in  textures  and  glands  the  most  diversified. 
We  are  therefore  obliged  to  ascribe  it  to  an  influence  seated  in  the 
textures  themselves.  This  iu  its  nature  must  be  attractive  and  selective: 
attractive,  in  so  far  that  matters  are  drawn  from  the  circulation  to  be 
added  to  the  textures ; and  selective,  in  so  far  as  particular  constituents 
of  the  circulating  fluid  are  chosen  by  one  tissue,  and  different  ones  by 
another.  This  power  is  not  seated  in  cells  only,  as  has  been  supposed, 
but  iu  all  the  tissues.  Muscle  which  is  molecular,  gland  which  is  cellular, 
tendon  which  is  fibrous,  and  brain  which  is  tubular — all  possess  it.  In 
cartilage,  we  see  it  most  powerful  in  the  inter-cellular  tissue,  which  is  the 
first  to  attract  from  the  blood  the  fluid  loaded  with  mineral  particles. 
Hence  it  seems  to  be  as  strong  relatively  in  the  minutest  molecule  as  in 
the  largest  cell.  This  power  of  growth,  then,  of  which  secretion  is  a 
modification,  is,  like  the  power  of  contractility  and  of  sensibility,  an  ulti- 
mate fact  in  physiology.  For  the  conditions  regulating  it,  I cannot  do 
better  than  refer  you  to  the  able  writings  of  Mr.  Paget. 

It  often  happens  that  the  attractive  and  selective  power  in  the  tissues 
is  deranged,  so  as  to  produce  increase  or  diminution  in  growth  or  in 
secretion,  general  or  partial.  Not  unfrequently  the  selective  power 
appears  to  be  lost,  and  the  attractive  power  so  much  increased,  that  the 
liquor  sanguinis  is  drawn  out  through  the  vessels,  so  that  its  fibrin  coagu- 
lates in  a mass  outside  them.  This  result,  preceded  or  accompanied  by 
certain  changes  in  the  vessels  themselves,  and  more  or  less  stagnation  of 
the  current  of  blood,  constitutes  the  phenomena  hitherto  described  as 
inflammation.  Under  these  circumstances,  other  cells  and  tissues,  alto- 
gether foreign  to  the  healthy  condition  of  the  economy,  are  produced  in 
what  is  now  called  the  exudation,  although  the  same  general  laws  of 
growth  and  transformation  preside  over  the  abnormal  as  over  the  normal 
})roducts.  In  this  manner  pus  and  cancer  cells  may  be  formed,  or  fibrous, 
cartilaginous,  osseous,  and  other  tissues  causing  different  kinds  of  morhid 
growth. 

4.  The  Disappearance  of  the  Transformed  Tissues  and  their  Re-ahsorption 

into  the  Blood. 


The  secondary  digestion. — Growth  having  been  effected,  it  is  necessary 
that  the  particles  of  the  tissues  which  have  fulfilled  their  function  and 
are  worn  out  should  be  removed  to  give  place  to  new  ones.  This  con- 
stitutes the  so-called  secondary  digestion  ^ that  is,  in  the  same  way  that  a 
piece  of  food — say  flesh — is  broken  down,  rendered  molecular  and  fluid, 
and  is  absorbed  into  the  blood  to  add  bulk  to  the  frame,  so  is  our  own 
living  flesh  constantly  breaking  down,  rendered  molecular  and  fluid,  and 
absorbed  into  the  blood,  to  be  finally  thrown  out  of  the  system.  Thus  the 
blood  receives  matter  from  two  sources — the  primary  and  secondary  diges- 
tions ; and  is  continually  giving  off  matter  in  two  directions — one  to  build 
up  the  tissues  and  form  the  secretions,  the  other  to  produce  the  excretions. 


132 


PRINCIPLES  OF  MEDICINE. 


Chemical  constitution  of  healthy  Hood. — Numerous  analyses  have 
been  made  of  this  fluid  by  the  most  distinguished  chemists,  and  yet  no 
two  of  them  have  been  alike.  This  is  explained  by  the  fact  that  the 
chemical  constitution  of  blood  must  constantly  be  undergoing  changes, 
not  only  in  various  individuals,  but  in  the  same  individual,  from  differ- 
ences in  diet,  assimilation,  respiration,  excretion,  exercise,  and  the 
numerous  circumstances  which  influence  the  animal  economy.  It  also 
varies  in  the  two  sexes.  From  a calculation  deduced  from  numerous 
analyses,  I think  you  may  adopt  the  following  conclusions  with  safety  as 
to  the  chemical  constitution  of  the  blood  in  health: — 1.  That  the  great 
bulk  of  the  blood  is  made  up  of  water,  varying  from  760  to  800  parts  in 
1000  parts.  2.  That  the  fibrin  is  very  small  in  quantity,  varying  from 
li  to  3 in  1000  parts.  3.  That  the  amount  of  albumen  ranges  between 
60  to  70  parts.  4.  That  the  amount  of  corpuscles  ranges  between  130 
to  150  parts.  6.  That  the  extractive  matter  and  fat  range  from  1 to  4 
parts.  6.  That  the  saline  matters  range  from  5 to  10  parts. 

Function  of  the  blood. — The  blood  circulating  through  the  body  may 
be  regarded  as  a river  flowing  by  numerous  canals  through  a populous 
city,  which  not  only  supplies  the  wants  of  its  inhabitants,  but  conveys 
from  them  all  the  impurities  which  through  various  channels  find  their 
way  into  its  stream.  The  chief  supplies  enter  the  circulation,  as  we  have 
previously  seen,  in  the  form  of  water  and  of  blood  corpuscles  from  the 
primary  digestion.  These  receive  oxygen  in  the  lungs,  where  they  be- 
come colored,  are  sent  all  over  the  body,  and  in  the  ultimate  capillaries 
yield  up  their  oxygen,  which  combines  with  carbon  and  other  chemical 
constituents  of  the  tissues  to  form  numerous  combinations.  After  a time 
they  are  dissolved  in  the  liquor  sanguinis,  which  fluid  they  serve  to 
elaborate.  The  blood  also  receives  and  holds  in  solution  the  products  of 
the  secondary  digestion,  so  that  it  is  a highly  elaborated,  viscous,  and 
complex  organic  liquid.  It  is  the  blastema  from  which,  on  the  one  hand, 
the  living  molecules,  nuclei,  cells,  and  other  elements  of  the  tissues,  are 
attracting  new  matter  to  supply  the  place  of  what  is  lost,  while  on  the 
other,  they  are  imparting  to  it  old  matter  which  has  sufficiently  served  the 
purposes  of  the  frame.  In  what  manner  this  important  fluid  utilizes  the 
various  products  it  receives  from  both  sources  is  as  yet  unknown.  All 
that  w^e  can  determine  is  that  the  whole  is  in  incessant  motion,  rushing 
rapidly  out  from  the  heart  through  the  arteries,  divided  into  minute 
streams  by  capillaries  in  the  tissues,  returning  more  slowly  by  the  veins 
— a circuit  through  the  frame  completed  in  half  a minute — subjected  to 
the  constant  collision  of  about  two  billions  of  semi-solid  corpuscles,  inces- 
santly undergoing  chemical  alterations  when  exposed  to  the  peculiar 
action  of  every  organ  in  the  body ; and  while  giving  off  one  or  more  of 
its  constituent  principles  in  this  or  that  tissue  as  it  passes  through  it, 
at  the  same  time  taking  up  those  wdiich  have  been  worn  out  in  the 
service  of  the  economy.  Blood,  therefore,  is  the  mixture  of  the  histo- 
genetic  and  histolytic  processes  of  the  body.  It  is  in  the  circulation  they 
mingle  together,  and  it  is  there  consequently  we  must  look  for  an  ex- 
planation of  numerous  morbid  conditions  which  derangements  in  so  nicely 
balanced  an  organic  fluid  may  be  expected  to  produce. 

Morbid  conditions  of  the  blood. — I need  not  dwell  upon  the  vast 


HEALTHY  AND  DISEASED  NUTRITION. 


133 


importance  from  the  earliest  times  has  been  attached  to  alterations 

in  the  blood  as  the  cause  of  disease.  The  red,  white,  yellow,  and  black 
bloods  of  Hippocrates — the  acid  and  alkaline  blood  of  Van  Helinont — 
the  error  loci  among  the  blood  corpuscles  of  Boerhaave — and  the  sthenic 
and  asthenic  states  of  the  constitution  contended  for  by  Brown  and 
Broussais — have  each  in  turn  regulated  the  medical  practice  of  civilized 
nations.  In  recent  times,  most  laborious  efforts  have  been  made  by 
means  of  the  microscope  and  of  chemical  researches  to  investigate  the 
exact  condition  of  the  blood  in  disease.  The  changes  which  occur 
structurally  have  been  previously  noticed  (see  p.  92) ; and  the  discovery 
of  leucocythemia  by  myself,  of  the  softening  and  breaking  up  of  blood 
coagula  by  Gulliver,  of  the  effect  of  emboli  by  Virchow,  and  other  mor- 
bid conditions  of  that  fluid,  will  be  subsequently  referred  to. 

Chemical  alierations  of  the  hlood  in  disease. — The  most  laborious 
investigations  into  this  subject  have  been  made  by  the  French  chemists 
and  pathologists,  more  especially  by  Andral  and  Gavarret,  in  1840,  and 
by  Becquerel  and  Bodier,  in  1844,  whose  researches  have  for  the  most 
part  been  confirmed  by  subsequent  investigators.  The  results  which  the 
latter  chemists  arrived  at  are  as  follows  : — 1st,  Venesection  greatly  di- 
minishes the  number  of  the  blood  corpuscles,  increases  the  amount  of 
water,  slightly  diminishes  the  albumen,  but  in  no  way  affects  the  fibrin, 
extractive  matters,  or  salts.  2d,  That  plethora  is  a simple  increase  of 
all  the  constituents  of  the  blood.  3d,  That  anaemia  is  in  truth  a mis- 
nomer, but  is  used  in  the  sense  of  a diminished  number  of  the  corpuscles, 
or  spanaemia.  4th,  That  inflammation  increases  the  amount  of  the 
fibrin  from  3 to  10  in  1000  parts,  doubles  the  quantity  of  cholesterine, 
and  diminishes  the  albumen.  5th,  That  the  fibrin  is  diminished  in 
fevers,  exanthematous  disorders,  intoxicatioo,  starvation,  and  purpura 
haemorrhagica.  6th,  When  any  secretion  is  checked,  its  essential  prin- 
ciples accumulate  in  the  blood.  7th,  The  albumen  of  the  blood  is 
diminished  in  Bright’s  disease,  in  cardiac  dropsy,  and  in  puerperal  fever. 

These  conclusions,  founded  on  a large  number  of  data,  are  most  im- 
portant, and,  as  we  shall  subsequently  see,  while  opposed  to  former 
views  of  medical  practice,  especially  in  acute  inflammatory  diseases,  com- 
pletely harmonize  with  the  results  of  modern  experience. 

5.  The  Excretion  of  the  Effete  Matters  from  the  Body  in  Various  Forms 
ayid  hy  Different  Channels. 

The  matters  admitted  into  the  blood  as  the  result  of  the  secondary 
digestion  circulate  with  that  fluid,  but  are  soon  separated  from  it  in 
various  foiuns,  to  be  conducted  out  of  the  system  by  different  channels. 

1st,  In  the  form  of  carbonic  acid  and  watery  vapor  by  the  lungs. 

2d,  Through  the  liver,  and  this  in  the  form  of  bile,  fat,  and  hydrated 
starch,  whereby  a large  amount  of  hydro-carbon  is  excreted.  Of  the  bile 
we  have  already  spoken.  Fat  is  found  in  considerable  quantity  in  the 
liver,  giving  rise,  in  cases  where  there  is  excess  of  heat  and  food  with 
little  exercise,  to  a want  of  balance  between  the  hepatic  aod  pulmonary 
excretions.  Thus  fatty  liver  is  found  in  all  stall-fed  animals,  and  is 
likely  to  be  present  among  Europeans  in  India,  and  drunkards  at  home. 


134 


PRINCIPLES  OF  MEDICINE. 


Lastly,  it  has  been  shown  by  Bernard  that  a large  quantity  of  hydrated 
starch  {glycogen)  is  continually  forming  in  the  liver,  which,  he  thinks,  on 
contact  with  the  blood,  is  transformed  into  sugar,  and  in  health  is  sepa- 
rated as  carbonic  acid  by  the  lungs.  If  this  be  in  excess,  or  if  the  action 
of  the  lungs  be  defective,  it  passes  off  as  sugar  by  the  kidneys,  constitut- 
ing diabetes.  This  view,  though  supported  with  great  ingenuity,  and 
apparently  unanswerable  experimental  arguments,  has  recently  been 
questioned  by  Dr.  Pavy,  who  has  endeavored  to  show  that  the  phe- 
nomena described  by  Bernard  are  post  mortem^  and  do  not  occur  in  the 
living  animal  (see  Diabetes.)  But  however  the  products  of  the  liver 
may  ultimately  pass  out  of  the  system,  its  chief  function  must  be  regarded 
as  excretory. 

3d,  Through  the  kidneys  there  pass  off  from  the  body  a large 
amount  of  water,  of  earthy  salts,  and  especially  two  compounds  rich  in 
nitrogen — viz,,  urea  and  uric  acid.  These  constituents  may  be  derived 
from  either  the  primary  or  secondary  digestion  ; so  that  the  functions  of 
the  kidneys  are  altogether  excretory. 

4th,  The  skin  is  constantly  excreting  water  and  oil,  a minute 
quantity  of  carbonic  acid,  and  a mass  of  gelatine  and  horny  matter,  in 
the  form  of  epidermis,  hair,  nail,  and  other  integumentary  appendages. 

5th  and  lastly.  In  addition  to  the  residue  of  the  food,  there  are  dis- 
charged from  the  bowels  fatty  and  earthy  matters. 

The  amount  of  excretory  matters  separated  in  this  way  may  be  esti- 
mated as  follows: — Of  carbonic  acid  there  are  given  off  about  two  pounds, 
or  seven  cubic  feet,  of  which  an  ounce  and  a half  may  be  separated  by 
the  skin.  Of  water  there  are  about  six  pounds  sepa  ated,  one  half  by 
the  urine  and  faeces,  and  the  other  half  by  the  lungs  and  skin.  The 
urine  contains  ten  times  as  much  as  the  faeces ; and  the  skin  gives  off 
twice  as  much  as  the  lungs  or  somewhat  more.  As  it  is  calculated  that 
only  five  pounds  pass  into  the  body  mixed  with  the  fluid,  the  extra  pound 
is  supposed  to  be  formed  in  the  system  by  the  union  of  oxygen  with 
water.  Of  urea  an  ounce  is  separated  in  the  urine  daily  of  an  adult  man, 
together  with  eight  or  ten  grains  of  uric  acid.  It  is  by  these  substances, 
which  contain  about  fifty  per  cent  of  nitrogen,  that  the  azote  which  enters 
the  body  is  almost  altogether  separated  from  it.  The  earthy  salts  pass 
out  in  minute  quantity  dissolved  in  the  sweat,  and  are  given  off  more 
largely  by  the  urine,  which  contains  daily  four  drachms  and  a half  of 
chloride  of  sodium,  four  drachms  of  sulphate  of  soda  and  potash,  two 
drachms  of  acid  phosphate  of  soda,  and  one  drachm  of  phosphate  of  lime 
and  magnesia.  In  the  faeces  another  four  or  six  drachms  of  mineral 
matter  may  be  passed  daily,  the  chief  portion  of  which  is  derived  from 
the  residue  of  the  food.  Besides  the  substances  named,  a certain  quan- 
tity of  fatty,  coloring,  extractive,  and  other  matters  is  excreted,  the 
amount  of  which  has  not  been  yet  estimated. 

In  this  way,  the  albuminous,  fatty,  and  mineral  ingredients  of  the 
food,  after  having  entered  the  body  to  form  blood,  and  through  it  to 
build  up  tissue,  is  ultimately  ejected  from  the  economy,  after  having 
undergone  a series  of  histogenetic  and  histolytic  molecular  changes,  and 
been  metamorphosed  by  chemical,  mechanical,  and  vital  agencies.  The 


HEALTHY  AXD  DISEASED  NUTRITION. 


135 


mode  in  which  this  is  accomplished  is  now  tolerably  well  known. 
D )ubtless  several  points  have  yet  to  be  determined,  and  numerous- 
details  require  investigation.  But  the  great  function  of  nutrition,  as  I 
have  now  placed  it  before  you,  may  be  said  to  be  established  in  science. 
In  the  same  manner  that  the  chemist,  following  Dumas,  recognises  in 
nature  at  large  the  exchanges  which  are  constantly  going  on  between  the 
mineral,  the  vegetable,  and  the  animal  worlds — the  earth  and  air  build- 
ing up  vegetables  : these  building  up  animals,  and  these  on  their  decom- 
position being  again  restored  to  earth  and  air — so  does  the  physiologist  in 
each  animated  creature  trace  the  food  through  its  changes  until  it  is  con- 
verted into  tissue,  has  enjoyed  life  for  a time,  and  is  then  decomposed, 
returnino;,  thou^jh  in  an  altered  form,  to  the  external  world  whence  it  came. 

The  molecular  law  of  development,  formerly  described,  is  singularly 
well  illustrated  by  the  function  of  nutrition  as  now  explained.  Food 
consisting  of  well-formed  organic  matter,  animal  and  vegetable,  is  disin- 
tegrated by  the  primary  digestion.  The  histolytic  molecules  so  produced 
become  histogenetic  ones,  and  build  up  the  blood  corpuscles.  These  are 
in  turn  disintegrated  and  dissolved  to  form  the  liquor  sanguinis,  but 
once  more  other  molecules  are  obtained  from  it  to  keep  up  the  growth  of 
the  tissues,  whether  nutritive  or  secretory.  The  histogenetic  molecules 
so  produced  are  again  rendered  histolytic  by  the  secondary  digestion, 
and,  circulating  in  the  blood,  undergo  various  combinations  before  being 
excreted  from  the  economy.  In  this  manner  the  great  function  of  nutri- 
tion is  shown  to  be  essentially  molecular. 

Animal  Heat. — We  must  not  forget  that  the  changes  we  have  re- 
ferred to — that  is  to  say,  the  various  metaphormoses  of  the  tissues  and 
their  chemical  combinations — produce  the  animal  heat  of  the  body. 
One  of  the  most  important  contributions  to  science  of  Liebig  is  unques- 
tionably the  demonstration  that  the  union  of  oxygen  with  the  blood  in 
the  lungs,  and  the  formation  of  carbonic  acid  in  the  capillaries  united, 
produce  sufficient  heat  to  account  for  what  is  found  in  the  animal  body. 
Other  causes,  however,  co-operate,  among  which  muscular  contraction  is 
important.  Helmholz  has  shown  that  heat  is  thereby  generated  in  con- 
tractile muscle  recently  cut  from  the  animal,  and  therefore  unconnected 
with  a circulation.  These  metaphormoses  further  produce  the  force  and 
energy  which  are  applied  in  so  many  forms  and  combinations  to  maintain 
the  physical  and  vital  actions  of  the  economy. 

From  the  foregoing  considerations,  it  follows  that  an  eliminative 
function  is  to  a certain  extent  brought  about  by  all  the  processes  of 
growth  referred  to,  and  that  there  can  be  no  change,  however  limited, 
that  is  not  necessarily  associated  with  a general  one  in  the  system  at 
large.  As  all  the  nutritive  functions  are  connected  with  one  another, 
an  excess  or  diminution  of  local  growth,  by  subtracting  from  or  adding 
to  the  constituents  of  the  blood,  must  produce  an  alteration  in  that  fluid 
both  as  to  quantity  and  quality.  The  idea  of  Treviranus,  viz.,  “ that 
each  single  part  of  the  body,  in  respect  of  its  nutrition,  stands  to  the 
whole  body  in  the  relation  of  an  excreted  substance,”  has  been  ably 
shown  by  Mr.  Paget  to  account  for  various  processes  in  health,  under  the 
name  of  “ complemental  nutrition.”  The  same  notion  has  been  still 
* Lectures  on  Surgical  Pathology.  Lecture  2. 


136 


PKINCIPLES  OF  MEDICINE. 


furtlier  extended  by  Dr.  William  Addison,  who  correctly  points  out,  that 
in  the  distinctive  eruptive  fevers,  such  as  small-pox,  the  numerous  minute 
abscesses  in  the  skin  eliminate  the  morbid  poison,  which  formerly  existed 
in  the  blood,  and  are  in  this  way  essential  to  the  cure.  This  provident 
action  he  denominates  “ cell  therapeutics.”  * Hence  they  are  fixed  pro- 
cesses in  abnormal  as  in  normal  nutrition,  with  which  it  is  essential  for 
the  medical  practitioner  to  be  acquainted,  in  order  that,  instead  of  oper- 
ating blindly  or  empirically,  he  may  act  scientifically,  or  in  accordance 
with  natural  laws. 

Further  we  cannot  avoid  observing  that  the  process  of  nutrition  is  a 
continuous  round,  which  in  the  natural  world  may  be  said  to  commence 
with  the  reception  and  terminate  with  the  preparation  of  aliment,  vege- 
table or  animal;  that  this  is  observable  not  only  in  the  “ chemical 
balance  of  organic  nature,”  so  beautifully  described  by  Dumas,  but  in 
the  incessant  chemical  compositions  and  decompositions,  as  well  as 
structural  formations  and  disintegrations,  which  are  peculiar  to  all  vital 
entities.  If  so,  it  must  be  apparent  that  our  knowledge  of  the  animal 
economy,  and  of  the  diseases  to  which  it  is  liable,  can  only  be  elucidated 
by  investigating  the  nature  of  such  chemical  and  structural  changes, 
together  with  the  necessary  relations  that  each  one  bears  to  the  others  ; 
and  that  it  is  on  such  kind  of  knowledge  alone  that  medicine,  as  a 
scientific  art,  can  ever  repose  in  security. 

We  can  now  readily  understand  how  derangement  in  one  stage  of 
the  nutritive  process  more  or  less  affects  the  others.  Thus,  if  alimentary 
matters  are  not  furnished  in  sufficient  quantity,  and  of  a proper  quality, 
the  blood  is  rendered  abnormal,  and  it  necessarily  follows  that  the 
matters  it  gives  off  will  be  abnormal  also,  and  its  subsequent  transforma- 
tions more  or  less  modified.  Again,  if  secretion  be  checked,  the  blood  is 
not  drained  of  its  effete  matter ; and  if  excretion  be  prevented,  the  secre- 
tions themselves  may  enter  the  blood,  and  act  upon  it  as  a poison. 

A deceased  or  morbid  state  of  the  blood,  therefore,  may  arise  from 
either  of  the  stages  of  nutrition  which  we  have  described  being  rendered 
irregular,  or  otherwise  abnormal.  In  whatever  part  of  the  circle  inter- 
ruption takes  place,  it  will,  if  long  continued,  affect  the  whole.  Thus,  a 
bad  assimilation  of  food  produces  through  the  blood  bad  secretions  and 
excretions,  whilst  an  accidental  arrest  of  one  of  the  latter  reacts  through 
the  blood  on  the  assimilating  powers.  The  forms  of  dbease  thus  arising 
may  be  endless,  but  as  regards  nutrition,  they  may  all  be  traced  to  the 
following  causes  : — 

1.  An  improper  quantity  or  quality  of  the  food. 

2.  Circumstances  preventing  assimilation  or  impeding  respiration. 

3.  Altered  quantity  or  quality  of  nutritive  matters  passing  out  of 
the  blood. 

4.  The  accumulation  of  effete  matters  in  the  blood. 

5.  Obstacles  to  the  excretion  of  these  from  the  body. 

Examples  in  which  each  of  these  causes,  separately  or  combined, 
have  occasioned  disease,  must  have  occurred  to  every  practitioner.  It  is 
true  that  all  general  diseases  are  acconq3anied  by  certain  changes  in  the 
* Addison  on  Cell  Therapeutics.  1856. 


HEALTHY  AND  DISEASED  INNERVATION. 


137 


blood,  but  these  changes  are  to  be  removed,  not  by  operating  on  that 
fluid  directly,  but  by  obviating  or  removing  those  circumstances  which 
have  deranged  the  stage  of  nutrition  primarily  affected.  For  instance,  a 
very  intense  form  of  disease  may  be  produced  in  infants,  through  im- 
proper lactation.  The  remedy  is  obvious ; we  procure  a healthy  nurse. 
Ischuria  is  followed  by  coma,  in  consequence  of  the  accumulation  of  urea 
in  the  blood ; we  give  diuretics  to  increase  the  flow  of  urine,  and  the 
symptoms  subside.  In  the  one  case  we  furnish  the  elementary  principles 
necessar}'  for  nutrition ; in  the  other,  we  remove  the  residue  of  the  pro- 
cess. In  both  cases  the  blood  is  diseased,  but  its  restoration  to  health 
is  produced  by  acting  on  a knowledge  of  the  causes  which  led  to  its 
derangement. 

In  the  same  manner  we  might  illustrate  the  indications  for  correct 
practice  in  the  other  classes,  of  causes  tending  to  derange  the  blood. 
Thus,  although  there  be  a proper  quantity  or  quality  of  food,  there  may 
be  circumstances  which  impede  its  assimilation  ; for  instance,  a too  great 
acidity  or  irritability  of  the  stomach — the  use  of  alcoholic  drinks — 
inflammation  or  cancer  of  the  organ.  It  is  the  discovery  and  removal 
of  these  that  constitute  the  chief  indications  for  the  scientific  practitioner. 
Again,  the  capillary  vessels  become  over-distended  with  blood,  and  the 
exudation  of  liquor  sanguinis  to  an  unusual  amount  takes  place,  con- 
stituting inflammation.  How  is  this  to  be  treated  ? In  the  early  stage 
topical  bleeding,  if  directly  applied  to  the  part,  may  diminish  the  con- 
gestion, and  the  application  of  cold  will  check  the  amount  of  exudation. 
But  the  exudation  having  once  coagulated  outside  the  vessels,  acts  as  a 
foreign  body,  and  the  treatment  must  then  be  directed  to  furthering  the 
transformations  which  take  place  in  it,  and  facilitating  the  absorption 
and  excretion  of  effete  matter.  This  is  accomplished  by  the  local  appli- 
cation of  heat  and  moisture — the  internal  use  of  neutral  salts  to  dissolve 
the  increase  of  fibrin  in  the  blood,  and  the  employment  of  diuretics  and 
purgatives  to  assist  its  excretion  by  urine  or  stool. 

The  general  principle  we  are  anxious  to  establish  from  this  general 
sketch  of  the  nutritive  functions  is — that  diseases  of  nutrition  and  of  the 
blood  are  only  to  be  combated  by  an  endeavor  to  restore  the  deranged 
processes  to  their  healthy  state,  in  the  order  in  which  they  were  impaired ; 
that  a knowledge  of  the  process  of  nutrition  is  a preliminary  step  to  the 
proper  treatment  of  these  affections  ; that  the  theory  of  acting  directly 
on  the  blood  is  incorrect ; and  that  an  expectant  system  is  as  bad  as  a 
purely  empirical  one. 


OF  THE  GENERAL  LAWS  OF  INNERVATION  IN  HEALTH 
AND  DISEASE. 

The  function  of  innervation  is  also  made  up  of  the  performance  of 
various  actions,  widely  different  from  each  other,  although  associated 
together.  These  actions  lead  to  the  manifestation  of  intelligence,  sensa- 
tion, and  combined  motion.  But  as  the  connection  between  these  is  not 
capable  of  exhibiting  such  an>  order  of  sequence  as  has  been  made  appa- 


138 


PRINCIPLES  OF  MEDICINE. 


rent  among  the  nutritive  processes,  it  will  be  necessary  to  describe  them 
in  a different  manner. 


General  Anatomy  and  Physiology  of  the  Nervous  System. 

Structure  and  Arrangement  of  the  Nervous  System. — To  the  eye, 
the  nervous  system  appears  to  be  composed  of  two  structures—  the  grey 
or  ganglionic,  and  the  white  or  fibrous.  The  ganglionic,  when  examined 
under  high  powers,  may  be  seen  to  be  composed  of  nucleated  cells,  vary- 
ing greatly  in  size  and  shape,  mingled  with  a greater  or  less  number  of 
nerve  tubes,  also  varying  in  calibre.  One  important  fact  with  regard  to 
these  corpuscles  is,  that  many  of  them  may  be  demonstrated  to  throw 
out  prolongations,  which  may  be  seen  in  well-preserved  preparations  to 
be  in  direct  communication  with  the  central  band  or  axis  of  Remak  and 
Purkinje  within  the  fibres.  The  so-called  fibres,  indeed,  may  be  shown 
to  consist  of  minute  tubes,  which  are  smallest  towards  the  periphery  of 
the  cerebrum,  larger  towards  its  base,  and  largest  in  the  nerves.  They 
are  of  three  kinds — 1st,  Finely  cylindrical,  as  observed  in  the  optic  and 
auditory  nerves;  2d,  Varicose,  as  in  the  white  substance  of  the  cerebral 
lobes  and  of  the  spinal  cord  ; and  3d,  Larger  and  of  regular  size  through- 
out, as  in  the  nerves.  There  are  also  bundles  of  gelatinous  or  flat  fibres, 
the  nature  of  which  is  much  disputed,  very  common  in  the  olfactory 
nerve  and  sympathetic  system  of  nerves. 

The  general  arrangement  of  the  two  kinds  of  structures  should  be 
known.  By  cerebrum,  or  brain  proper,  ought  to  be  understood  that 
part  of  the  encephalon  constituting  the  cerebral  lobes,  situated  above 
and  outside  the  corpus  callosum ; by  the  spinal  cord  all  the  parts  situated 
below  this  great  commissure,  consisting  of  the  corpora  striata,  optic 
thalami,  corpora  quadrigemina,  cerebellum,  pons  varolii,  medulla  oblon- 
gata, and  medulla  spinalis.  In  this  way,  we  have  a cranial  and  a verte- 
bral portion  of  the  spinal  cord. 

In  the  cerebrum,  or  brain  proper,  the  ganglionic  or  corpuscular 
structure  is  external  to  the  fibrous  or  tubular.  It  presents  on  the  sur- 
face numerous  anfractuosities,  whereby  a large  quantity  of  matter  is 
capable  of  being  contained  in  a small  space.  This  crumpled-up  sheet  of 
grey  substance  has  been  appropriately  called  the  hemispherical  ganglion 
(Solly).  In  the  cranial  portion  of  the  spinal  cord,  the  grey  matter 
exists  in  masses,  constituting  a chain  of  ganglia  at  the  base  of  the 
encephalon,  more  or  less  connected  with  each  other  and  with  the  white 
matter  of  the  brain  proper  above,  and  the  vertebral  portion  of  the  cord 
below.  In  this  last  part  of  the  nervous  system  the  grey  matter  is  in- 
ternal to  the  white,  and  on  a transverse  section  presents  the  form  of  the 
letter  x,  having  two  posterior  and  two  anterior  cornua — an  arrangement 
which  allows  the  latter  to  be  distributed  in  the  form  of  nerve  tubes  to 
all  parts  of  the  frame. 

The  white  tubular  structure  of  the  vertebral  portion  of  the  cord  is 
divided  by  the  anterior  and  posterior  horns  of  grey  matter,  together  with 
the  anterior  and  posterior  sulci,  into  three  divisions  or  columns  on  each 
side.  On  tracing  these  upwards  into  the  medulla  oblongata,  the  ante- 


HEALTHY  AND  DISEASED  INNERVATION. 


139 


rior  and  middle  ones  may  be  seen  to  decussate  there  with  each  other, 
whilst  the  posterior  columns  do  not  decussate.  On  tracing  the  columns 
up  into  the  cerebral  lobes,  we  observe  that  the  anterior,  or  pyramidal 
tracts,  send  off  a bundle  of  fibres,  which  passes  below  the  olivary  body, 
and  is  lost  in  the  cerebellum— land  of  Solly).  The  principal 
portion  of  the  tract  passes  through  the  corpus  striatum,  and  anterior 
portion  of  the  optic  thalamus,  and  is  ultimately  lost  in  the  white  sub- 
stance of  the  cerebral  hemispheres.  The  middle  column,  or  olivary  tract, 
maybe  traced  through  the  substance  of  the  optic  thalamus  and  corpora  qua- 
drigemina,  to  be  in  like  manner  lost  in  the  cerebral  hemispheres.  Tlie  pos- 
terior column,  or  restiform  tract,  passes  almost  entirely  to  the  cerebellum. 

In  addition  to  the  diverging  fibres  in  the  cerebral  hemispheres 
which  may  be  traced  from  below  upwards,  connecting  the  hemispherical 
ganglion  with  the  structures  below,  the  brain  proper  also  possesses 
bands  of  transverse  fibres,  constituting  the  commissures  connecting  the 
two  hemispheres  of  the  brain  together,  as  well  as  longitudinal  fibres 
connecting  the  anterior  with  the  posterior  lobes.  In  the  posterior 
columns  of  spinal  cord  it  results  from  the  investigations  of  Lockhart 
Clarke,  that  there  is  a decussation  of  various  bundles  of  fibres  through- 
out its  whole  extent.  It  is  now  also  determined,  that  many  of  the  fibres 
in  the  nerves  may  be  traced  directly  into  the  grey  substance  of  the  cord 
— a fact  originally  stated  by  Grainger,  but  confirmed  by  Budge  and 
KoHiker.  Further,  it  has  recently  been  shown,  that  b}^  means  of  these 
fibres  an  anastomosis  is  kept  up  between  the  various  columns,  even  tho.m 
on  both  sides  of  the  cord,  through  the  medium  of  nerve  cells  in  the  grey 
matter,  an  important  fact  principally  demonstrated  by  the  labors  of 
Stilling,  Remak,  Van  der  Kolk,  Lockhart  Clarke,  and  others.  / 

These  later  observations,  indeed,  render  it  certain  that  the  numerous 
actions  hitherto  called  reflex  are  truly  direct,  and  are  carried  on  by  a 
series  of  nervous  filaments  running  in  different  directions  through  the 
cord ; and  hence  the  term  diastaltic^  proposed  by  Marshall  Hall  instead 
of  reflex,  is  in  every  way  more  appropriate. 

Functions  of  the  Nervous  System. — The  great  difference  in  structure 
existing  between  the  grey  and  white  matter  of  the  nervous  system, 
would,  d priori.,  lead  to  the  supposition  that  they  performed  separate 
functions.  The  theory  at  present  entertained  on  this  point  is,  that, 
while  the  grey  matter  eliminates  or  evolves  nervous  power,  the  white 
matter  simply  conducts  to  and  from  this  ganglionic  structure  the  in- 
fluences which  are  sent  or  originate  there. 

Cerebrum. — This  portion  of  the  nervous  system  consists  of  that  mass 
of  grey  and  white  matter  situated  above  and  outside  the  corpus  callosum, 
composing  what  are  denominated  the  two  cerebral  lobes.  On  carefully 
examining  a thin  section  of  this  structure,  prepared  after  the  manner 
of  Lockhart  Clarke,  and  steeped  in  carmine,  the  white  substance  in  the 
adult  may  be  seen  to  be  composed  wholly  of  nerve  tubes.  These  become 
more  and  more  minute  as  they  reach  the  grey  matter  of  the  convolutions, 
and  are  gradually  lost  in  it.  The  layer  of  grey  matter  consists  of  a 
finely  molecular  substance,  in  which  are  embedded  minute  nerve  cells, 
varying  in  shape  and  size. 

The  cerebral  lobes  furnish  the  conditions  necessary  for  the  manifesta- 


140 


PRINCIPLES  OF  MEDICINE. 


tion  of  tlie  intellectual  faculties  properly  so  called,  of  the  emotions  and 
passions,  of  volition,  and  are  essential  to  sensation.  That  the  evolution 
of  the  power  especially  connected  with  mind  is  dependent  on  the 
hemispherical  ganglion,  is  rendered  probable  by  the  following  facts:  — 
1.  In  the  animal  kingdom  generally,  a correspondence  is  observed  between 
the  quantity  of  grey  matter,  depth  of  convolutions,  and  the  sagacity  of 
the  animal.  2.  At  birth,  the  grey  matter  of  the  cerebrum  is  very 
defective ; so  much  so,  indeed,  that  the  convolutions  are,  as  it  were,  in 
the  first  stage  of  their  formation,  being  only  marked  out  by  superficial 
fissures  almost  confined  to  the  surface  of  the  brain.  As  the  cirieritious 
substance  increases,  the  intelligence  becomes  developed.  3.  The  results 
of  experiments  by  Flourens,  Rolando,  Hertwig,  and  others,  have  shown 
that,  on  slicing  away  the  brain,  the  animal  becomes  more  dull  and  stupid 
in  proportion  to  the  quantity  of  cortical  substance  removed.  4.  Clinical 
observation  points  out,  that  in  those  cases  in  which  the  disease  has  been 
afterwards  found  to  commence  at  the  circumference  of  the  brain,  and 
proceed  towards  the  centre,  the  mental  faculties  are  affected  first; 
whereas  in  those  diseases  which  commence  at  the  central  parts  of  the 
organ,  and  proceed  towards  the  circumference,  they  are  affected  last. 

The  grey  matter,  therefore,  evolves  that  force  or  quality  which  is 
essential  to  mind,  and  the  conditions  necessary  for  this  are  evidently 
connected  with  the  molecular  and  cell  structure.  The  white  matter,  on 
the  other  hand,  conducts  the  influences  originating  in,  and  going  to,  the 
grey  matter.  These  may  be  said  to  travel  in  four  directions — 1st,  Out- 
wards to  the  circumference  of  the  body  along  the  nerve  tubes;  2d,  In- 
wards and  upwards  to  the  hemispherical  ganglion;  3d,  From  one  hemi- 
sphere to  another  by  the  commissures ; and  4th,  From  the  anterior  to 
the  posterior  lobes,  and  vice  versa,  by  the  so-called  longitudinal  fibres 
of  the  hemispheres.  This  power  of  conducting  mental  influences  in 
various  directions  is  probably  subservient  to  that  combination  of  faculties 
which  characterises  thought. 

By  the  term  sensibility  I understand  the  peculiar  vital  property 
possessed  by  nervous  substance  of  conducting  the  influence  generated  by 
impressions  made  upon  it.  By  sensation  I understand  the  mental  con- 
sciousness of  such  impression.  Now  the  experiments  of  Flourens, 
Hertwig,  Longet,  and  others,  have  shown  that  on  removing  the  cerebral 
lobes  from  animals,  the  mental  faculties,  including,  of  course,  conscious- 
ness and  volition,  and  therefore  sensation  and  voluntary  motion,  are 
abolished,  while  the  creature  can  stand  when  put  on  its  legs,  fly  when 
thrown  into  the  air,  and  walk  when  pushed.  Hertwig  has  kept  pigeons 
in  this  condition  for  three  months,  deglutition  and  all  other  reflex  acts 
being  perfect,  the  mental  faculties  only  absent.  Longet  and  Dalton  have 
recently  maintained  that  sensation  may  exist  without  the  cerebral  lobes. 
The  former  says,  when  the  cerebrum  was  removed  from  a pigeon,  and  a 
light  suddenly  brought--  near  its  eyes,  there  was  contraction  of  the  pupil, 
and  even  winking.  Further,  when  a rotatory  motion  was  given  to  the 
candle  at  such  a distance  that  no  heat  could  operate,  the  pigeon  made  a 
similar  movement  with  its  head.  But  of  these  facts  I would  observe 
that  the  pupil  will  contract  on  the  application  of  light  when  the  eye  has 
been  cut  out  of  the  head,  and  a sunflower  follows  the  course  of  the  sun. 


HEALTHY  AND  DISEASED  INNERVATION. 


141 


It  cannot,  therefore,  be  said  that  under  such  circumstances  the  eye  and 
the  flower  possess  sensation  or  can  see. 

Dalton’s  description  of  what  occurs  after  removal  of  the  cerebrum  is 
as  follows ; — “ The  effect  of  this  mutilation  is  simply  to  plunge  the  ani- 
mal into  a state  of  profound  stupor,  in  which  he  is  almost  entirely  in- 
attentive to  surrounding  objects.  The  bird  remains  sitting  motionless 
upon  his  perch  or  standing  upon  the  ground,  with  the  eyes  closed  and 
t'ae  head  sunk  between  the  shoulders.  . . . This  state  of  immobility, 
however,  is  not  accompanied  by  the  loss  of  sight,  of  hearing,  or  of  ordi- 
nary sensibility.  All  these  functions  remain,  as  well  as  that  of  voluntary 
motion.  If  a pistol  be  discharged  behind  the  back  of  the  animal,  he  at 
once  opens  his  eyes,  moves  his  head  half  round,  and  gives  evident  signs 
of  having  heard  the  report;  but  he  immediately  becomes  quiet  again, 
and  pays  no  further  attention  to  it.  Sight  is  also  retained,  since  the 
bird  will  sometimes  fix  its  eye  on  a particular  object  and  watch  it  for 
several  seconds  together.  Ordinary  sensation  also  remains  after  removal  of 
the  hemispheres,  together  with  voluntary  motion.  If  the  foot  be  pinched 
with  a pair  of  forceps,  the  bird  becomes  partially  aroused,  moves  uneasily 
once  or  twice  from  side  to  side,  and  is  evidently  annoyed  at  the  irritation.” 

From  the  observed  facts  Dalton  concludes  that  “ the  animal  is  still 
capable,  after  removal  of  the  hemispheres,  of  receiving  sensations  from 
external  objects.  But  these  sensations  appear  to  make  upon  him  no 
lasting  impression.  He  is  incapable  of  connecting  with  his  perceptions 
any  distinct  succession  of  his  ideas.  He  hears,  for  example,  the  report 
of  a pistol,  but  he  is  not  alarmed  by  it ; for  the  sound,  though  distinctly 
enough  perceived,  does  not  suggest  any  idea  of  danger  or  injury.  There 
is  accordingly  no  power  of  forming  mental  associations,  nor  of  perceiving 
the  relation  between  external  objects.  The  memory,  more  particularly, 
is  altogether  destroyed,  and  the  recollection  of  sensations  is  not  retained 
from  one  moment  to  another.  The  limbs  and  muscles  are  still  under 
the  control  of  the  will,  but  the  will  itself  is  inactive,  because  apparently 
it  lacks  its  usual  mental  stimulus  and  direction.” 

I think  the  facts  may  be  interpreted  differently  and  more  correctly. 
The  turning  round  of  the  animal’s  head  on  the  explosion  of  a pistol,  and 
many  other  movements,  may  be  altogether  reflex,  dependent  on  irritations 
communicated  to  the  cranial  portion  of  the  spinal  cord  through  the 
tympanum.  Again,  that  the  pigeon  should  open  its  eyes  with  a vacant 
stare,  or  apparently  fix  them  on  an  object,  is  no  proof  of  sight.  We 
constantly  do  these  things  ourselves  with  the  brain  entire,  and  see 
nothing.  Lastly,  that  the  limbs  and  muscles  are  under  the  control  of 
the  will,  while  the  will  is  inactive,  appears  to  be  contradictory  language. 
One  of  the  most  active  operations  of  the  will  is  to  direct  motion;  and  to 
say  of  a bird  which  flies  away  on  the  production  of  the  slightest  noise  in 
health,  but  does  not  move  on  the  discharge  of  a pistol,  that  in  the  latter 
case  its  limbs  and  muscles  are  still  under  the  control  of  the  will,  appears 
to  be  a most  unfounded  conclusion.  The  truth  evidently  is  that  there 
is  no  will,  no  sensation  in  such  a case,  any  more  than  there  is  in  a sensi- 
tive plant,  which  shrinks  on  being  touched,  but  which  surely  cannot  be 
said  to  exercise  either  the  one  mentnl  faculty  or  the  other. 

With  regard  to  the  relation  existing  between  mind  and  brain,  two 


142 


PEINCIPLES  OF  MEDICINE. 


views  are  contended  for  : one,  that  the  brain  originates ; the  other,  that 
it  is  only  the  instrument  of  thought.  The  discussion  is  metaphysical 
rather  than  physiological,  because  the  phenomena  observed  in  either  case 
are  the  same,  and  these  depend  upon  the  structure  and  quality  of  the 
organ  itself.  In  this  respect  the  brain  is  exactly  similar  to  a nerve  or 
muscle.  It  possesses  properties  and  functions  which  it  is  our  duty  to 
study.  AVhy  it  does  so  we  are  ignorant,  and  are  content  to  regard  them 
as  ultimate  facts  in  our  science.  In  the  same  way,  therefore,  that  con- 
tractility is  a property  of  muscle,  sensibility  of  nerve,  growth  of  tissue, 
and  secretion  of  gland,  so  we  regard  thought  as  a property  of  the  brain. 
But  to  avoid  metaphysical  subtleties,  we  are  quite  willing  to  say  that  it 
furnishes  the  conditions  necessary  for  the  manifestation  of  mind. 

From  the  various  facts  now  known,  I think  it  may  be  concluded  that 
the  cortical  substance  of  the  cerebral  lobes  furnishes  those  conditions 
which  are  necessary  for  thought,  including  all  mental  operations,  sensa- 
tion, and  volition.  . I do  not  think  that  in  the  present  state  of  science  we 
are  warranted  in  proceeding  further,  for  the  same  facts  entirely  negative 
all  those  theories  which  have  been  advanced  having  for  their  object  a 
localization  of  the  different  faculties  into  which  the  mind  has  been  arbi- 
trarily divided.  Some  have  maintained  that  volition  is  seated  in  one 
place,  memory  in  a second,  sensation  in  a third,  and  so  on ; but  we  have 
no  sufficiently  extended  series  of  facts  to  establish  any  of  these  or  of 
similar  propositions. 

There  can  be  no  doubt  that  the  relation  between  the  molecular, 
nuclear,  and  cell  elements  of  the  hemispherical  ganglion,  as  the  instru- 
ment of  mind,  must  be  most  important ; and  yet  I am  not  acquainted 
with  any  one,  who,  having  first  qualified  himself  for  the  task  by  a pro- 
longed and  careful  study  of  histology,  has  investigated  the  brain  in  cases 
of  insanity.  Psychologists  content  themselves  with  repeating  well-known 
clinical  observations,  with  the  ordinary  morbid  anatomy  or  density  of  the 
brain,  and  with  the  metaphysical  speculations  which  have  been  pushed 
as  far  as,  if  not  further  than,  human  intellect  can  carry  them.  Need  we 
feel  surprised  that  the  true  pathology  of  insanity  is  unknown  ? What 
we  desiderate  is  a careful  scrutiny  of  the  organ.  Hitherto  the  difficul- 
ties of  such  an  investigation  have  been  insurmountable,  in  consequence 
of  our  imperfect  methods  of  research.  But  let  any  one  possessing  a com- 
petent knowledge  of  histology  and  the  use  of  our  best  microscopes,  with 
the  opportunities  our  large  asylums  offer,  only  now  dedicate  himself  to 
the  task,  and  he  may  be  assured  that  while  extending  the  bounds  of 
science  he  will  certainly  obtain  an  amount  of  fame  and  honor  that  few 
can  hope  to  arrive  at.  The  molecules  on  which  muscular  contractility 
depends  are,  as  we  have  seen,  visible  molecules,  and  so  I believe  are 
those  in  the  hemispherical  ganglion,  so  essentially  connected  with  the 
functions  of  the  brain. 

CcreeUhim. — The  ganglionic  surface  of  the  cerebellum  is  structurally 
altogether  unlike  that  of  the  cerebrum.  On  looking  at  a well-made  verti- 
cal section  of  the  former,  prepared  after  the  method  of  Lockhart  Clarke, 
and  steeped  in  carmine,  under  a magnifying  power  of  25  diameters,  the 
fine  tubular  substance  in  the  centre  is  seen  to  be  bounded  externally  by 
a granular  layer,  outside  which  is  a row  of  nerve  cells  with  branched  pro- 


HEALTHY  AND  DISEASED  INNERVATION. 


143 


cesses  gradually  terminating  towards  tbe  margin  of  the  exterior  layer, 
which  is  finely  molecular.  On  increasing  the  magnifying  power  to  250 
diameters,  we  see  more  distinctly  the  relation  of  these  various  parts  to 
one  another,  and  recognise  in  the  interior  of  each  granule  an  included 
rounded  body.  According  to  Gerlach,  these  corpuscles  are  united  to 
one  another  by  a slender  filament,  which  he  has  figured  in  a hypothetical 
diagram.  Although  such  an  appearance  as  he  has  imagined  cannot  be 
discovered  in  the  natural  structure,  I have  seen  the  tubes  running 
between  the  granules,  and  traced  them  to  the  external  margin  of  the 
granular  layer.  The  external  layer  is  the  structure  which  demands  the 
greatest  attention.  It  is  composed  essentially  of  a finely  molecular  mass, 
containing  numerous  capillaries  derived  from  the  vessels  of  the  meninges. 
Large  ganglionic  cells  external  to  the  granular  layer  send  olF  branching 
processes  externally,  which  are  gradually  lost  as  they  proceed  outwards. 
Both  in  the  external,  as  well  as  in  the  internal  granular  layer,  the  basis 
of  the  texture  is  evidently  molecular — a fact  which  hitherto  has  received 
far  too  little  attention. 

If  the  cerebellum  be  removed  gradually  from  a pigeon  in  successive 
slices,  there  is  progressive  circumscription  of  the  locomotive  actions.  On 
taking  away  only  the  upper  layer  there  is  some  weakness  and  a hesitation 
in  its  gait.  When  the  sections  have  reached  the  middle  of  the  organ 
the  animal  staggers  much,  and  assists  itself  in  walking  with  its  wings. 
The  sections  being  continued  further,  it  is  no  longer  able  to  preserve  its 
equilibrium  without  the  assistance  of  its  wings  and  tail;  its  attempts  to 
fly  or  walk  resemble  the  fruitless  efforts  of  a nestling,  and  the  slighest 
touch  knocks  it  over.  At  last,  when  the  whole  cerebellum  is  removed, 
it  cannot  support  itself  even  with  the  aid  of  its  wings  and  tail ; it  makes 
violent  efforts  to  rise,  but  only  rolls  up  and  down ; then,  fatigued  with 
struggling,  it  remains  for  a few  seconds  at  rest  on  its  back  or  abdomen, 
and  then  again  commences  its  vain  struggles  to  rise  and  walk.  Yet  all 
the  while  its  sight  and  hearing  are  perfect.  The  slightest  noise,  threat, 
or  stimulus,  at  ouce  renews  its  contortions,  which  have  not  the  slightest 
appearance  of  convulsions.  These  eSects,  first  described  by  Flourens, 
have  been  confirmed  by  all  experimenters,  and  occur  in  all  animals. 
The  results  contrast  strongly  with  those  of  the  much  more  severe  opera- 
tion of  removing  the  cerebral  lobes.  “ Take  two  pigeons,”  says  Longet; 
“ from  one  remove  completely  the  cerebral  lobes,  and  from  the  other  only 
half  the  cerebellum  ; the  next  day  the  first  will  be  firm  upon  its  feet,  the 
second  will  exhibit  the  unsteady  and  uncertain  gait  of  drunkenness.” 

These  facts  induced  Flourens  to  consider  the  cerebellum  as  the  co- 
ordinator of  motion,  in  which  view  he  was  supported  by  the  late  Dr. 
Todd  and  others.  Foville,  on  the  other  hand,  supposed  it  to  be  the  seat 
of  sensation,  and  argued  that,  as  it  is  by  means  of  this  function  that  we 
regulate  muscular  motion,  so,  when  it  is  destroyed,  the  faculty  of  per- 
ceiving the  movements  being  lost,  we  cannot  answer  for  their  precision 
or  duration.  That  it  should  be  the  seat  of  sensation  generally  is  dis- 
proved by  the  fact  that  the  animal  is  evidently  conscious  of  impressions 
after  its  removal ; but  that  it  should  be  the  organ  of  that  peculiar  sense, 
which  has  been  variously  called  “ muscular  sense,”  “ sen^e  of  resistance,” 
and  “sense  of  weight,”  is  very  probable.  Accordingly  we  find  that 


144 


PEINCIPLES  OF  MEDICINE. 


Professor  Lussana  of  Parma  lias  recently  brought  together  all  the  argu 
ments  which  exist  as  to  this  matter,  along  with  numerous  original  obser- 
vations, confirmatory  of  the  view  that  the  cerebellum  does  indeed  regulate 
motion,  but  in  consequence  of  its  being  the  seat  of  the  muscular  sense.* 

It  has  been  suggested  by  Carpenter  and  Dunn  that  the  corpus  den- 
tatum  in  the  cerebellum  is  the  ganglion  which  is  connected  with  this 
sense — a view  rendered  improbable  by  Brown-Sequard’s  analysis  of  cases 
where  the  organ  was  diseased.  I submit  that  the  function  is  seated  in 
the  external  layers  of  grey  matter  rather  than  in  the  corpus  dentatum — 
a theory  to  which  the  same  objections  do  not  apply.  Mind  frequently 
remains  when  portions  of  the  hemispherical  ganglion  are  injured,  although 
we  know  of  no  instance  in  which,  where  the  whole  of  it  has  been  dis- 
eased, intellect  has  been  preserved.  So  the  co-ordinating  motor  power 
may  remain  when  parts  only  of  the  cerebellar  leaflets  are  destroyed,  but 
is  certainly  lost  when  the  whole  grey  matter  is  diseased.  That  the  cere- 
bellum, therefore,  is  connected  with  a special  sense,  through  which  it 
influences  the  co-ordinate  action  of  the  muscles,  is  a doctrine  worthy  the 
attention  of  physiologists.  Its  external  layers  of  grey  matter,  constituting 
a complex  ganglionic  structure,  has  probably  the  same  relation  to  the  mus- 
cular sense  as  the  hemispherical  ganglion  has  to  sensation  in  general. 

The  spinal  cord  has  two  portions — a cranial  and  a vertebral.  The 
former  consists  of  a chain  of  ganglia  more  or  less  connected  with  one 
another,  as  well  as  with  the  cerebrum  above  and  the  vertebral  part  of  the 
cord  below ; the  latter  is  composed  of  two  lateral  halves  divided  by  an 
anterior  and  posterior  fissure.  Each  half  is  subdivided  into  three 
columns — an  anterior,  middle,  and  posterior — by  the  two  cornua  of  the 
central  mass  of  grey  matter.  Through  the  centre  runs  the  spinal  canal, 
lined  with  columnar  epithelium.  The  white  matter  of  the  lateral  columns 
is  composed  of  tubes,  which,  as  shown  by  Lockhart  Clarke,  on  being 
traced  inwards  from  the  spinal  nerves,  join  the  ganglionic  cells  in  the 
grey  matter,  and,  through  them,  keep  up  a communication — 1st,  with 
the  opposite  lateral  columns;  2d,  with  the  cerebrum;  and  3d,  with  the 
anterior  and  posterior  roots  of  the  nerves.  The  coarse  of  the  conducting 
tubes,  as  pointed  out  by  Clarke,  shows  that  the  views  of  Sir  Charles 
Bell,  though  correct  as  to  the  functions  of  the  roots  of  the  nerves,  were 
erroneous  with  regard  to  the  columns  of  the  cord.  The  few  experiments 
Bell  made  on  those  roots  confirmed  the  conclusions  he  drew  from  dis- 
section. Had  he  experimented  on  the  cord  itself,  he  might  have  formed 
juster  views.  What  he  neglected,  however,  was  performed  by  Brown- 
Sequard,  with  the  effect  of  demonstrating  that  a section  of  the  anterior 
columns  does  not  produce  paralysis  of  voluntary  motion,  nor  section  of 
the  posterior  columns  prevent  conduction  between  the  brain  and  poste- 
rior roots.  To  produce  either  of  these  results,  the  section  must  be  con- 
tinued into  the  grey  matter.  If  two  sections  be  made,  however,  midway 
between  two  neighboring  spinal  nerve  roots,  then  conduction  between 
the  parts  above  and  below  the  sections  is  cut  off.  The  explanation  of 
this  is  to  be  found  in  the  course  taken  by  the  nerve  tubes  as  shown  by 
Locklmrt  Clarke,  which  so  diverge  from  one  another,  on  passing  into  the 
cord,  that  no  one  transverse  section  of  the  column  can  divide  them, 
* Journal  de  la  Physiologic,  tome  v.,  p.  418,  et  seq. 


HEALTHY  AND  DISEASED  INNEEVATION. 


145 


although  two  at  a certain  distance  from  one  another  may.  Thus,  histolo- 
gical research  and  experimental  investigation  support  one  anotlier,  and  the 
two  have  now  demonstrated  that  the  conducting  nerve  tubes  of  the  spinal 
roots  of  the  nerves  communicate  through  the  grey  matter  of  the  cord,  not 
only  with  the  brain  and  the  two  sides  of  the  body,  but  with  each  other. 

These  facts  have  served  also  to  explain  more  fully  the  nature  of 
those  actions  variously  denominated  automatic,  reflex,  and  diastaltic,  for 
the  true  knowledge  of  which  we  are  indebted  to  the  labors  of  Marshall 
Hall.  It  is  now  clear  that  the  influences  excited  by  irritation  of  nerves 
run  continuously  through  the  cord  in  certain  directions,  now  communi- 
cating with  muscles  to  produce  spasms,  and  now  with  the  glands  and 
vessels  to  produce  secretion  and  vaso  motor  action,  and  this  without  any 
necessary  connection  with  the  brain,  and  therefore  without  sensation. 

Nerves. — The  various  nerves  of  the  body  consist  for  the  most  part  of 
nerve  tubes,  running  in  parallel  lines.  Yet  some  contain  ganglionic  cor- 
puscles, as  the  olfactory  and  the  ultimate  expansion  of  the  optic  and  audi- 
tory nerves,  whilst  the  sympathetic  nerve  contains,  in  various  places,  not 
only  ganglia,  but  gelatinous  flat  fibres.  The  posterior  roots  of  the  spinal 
nerves  possess  a ganglion,  the  function  of  which  is  quite  unknown. 
These  roots  are  connected  with  the  posterior  horn  of  grey  matter  in  the 
cord,  while  the  anterior  roots  are  connected  with  the  anterior  horns. 
As  regards  function,  the  nerves  maybe  considered  as — 1st,  Nerves  of 
special  sensation,  such  as  the  olfactory,  optic,  auditory,  part  of  the  glosso- 
pharyngeal and  lingual  branch  of  the  fifth.  2d,  Nerves  of  common  sen- 
sation such  as  the  greater  portion  of  the  fifth,  and  part  of  the  glosso- 
pharyngeal. 3d,  Nerves  of  motion,  such  as  the  third,  fourth  lesser 
division  of  the  fifth,  sixth,  facial,  or  portio  dura  of  the  seventh,  and  the 
hypo-glossal.  4th,  Senso-motory  or  mixed  nerves,  such  as  the  pneumo- 
gastric,  the  accessory,  and  the  spinal  nerves.  5th,  Sympathetic  nerves. 

All  nerves  are  endowed  with  a peculiar  vital  property  called  excita- 
bility, inherent  in  their  structure,  by  virtue  of  which  they  may  be 
excited  on  the  application  of  appropriate  stimuli,  so  as  to  transmit  the 
influence  of  the  impressions  they  receive  to  or  from  the  brain,  spinal 
cord,  or  certain  ganglia,  which  may  be  considered  as  nervous  centres. 
The  nerves  of  special  sensation  convey  to  their  nervous  centres  the 
influence  of  impressions  caused  by  odoriferous  bodies,  by  light,  sound, 
and  by  sapid  substances.  The  nerves  of  common  sensation  convey  to 
their  nervous  centres  the  influence  of  impressions  caused  by  mechanical 
or  chemical  substances.  The  nerves  of  motion  carry yrom  the  nervous 
centres  the  influence  of  impressions,  whether  psychical  or  physical  (Todd). 
The  mixed  nerves  carry  the  influence  of  stimuli  both  to  and  from,  thus 
combining  in  themselves  the  powers  necessary  for  the  functions  of  com- 
mon sensation  and  of  motion. 

But  there  are  doubtless  numerous  other  individual  nerve  tubes  pecu- 
liarly qualified  to  receive  impressions  connected  with  particular  sensations 
— such,  for  example,  as  those  of  cold  or  warmth,  of  weight,  of  hunger, 
thirst,  and  numerous  other  feelings — which,  although  not  yet  actually 
discovered,  must  have  relation  to  the  special  endowments  of  these  tubes. 
As  to  the  direction  in  which  these  influences  travel,  we  now  know  that 
they  pass,  first,  from  the  brain  to  the  voluntary  muscular  system  gen- 
10 


146 


PEIXCIPLES  OF  MEDICINE. 


erally ; second,  from  the  surface  and  the  organs  of  sense  to  the  brain ; 
third,  from  one  side  of  the  body  to  the  other,  through  the  spinal  cord  ; 
fourth,  from  the  cerebro-spinal  system  through  ganglia  to  numerous 
glands,  non-voluntary  muscles,  and  to  the  blood-vessels.  There  may  be 
other  directions  in  which  nervous  influence  travels,  but  such  have  not 
yet  been  discovered.  In  the  meantime  we  know  that  the  nerve  tubes 
are  not  only  idio-motor  and  sensitive  (general  and  special),  but  diastal- 
tic,  nutritive,  secretory,  and  vaso-motor. 

The  ganglionic  system  of  nerves  consists  of  numerous  ganglia  having 
connecting  filaments,  keeping  up  a communication  with  each  other  and 
with  the  cerebro-spinal  centres.  These  communications  are  not  direct, 
the  various  nerve  tubes  separating  in  a ganglion,  and,  whether  they  do 
or  do  not  anastomose  with  nerve  cells,  on  leaving  it  form  a dififerent 
combination  of  nerves.  Hence  every  ganglion  serves  to  break  the  con- 
ducting power  of  the  nerves,  or  to  modify  it — probably  both.  In  health 
W’e  are  not  conscious  of  the  actions  of  internal  viscera  principally  supplied 
with  these  nerves,  nor  can  volition  act  on  muscular  parts  to  which  they 
are  distributed.  But  let  them  be  diseased,  and  they  often  excite  excru- 
ciating yet  peculiar  pain,  as  in  that  caused  by  angina,  by  colic,  or  by  a 
gall-stone.  Again,  mental  emotions  have  a powerful  influence  on  the 
contractions  of  the  organic  contractile  tissue,  as  in  palpitations  of  the 
heart,  or  as  visible  in  blood-vessels  on  the  production  of  pallbr  or  of  a 
blush.  In  the  same  manner  mental  emotions  or  desires  act  on  the  vari- 
ous glands,  exciting  or  diminishing  their  action.  Such  results  can  only 
be  explained  by  the  connection  known  to  exist  between  these  nerves  and  » 
the  spinal  cord.  Similar  phenomena  may  be  produced  by  direct  stimu- 
lation or  by  reflex  action,  each  ganglion  being  a centre  through  which 
alferent  and  efferent  nerves  communicate — the  whole  constituting  an 
excito-nutrient  and  excito-secretory  system,  as  has  been  well  described  by 
Dr.  Campbell  of  the  United  States."^ 

The  observations  as  to  the  eflects  of  injuring  the  trunk  of  the  gan- 
glionic system,  more  especially  in  the  neck,  have  excited  the  attention  of 
numerous  physiologists  since  the  days  of  Petit  in  1727,  and  more  espe- 
cially of  Dupuy  (1816),  Breschet  (1837),  John  Beid  (1838),  Bifid  (1&46), 
Budge  and  Waller  (1851),  and  finally  of  Bernard  and  Brown- Sequard 
(1852).  Bernard  discovered  the  remarkable  increase  of  heat  which  fol- 
lowed section  of  the  nerve,  and  Brown-Scquard  showed  that  cold  was 
produced  on  applying  galvanism  to  it.  It  is  now  recognised  that  if  we 
cut  the  trunk  of  the  sympathetic,  heat  commences  in  the  neighboring 
])arts  almost  immediately,  and  will  continue  for  weeks  without  producing 
inflammation,  oedema,  or  other  effect,  so  long  as  the  animal  remains  in 
good  condition.  But  if  it  falls  sick,  either  spontaneously  or  in  conse- 
quence of  other  operations,  the  na.sal  and  ocular  mucous  membranes  of 
the  affected  side  become  red  and  swollen,  and  secrete  pus  in  great  abun- 
dance. The  inflammation  of  the  conjunctiva  described  by  Dupuy,  J. 
Beid,  and  others,  is  therefore  an  accidental  phenomenon  produced  by  the 
debility  of  the  animal,  and  may  be  avoided  by  giving  it  food  and  sup- 
porting its  strength. 

* Essays  on  the  Secretory  and  Excito-Secretory  System  of  Nerves,  etc.  Phila- 
delphia. 1857. 


HEALTHY  AND  DISEASED  INNERVATION. 


147 


Thus  in  the  same  manner  that  when  we  irritate  a sensitive  nerve  we  . 
excite  motion  through  a motor  nerve,  or  secretion  and  nutrition  through 
thi  nerves  distributed  to  glands  or  to  the  tissues,  so  we  excite  cold  by 
iiritating  the  ganglionic  system  of  nerves,  and  heat  by  destroying  their 
action  or  exhausting  it.  These  phenomena  are  those  of  fever. 

Sensation  may  be  defined  to  be  the  consciousness  of  an  impression^ 
and  that  it  may  take  place,  it  is  necessary — 1st,  That  a stimulus  should 
be  applied  to  a sensitive  nerve,  which  receives  an  impression;  2d,  That, 
in  consequence  of  this  impression,  a something,  which  we  designate  an 
influence,  should  be  generated,  and  conducted  along  the  nerve  to  the 
hemispherical  ganglion  ; 3d,  On  arriving  there,  it  calls  into  action  that 
fiiculty  of  the  mind  called  consciousness  or  perception,  and  sensation  is 
the  result.  It  follows  that  sensation  may  be  lost  by  any  circumstance 
which  destroys  the  sensibility  of  the  nerve  to  impressions;  which  im- 
pedes the  progress  of  the  influence  generated  by  these  impressions ; or, 
lastly,  which  renders  the  mind  unconscious  of  them.  Illustrations  of 
how  sensation  may  be  affected  in  all  these  ways  must  be  familiar  to  you, 
from  circumstances  influencing  the  ultimate  extremity  of  a nerve,  as  on 
exposing  the  foot  to  cold;  from  injury  to  the  spinal  cord,  by  which  the 
communication  with  the  brain  is  cut  off;  or  from  the  mind  being  inat- 
tentive, excited,  or  suspended. 

The  independent  endowment  of  nerve  is  remarkably  well  illustrated 
by  the  fact,  that  whatever  be  the  stimulus  which  calls  their  sensibility 
into  action,  the  same  result  is  occasioned.  Mechanical,  chemical,  galvanic, 
or  other  physical  stimuli,  when  applied  to  the  course  or  the  extremities 
of  a nerve,  cause  the  very  same  results  as  may  originate  from  suggestive 
ideas,  perverted  imagination,  or  psychical  stimuli.  Thus  a chemi- 

cal irritant,  galvanism,  or  pricking  and  pinching  a nerve  of  motion  will 
cause  convulsion  and  spasms  of  the  muscles  to  which  it  is  distributed. 
The  same  stimuli  applied  to  a nerve  of  common  sensation  will  cause  pain, 
to  the  optic  nerve  flashes  of  light,  to  the  auditory  nerve  ringing  sounds, 
and  to  the  tip  of  the  tongue  peculiar  tastes.  Again,  we  have  lately  had 
abundant  opportunities  of  seeing  that  suggestive  ideas,  or  stimuli  arising 
in  the  mind,  may  induce  peculiar  effects  on  the  muscles,  give  rise  to  pain 
or  insensibility,  and  cause  perversion  of  all  the  special  senses. — (See 
Section  on  General  Therapeutics.) 

Motion  is  accomplished  through  the  agency  of  muscles,  which  are 
endowed  with  a peculiar  vital  property,  called  contractility,  in  the  same 
way  that  nerve  is  endowed  with  the  property  of  sensibility.  Contractility 
may  be  called  into  action  altogether  independent  of  the  nerves  (Haller), 
as  by  stimulating  an  isolated  muscular  fasciculus  directly  (Weber).  It 
may  also  be  excited  by  a physical  or  psychical  stimulus,  operating  through 
the  nerves.  Physical  stimuli  (as  pricking,  pinching,  galvanism,  etc.) 
applied  to  the  extremities  or  course  of  a nerve,  may  cause  convulsion  of 
the  parts  to  which  the  motor  filaments  are  distributed  directly,  or  they 
may  induce  combined  movements  in  other  parts  of  iliahodiy  diastaltically 
(Marshall  Hall) — that  is,  through  the  spinal  cord.  In  this  latter  case 
the  following  series  of  actions  take  place  : — 1st,  The  influence  of  the  im- 
pression is  conducted  to  the  spinal  cord  by  the  afferent  or  esodlc  filaments 
which  enter  the  grey  matter.  2d,  A motor  influence  is  transmitted  out- 


148 


PRINCIPLES  OF  MEDICINE. 


wards  by  one  or  more  efferent  or  exodic  nerves.  3d,  This  stimulates  the 
contractility  of  the  muscles  to  which  the  latter  are  distributed,  and 
motion  is  the  result.  Lastly,  contractility  may  be  called  into  action  by 
psychical  stimuli  or  mental  acts — such  as  by  the  will  and  by  certain 
emotions.  Integrity  of  the  muscular  structure  is  necessary  for  contractile 
movements;  of  the  spinal  cord,  for  diastaltic  or  reflex  movements;  and 
of  the  brain  proper,  for  voluntary  or  emotional  movements. 

Thus,  then,  we  may  consider  that  the  brain  acting  alone  furnishes  the 
conditions  necessary  for  intelligence ; the  spinal  cord  acting  alone  fur- 
nishes the  conditions  essential  for  the  co-ordinate  movements  necessary  to 
the  vital  functions : and  the  brain  and  spinal  cord  acting  together  furnish 
the  conditions  necessary  for  voluntary  motion  and  sensation. 

The  following  aphorisms  will  be  found  useful  in  endeavoring  to 
reason  correctly  on  the  functions  of  the  nervous  system : 

1.  The  brain  proper  is  that  portion  of  the  encephalon  situated 
above  the  Corpus  Callosum. 

2.  The  spinal  cord  is  divided  into  a cranial  and  a vertebral  portion. 

3.  The  grey  matter  evolves  and  the  white  conducts  nervous  power. 

4.  ContractilUy  is  the  property  peculiar  to  fibrous  texture,  whereby 
it  is  capable  of  shortening  its  fibres.  Motion  is  of  three  kinds,  contractile^ 
dependent  on  muscle — diastaltic,  dependent  on  muscle  and  spinal  cord — 
voluntary,  dependent  on  muscle,  spincti  cord,  and  brain. 

5.  Sensibility  or  excitability  is  the  property  peculiar  to  nervous  tex- 
ture, whereby  it  is  capable  of  receiving  impressions.  Sensation  is  the 
consciousness  of  receiving  such  impressions. 

General  Pathology  of  the  Nervous  System. 

For  the  purposes  of  diagnosis  and  treatment,  it  is  a matter  of  great 
importance  to  attend  to  the  following  pathological  laws  which  regulate 
diseased  action  of  the  nervous  centres. 

(1.)  The  amount  of  fluids  within  the  cranium  must  always  be  the 
same  so  long  as  its  osseous  lualls  are  capable  of  resisting  the  pressure  of 
the  atmosphere.  There  are  few  principles  in  medicine  of  greater  practical 
importance  than  the  one  yre  are  about  to  consider, — the  more  so,  as  many 
able  practitioners  have  lately  abandoned  their  former  opinions  on  this 
head,  and  on  what  I consider  to  be  very  insufficient  grounds.  On  this 
point,  therefore,  I cannot  do  better  than  condense  and  endeavor  to  put 
clearly  before  you  the  forcible  arguments  of  the  late  Dr.  John  Reid,  with 
such  other  considerations  as  have  occurred  to  myself. 

That  the  circulation  within  the  cranium  is  different  from  that  in 
other  parts  of  the  body,  was  first  pointed  out  by  the  second  Monro.  It 
was  tested  experimentally  by  Dr.  Kellie  of  Leith,  ably  illustrated  by  Dr. 
Abercrombie,  and  successfully  defended  by  Dr.  John  Reid.  The  views 
adopted  by  these  distinguished  men  were,  that  the  cranium  forms  a 
spherical  bony  case  capable  of  resisting  the  atmospheric  pressure,  the 
only  openings  into  it  being  the  different  foramina  by  which  the  vessels, 
nerves,  and  spinal  cord  pa^ss.  The  encephalon,  its  membranes,  and  blood- 
vessels, with  perhaps  a small  portion  of  the  cerebro-spinal  fluid,  com- 


HEALTHY  AND  DISEASED  INNERVATION. 


149 


pletely  fill  up  the  interior  of  the  cranium,  so  that  no  substance  can  be 
dislodged  from  it  without  some  equivalent  in  bulk  taking  its  place.  Dr. 
Monro  used  to  point  out,  that  a jar,  or  other  ve.ssel  similar  to  the  cranium, 
with  unjieldihg  walls,  if  filled  with  any  substance,  cannot  be  emptied 
without  air  or  some  substance  taking  its  place.  To  use  the  illustration 
of  Dr.  Watson,  the  contents  of  the  cranium  are  like  beer  in  a barrel, 
which  will  not  flow  out  of  one  opening  unless  provision  be  made  at  the 
same  time  that  air  rushes  in.  The  same  kind  of  reasoning  applies  to  the 
spinal  canal,  which,  with  the  interior  of  the  cranium,  may  be  said  to 
constitute  one  large  cavity,  incompressible  by  the  atmospheric  air. 

Before  proceeding  further,  we  must  draw  a distinction  between  pressure 
on,  and  compression  of,  an  organ.  Many  bodies  are  capable  of  sustaining 
a great  amount  of  pressure  without  undergoing  any  sensible  decrease  in 
bulk.  By  compression  must  be  understood,  that  a substance  occupies 
less  space  from  the  application  of  external  force,  as  when  we  squeeze  a 
sponge,  or  compress  a bladder  filled  with  air.  Fluids  generally  are  not 
absolutely  incompressible,  yet  it  requires  the  weight  of  one  atmosphere, 
or  fifteen  pounds  on  tli3  square  inch,  to  produce  a diminution  equal  to 
2 0^00  whole.  Now  this  is  so  exceedingly  small  a change 

upon  a mass  equal  in  bulk  to  the  brain,  as  not  to  be  appreciable  to  our 
senses.  Besides,  the  pressure  on  the  internal  surface  of  the  blood-vessels 
never  exceeds  ten  or  twelve  pounds  on  the  square  inch  during  the  most 
violent  exertion,  so  that,  under  no  possible  circumstances,  can  the  contents 
of  the  cranium  be  diminished  even  the  20000^^  part.  When  the  brain 
is  taken  out  of  the  cranium,  it  may,  like  a sponge,  be  compressed,  by 
squeezing  fluid  out  of  the  blood-vessels ; but  during  life,  surrounded,  as 
it  is,  by  unyielding  walls,  this  is  impossible.  For  let  us,  with  Aber- 
crombie, say,  that  the  whole  quantity  of  blood  circulating  within  the 
cranium  is  equal  to  10,  this  is  5 in  the  veins,  and  5 in  the  arteries;  if 
one  of  these  be  increased  to  6,  the  other  must  be  diminished  to  4,  so  that 
the  same  amount,  10,  shall  always  be  preserved.  It  follows,  that  when 
fluids  are  effused,  blood  extravasated,  or  tumors  grow  within  the  cranium, 
a corresponding  amount  of  fluid  must  be  pressed  out,  or  of  brain  absorbed, 
from  the  physical  impossibility  of  the  cranium  holding  more  matter.  At 
the  same  time,  it  must  be  evident  that  an  increased  or  diminished  amount 
of  pressure  may  be  exerted  on  the  brain,  proportioned  to  the  power  of  the 
heart’s  contraction,  the  effect  of  which  will  be,  not  to  alter  the  amount  of 
fluids  within  the  cranium,  but  to  cause,  usiug  the  words  of  Abercrombie, 
“ a change  of  circulation”  there.  This  is  all,  it  seems  to  me,  that  is 
shown  by  the  ingenious  experiments  of  Bonders,  who  saw  venous  con- 
gestion through  glass  plates  fixed  in  the  crania  of  rabbits.^ 

Dr.  Kellie  performed  numerous  experiments  on  cats  and  dogs,  in 
order  to  elucidate  this  subject.  Some  of  these  animals  were  bled  to 
death  by  opening  the  carotid  or  femoral  arteries,  others  by  opening  the 
jugular  veins.  In  some  the  carotids  were  first  tied,  to  diminish  the 
quantity  of  blood  sent  to  the  brain,  and  the  jugulars  were  then  opened, 
with  the  view  of  emptying  the  vessels  of  the  brain  to  the  greatest  possible 
extent;  while,  in  others,  the  jugulars  were  first  secured,  to  prevent  as 
much  as  possible  the  return  of  the  blood  from  the  brain,  and  one  of  the 
* Nederlandeche  Lancet,  1850. 


150 


PEINCIPLES  Of  medicine. 


carotids  was  then  opened.  He  inferred,  from  the  whole  inquiry,  which 
was  conducted  with  extreme  care,  “ That  we  cannot,  in  fact,  lessen,  to 
any  considerable  extent,  the  quantity  of  blood  within  the  cranium  by 
arteriotomy  or  venesection ; and  that  when,  by  profuse  haemorrhages,  de- 
structive of  life,  we  do  succeed  in  draining  the  vessels  within  the 
cranium  of  any  sensible  portion  of  red  blood  there  is  commonly  found 
an  equivalent  to  this  spoliation  in  the  increased  circulation  or  effusion  of 
serum,  serving  to  maintain  the  plenitude  of  the  cranium.” 

Dr.  Kellie  made  other  experin'.ents  upon  the  effects  of  position  imme- 
diately after  death  from  strangulation  or  hanging.  He  also  removed  a 
portion  of  the  unyielding  walls  of  the  cranium  in  some  animals,  by  means 
of  a trephine,  and  then  bled  them  to  death;  and  the  differences  between 
the  appearances  of  the  brain  in  these  cases,  and  in  those  where  the  cranium 
was  entire,  were  very  great.  One  of  the  most  remarkable  of  these  diffei- 
encos  was  its  shrunk  appearance,  in  those  animals  in  which  a portion  of 
the  skull  was  removed,  and  the  air  allowed  to  gravitate  upon  its  inner 
surface.  He  says : — “ The  brain  was  sensibly  depressed  below  the  cra- 
nium, and  a space  left,  which  was  found  capable  of  containing  a tea- 
spoonful of  water.” 

It  results  from  these  inquiries,  that  there  must  always  be  the  same 
amount  of  fluids  within  the  cranium  so  long  as  it  is  uninjured.  In 
morbid  conditions  these  fluids  may  be  blood,  serum,  or  pus ; but  in 
health,  as  blood  is  almost  the  only  fluid  present  (the  ce'rebro-spinal  fluid 
being  very  trifling),  its  quantity  can  undergo  only  very  slight  alterations. 
There  are  many  circumstances,  however,  which  occasion  local  congestions 
in  the  brain,  and  consequently  unequal  pressure  on  its  structure,  in  which 
case  another  portion  of  its  substance  must  contain  less  blood,  so  that  the 
amount  of  the  whole,  as  to  quantity,  is  always  preserved.  These  circum- 
stances are  mental  emotions,  haemorrhages,  effusions  of  serum,  and  morbid 
growths.  Such  congestions,  or  local  hyperhemias,  in  themselves  constitute 
morbid  conditions  ; and  nature  has,  to  a great  extent,  provided  against 
their  occurrence  under  ordinary  circumstances,  by  the  tortuosity  of  the  ar- 
teries and  the  presence  of  the  cerebro-spinal  fluid,  described  by  Magendie. 

The  views  now  detailed  had  been  very  extensively  admitted  into 
pathology,  when  Dr.  Burrows,  of  St.  Bartholomew’s  Hospital,  endeavored 
to  controvert  them,  first  in  the  Lumleian  lectures  of  1843,  and  subse- 
quently in  a work  published  in  1846,  entitled  “ On  Disorders  of  the 
Cerebral  Circulation,  and  on  the  connections  between  Affections  of  the 
Brain  and  Diseases  of  the  Heart.”  Dr.  Burrows,  however,  evidently 
misunderstood  the  doctrine  we  are  advocating.  Thus,  he  is  always  com- 
bating the  idea  that  blood-letting,  position,  strangulation,  etc.,  cannot 
affect  the  hlood  m the  hrain  ; whereas  the  real  proposition  is,  that  they 
cannot  alter  t\\Q  fluids  within  the  cranium.  By  thus  confounding  blood 
with  fluid,  and  brain  with  cranium,  he  has  only  overthrown  a doctrine  of 
his  own  creation. 

Dr.  Burrows  has  brought  forward  several  observations  and  experi- 
ments, which  he  considers  opposed  to  the  theory  now  advocated.  His 
facts  are  perfectly  correct.  I myself  have  repeated  his  experiments  on 
rabbits,  and  can  confirm  his  descriptions.  It  is  the  inferences  he  draws 
from  them  that  are  erroneous.  For  the  paleness  which  results  from 


HEALTHY  AND  DISEASED  INNEEVATION. 


151 


hseinorrliage,  and  the  difference  observable  in  the  color  of  the  brain, 
when  animals,  immediately  after  death,  are  suspended  by  their  ears  or 
by  their  heels,  is  explicable  by  the  diminished  number  of  colored  blood 
particles  in  the  one  case,  and  by  their  gravitation  downwards  in  the 
other.  That  the  amount  of  fluid  within  the  cranium  was  in  no  way 
affected,  is  proved  by  the  plump  appearance  of  the  brains  figured  by  Dr. 
Burrows,  and  the  total  absence  of  that  shrunken  appearance  so  well 
described  by  Dr.  Kellie. 

Neither  does  our  observation  of  what  occurs  in  asphyxia  or  apnoea, 
oppose  the  doctrine  in  question,  as  Dr.  Burrows  imagines,  but  rather 
confirms.it.  On  this  point  the  following  observations  by  Dr.  John  Beid 
are  valuable.  He  says — “ If  any  circumstance  could  produce  congestion 
of  the  vessels  within  the  cranium,  it  would  be  that  of  death  by  hanging; 
for  then  the  vessels  going  to  and  coming  from  the  brain  are,  with  the 
exception  of  the  vertebral  arteries,  compressed  and  then  obstructed. 
These  two  arteries,  which  are  protected  by  the  peculiarity  of  their  course 
through  the  foramina  of  the  transverse  processes  of  the  cervical  vertebras, 
must  continue  for  a time  to  force  their  blood  upon  the  brain,  while  a 
comparatively  small  quantity  only  can  escape  by  the  veins.  Indeed,  the 
greater  quantity  of  blood  carried  to  the  encephalon  by  the  vertebrals 
returns  by  the  internal  jugulars,  and  not  by  the  vertebral  veins,  which 
are  supplied  from  the  occipital  veins  of  the  spinal  cord ; and  the  anasto- 
moses, between  the  cranial  and  vertebral  sinuses,  could  carry  off  a small 
quantity  of  the  blood  only,  transmitted  along  such  large  arteries  as  the 
vertebrals.  And  yet  it  is  well  known  that  there  is  no  congestion  of  the 
vessels  within  the  cranium  after  death  by  hanging,  however  gorged  the 
external  parts  of  the  head  may  be  by  blood  and  serum.”  This  is  admit- 
ted by  Dr.  Burrows,  although  he  endeavors  to  get  rid  of  so  troublesome 
a fact  by  a gratuitous  hypothesis,  which  will  not  bear  a moment’s  exa- 
mination, but  for  the  refutation  of  which  I must  refer  to  the  works  of 
Dr.  Beid.^ 

On  the  whole,  whether  we  adopt  the  terms  of  local  congestion,  of 
change  of  circulation  within  the  cranium  (Abercrombie),  or  of  unequal 
pressure  (Burrows),  our  explanation  of  the  pathological  phenomena  may 
be  made  equally  correct,  because  each  of  these  modes  of  expression  im- 
plies pretty  much  the  same  thing.  But  if  we  imagine  that  venesection 
will  enable  us  to  diminish  the  amount  of  blood  in  the  cerebral  vessels,  the 
theory  points  out  that  this  is  impossible,  and  that  the  effects  of  bleeding 
are  explained  by  the  influence  produced  on  the  heart,  the  altered  pressure 
on  the  brain,  exercised  by  its  diminished  contractions,  and  the  change  of 
circulation  within  the  cranium  thereby  occasioned. 

I have  entered  somewhat  fully  into  this  theory,  because,  independent 
of  its  vast  importance  in  a practical  point  of  view,  it  is  one  which  origi- 
nated in  the  Edinburgh  School  of  Medicine.  Singular  to  say,  notwith- 
standing the  obvious  errors  and  fallacies  in  Dr.  Burrows’  work,  no  sooner 
did  it  appear,  than  the  whole  medical  press  of  England  and  Ireland 
adopted  its  conclusions,  and  even  Dr.  Watson,  in  the  two  last  editions  of 
his  excellent  work,  also  abandoned  the  theory  of  Monro,  Kellie,  and 
Abercrombie.  But  so  far  is  this  theory  concerning  the  circulation  within 
* Physiological,  Anatomical,  and  Pathological  Researches,  No.  XXV. 


152 


PPJJVCirLES  OF  MEDICINE. 


the  cranium  from  being  shaken  by  the  attack  of  Dr  Burrows,  that  ii  may 
be  said  now  to  stand  on  a firmer  basis  than  ever,  owing  to  that  attack 
having  drawn  forth  the  convincing  reasoning  and  unanswerable  argu- 
ments of  so  sound  an  anatomist,  physiologist,  and  pathologist,  as  the  late 
Dr.  John  Keid. 

(2.)  All  the  functions  of  the  nervous  system  may  he  increased,  'perverted^ 
or  destroyed^  according  to  the  degree  of  stimidus  or  disease  operating  on  its 
various  parts. — Thus,  as  a general  rule,  it  may  be  said,  that  a slight 
stimulus  produces  increased  or  perverted  action  ; whilst  the  same  stimu- 
lus, long  continued  or  much  augmented,  causes  loss  of  function.  All 
the  various  stimuli,  whether  mechanical,  chemical,  electrical,  or  psychical, 
produce  the  same  effects,  and  in  different  degrees.  Circumstances 
influencing  the  heart’s  action,  stimulating  drinks  or  food,  act  in  a like 
manner.  Thus,  if  we  take  the  effects  of  alcoholic  drink,  for  the  purpose 
of  illustration,  we  observe  that,  as  regards  combined  movements,  a slight 
amount  causes  increased  vigor  and  activity  in  the  muscular  system.  As 
the  stimulus  augments  in  intensity,  we  see  irregular  movements  occa- 
sioned, staggering,  and  loss  of  control  over  the  limbs.  Lastly,  when  the 
stimulus  is  excessive,  there  is  complete  inability  to  move,  and  the  power 
of  doing  so  is  temporarily  annihilated.  With  regard  to  sensibility  and 
sensation,  we  observe  cephalagia,  tingling,  and  heat  of  skin,  tinnitus 
aurium,  confusion  of  vision,  muscse  volitantes,  double  sight,  and  lastly, 
complete  insensibility  and  coma.  As  regards  intelligence,  we  observe  at 
first  rapid  flow  of  ideas,  then  confusion  of  mind,  delirium,  and  lastly, 
sopor  and  perfect  unconsciousness.  In  the  same  manner  pressure,  me- 
chanical irritation,  and  the  various  organic  diseases,  produce  augmented, 
perverted,  or  diminished  function,  according  to  the  intensity  of  the  sti- 
mulus applied,  or  amount  of  structure  destroyed. 

Then  it  has  been  shown  that  excess  or  diminution  of  stimulus,  too 
much  or  too  little  blood,  very  violent  or  very  weak  cardiac  contractions, 
and  plethora  or  extreme  exhaustion,  will,  so  far  as  the  nervous  functions 
are  concerned,  produce  similar  alterations  of  motion,  sensation,  and  in- 
telligence. Excessive  haemorrhage  causes  muscular  weakness,  convul- 
sions, and  loss  of  motor  power,  perversions  of  all  the  sensations,  and 
lastly,  unconsciousness  from  syncope.  Hence  the  general  strength  of  the 
frame  cannot  be  judged  of  by  the  nervous  symptoms,  although  the  treat- 
ment of  these  will  be  altogether  different,  according  as  the  individual  is 
robust  or  weak,  has  a full  or  small  pulse,  etc.  These  similar  effects  on 
the  nervous  centres  from  apparently  such  opposite  exciting  causes,  can, 
it  seems  to  me,  only  be  explained  by  the  peculiarity  of  the  circulation 
previously  noticed.  A change  of  circulation  within  the  cranium  takes 
place,  and,  whether  arterial  or  venous  congestion  occurs,  pressure  (3n 
some  portion  of  the  organ  is  ecpially  the  result.  The  importance  of  pay- 
ing attention  to  this  point  in  the  treatment  must  be  obvious. 

(3.)  The  seat  of  the  disease  in  the  nervous  system  influences  the  nature  of 
the  phenomena  or  symptoms  produced.  — It  is  a matter  of  very  great  im- 
portance to  ascertain  how  far  certitude  in  diagnosis  may  be  arrived  at, 
and  the  seat  of  the  disease  ascertained.  On  this  subject  it  may  be  affirmed 
that,  although  clinical  observation  combined  with  pathology  has  done 
much,  more  requires  to  be  accomplished.  As  a general  rule,  it  may  be 


HEALTHY  AND  DISEASED  INNERVATION. 


153 


stated,  that  disease  or  injury  of  one  side  of  the  encephalon,  especially 
influences  the  opposite  side  of  the  body.  It  is  said  that  some  very 
striking  exceptions  have  occurred  to  this  rule,  but  these  at  any  rate  are 
remarkably  rare.  Besides,  it  has  always  appeared  to  me  probable  that, 
inasmuch  as  extensive  organic  disease,  if  occurring  slowly,  may  exist 
without  producing  symptoms,  whilst  it  is  certain  most  important  symp- 
toms may  be  occasioned  without  organic  disease,  even  these  few  excep- 
tional cases  are  really  not  opposed  to  the  general  law.  Then,  as  a general 
rule,  it  may  be  said  that  diseases  of  the  brain  proper  are  more  especially 
connected  with  perversion  and  alteration  of  the  intelligence ; whilst 
disease  of  the  cranial  portion  of  the  spinal  cord  and  base  of  the  cranium 
are  more  particularly  evinced  by  alterations  of  sensation  and  motion.  In 
the  vertebral  portion  of  the  cord,  the  intensity  of  pain  and  of  spasm,  or 
else  the  want  of  conducting  power,  necessary  to  sensation  and  voluntary 
motion,  indicates  the  amount  to  which  the  motor  and  sensitive  fibres  are 
aflected.  Further  than  this  we  can  scarcely  generalise  with  prudence, 
although  there  are  some  cases,  as  we  shall  subsequently  see,  where  care- 
ful observation  has  enabled  us  to  arrive  at  more  positive  results. 

The  fatality  of  lesions  afiecting  various  parts  of  the  nervous  centres 
varies  greatly.  Thus  the  hemispheres  may  be  extensively  diseased,  often 
without  injury  to  life,  or  even  permanent  alteration  of  function.  Con- 
vulsions and  paralysis  are  the  common  results  of  disease  of  the  ganglia, 
in  the  cranial  portion  of  the  cord.  The  same  results  from  lesion  of  the 
pons  varolii.  But  if  the  medulla  oblongata,  where  the  eighth  pair 
originates,  be  affected,  or  injury  to  this  centre  itself  occur,  it  is  almost 
always  immediately  fatal. 

(4.)  The  rapidity  or  sloivness  with  which  the  lesion  occurs  influences  the 
phenomena  or  symptoms  produced. — It  may  be  said  as  a general  rule,  that 
a small  lesion  (for  instance,  a small  haemorrhagic  extravasation),  occur- 
ring suddenly,  and  with  force,  produces,  even  in  the  same  situation,  more 
violent  effects  than  a very  extensive  organic  disease  which  comes  on 
slowly.  This,  however,  will  depend  much  upon  the  seat  of  the  lesion. 
Very  extraordinary  cases  are  on  record,  where  large  portions  of  the 
nervous  centres  have  been  disorganised,  without  producing  anything  like 
the  violent  symptoms  which  have  been  occasioned  at  other  times  by  a 
small  extravasation  in  the  same  place.  -Here  again  the  nature  of  the 
circulation  within  the  cranium  offers  the  only  explanation,  for  the  ence- 
phalon must  undergo  a certain  amount  of  pressure,  if  no  time  be  allowed 
for  it  to  adapt  itself  to  a foreign  body;  whereas  any  lesion  coming  on 
slowly  enables  the  amount  of  blood  in  the  vessels  to  be  diminished  ac- 
cording to  circumstances,  wdiereby  pressure  is  avoided. 

(5.)  The  various  lesions  and  injarics  of  the  nervous  system  produce  phe- 
nomena similar  in  hind. — The  injuries  which  may  be  inflicted  on  the  ner- 
vous system,  as  well  as  the  morbid  appearances  discovered  after  death, 
are  various.  For  instance,  there  may  be  an  extravasation  of  blood, 
exudation  of  lymph,  a softening,  a cancerous  tumor,  or  tubercular 
deposit,  and  yet  they  give  rise  to  the  same  nervous  phenomena,  and  are 
modified  only  by  the  circumstances  formerly  mentioned,  of  degree,  seat, 
suddenness,  etc.  Certain  nervous  phenomena  also  are  of  a paroxysmal 
character,  whilst  the  lesions  supposed  to  occasion  them  are  stationary 


154 


PRINCIPLES  OF  MEDICINE. 


or  slowly  increasing.  It  follows,  that  the  effects  cannot  be  explained  by 
the  nature  of  the  lesions,  but  by  something  which  they  all  have  in  com- 
mon ; and  this,  it  appears  to  me,  may  consist  of — 1st,  Pressure  with  or 
without  organic  change  ; 2d,  More  or  less  destruction  or  disorganisation 
of  nervous  texture.  Further,  when  we  consider  that  the  same  nervous 
symptoms  arise  from  irregularities  in  the  circulation  ; from  increased  as 
well  as  diminished  action ; sometimes  when  no  appreciable  change  is 
found,  as  well  as  when  disorganisation  lias  occurred — the  theory  of  local 
congestions  to  explain  functional  alterations  of  the  nervous  centres  seems 
to  me  the  one  most  consistent  with  known  facts.  That  such  local  con- 
gestions do  frequently  occur  during  life,  without  leaving  traces  detectable 
after  death,  is  certain ; whilst  the  occurrence  of  molecular  changes,  or 
other  hypothetical  conditions  which  have  been  supposed  to  exist,  has 
never  yet  been  shown  to  take  place  under  any  circumstances. 

While  such  appear  to  me  to  be  some  of  the  generalisations  which  are 
important  to  the  physician  wdth  regard  to  the  nutritive  and  nervous 
functions,  viewed  separately,  it  should  never  be  forgotten  that  he  has 
constantly  to  do  with  their  conjoint  action.  Indeed,  the  derangement  of 
one  order  of  functions  exercises  a constant  influence  over  the  other,  so 
that  in  every  disease  the  effects  of  disordered  nutrition  are  visible  in 
perverted  innervation,  and  the  converse.  Thus  an  improper  quantity  or 
quality  of  food  produces  sometimes  excitement,  at  others  dulness  of  in- 
tellect. Various  articles  of  diet  have  been  known  to  cause  violent  head- 
ache and  different  kinds  of  nervous  phenomena,  while  starvation,  if  long 
continued,  excites  delirium,  paroxysms  of  mania,  and  lastly  stupor.  In 
children,  derangement  of  the  alimentary  canal  is  the  most  common  cause 
of  spasm  and  convulsion,  and  in  the  aged  it  often  leads  to  apoplexies  and 
palsy.  Again,  impeded  respiration,  poverty  of  the  blood,  accumulation 
of  effete  matters  in  the  system,  suppressed  secretions  and  obstructed 
excretions,  are  all  accompanied  or  followed  by  disorders  of  innervation. 
On  the  other  hand,  the  influence  of  the  nervous  system  on  nutrition  is 
equally  apparent.  Syncope  and  even  death  itself  have  been  occasioned 
by  mental  emotions.  Anxiety  and  suppressed  grief  predispose  to  diseases 
of  the  stomach,  and  thereby  to  altered  nutrition,  terminating  in  various 
maladies.  The  reception  of  joyful  or  distressing  intelligence,  it  is  well 
known,  invigorates  or  depresses  the  bodily  energies.  Various  organs  are 
excited  to  action  by  particular  trains  of  thoughts  or  desires,  and  the 
countenance  is  reddened  by  modesty,  and  blanched  by  fear.  As  a 
general  rule,  it  may  be  said,  while  slight  emotions  increase  the  secretions, 
very  violent  ones,  particularly  if  suppressed,  completely  suspend  them, 
and  are  most  dangerous  to  life.'^  Direct  mechanical  injury  to  the  large 
nervous  trunks,  in  addition  to  causing  paralysis,  is  now  recognised  in 
some  cases  to  produce  increased  heat  and  redness  in  parts,  often  followed 
by  exudation  and  ulceration.  In  chronic  cases,  such  paralysis  leads  to 
atrophy,  and  withering  of  a limb,  or  some  other  portion  of  the  body. 

Very  rarely,  injury  of  a great  sympathetic  trunk  produces  similar 
loss  of  nutrition  without  impairment  of  sensibility  or  motion,  of  which 

* “ Give  sorrow  words  ; the  grief  that  will  not  speak, 

Whispers  the  o’erfraught  heart,  and  bids  it  break.” — Shakspeare. 


INFLAMMATION. 


155 


tlio  most  remarkable  example  I am  acquainted  with  is  recorded  by  Pro- 
fessor Komberg  of  Berlin.  It  was  that  of  an  unmarried  woman,  aged 
twenty-eight,  in  whom,  as  the  result  of  extensive  suppuration  on  the 
left  side  of  the  neck,  which  burst  through  the  tonsil,  the  features  on 
the  corresponding  side  of 
the  face  gradually  became 
atrophied,  without  any  di- 
minution of  sensibility  or 
motion.  Looking  at  the 
two  halves  of  the  face  sepa- 
rately, it  appeared  as  if  the 
one  belonged  to  a young, 
and  the  other  to  an  old 
woman.  By  some  it  was 
supposed  that  the  diseased 
side  was  sound,  and  that 
the  other  was  swollen.  The 
hair,  eyebrows,  and  eye- 
lashes were  very  thin  on 
the  affected  side,  and  she 
was  in  the  habit  of  divid- 
ing her  hair  towards  the 
right,  so  as  to  equalise  the 
quantity.  Every  feature, 
including  the  brow,  eye, 
nostril,  lips,  cheek,  and 
chin,  as  well  as  the  left 
half  of  the  tongue  and 
left  palatine  arch,  was  smaller  than  those  of  the  opposite  one. 

Further  illustrations  of  the  general  principles  now  detailed  wi.l  be 
constantly  met  with  under  the  head  of  special  diseases. 

INFLAMMATION. 

The  important  morbid  change  in  the  animal  economy  denominated 
inflammation,  is  so  intimately  interwoven  with  the  theory  and  practice 
of  medicine,  that  it  meets  us  at  the  very  commencement  of  our  patho- 
logical inquiries.  In  all  ages  it  has  been  made  the  pivot  upon  which 
the  medical  philosophy  of  the  time  has  revolved,  and  any  doctrine  capable 
of  explaining  the  various  phenomena  it  presents,  cannot  but  furnish  those 
principles  on  which  our  science  and  art  must  ultimately  rest. 

I. — Phenomena  of  Inflammation. — When,  with  the  view  of  deter- 
mining the  phenomena  of  inflammation,  we  sufficiently  irritate  the  trans- 
parent vascular  membrane  of  some  animal — such  as  the  web  of  the  frog’s 
foot — we  observe,  1st,  An  increased  rapidity  of  the  circulation  in  the 
smaller  vessels ; 2d,  That  the  same  x^essels  become  enlarged,  and  the 
current  of  blood  is  slower,  although  even ; 3d,  That  the  fl^ow  of  blood 

Fir;.  184.  Remarkable  atrophy  of  the  left  side  of  the  face,  in  a woman  aged  28, 
without  loss  of  sensibility  or  motion  in  the  atfected  parts. — {Romberc/.) 


156 


PRINCIPLES  OF  MEDICINE. 


becomes  irregular  and  oscillates;  4th,  That  the  current  ceases,  and  the 
vessels  are  distended  with  colored  corpuscles ; and  5th,  That  the  liquor 
sanguinis  is  exuded  through  the  walls  of  the  vessels,  and  that  occasionally, 
in  consequence  of  their  rupture,  extravasation  of  blood  corpuscles  takes 
place. 

The  first  step  in  the  process,  viz.,  narrowing  of  the  capillaries,  is 
readily  demonstrated  on  the  application  of  acetic  acid  to  the  web  of  the 
frog’s  foot.  If  the  acid  be  weak,  the  capillary  contraction  occurs  more 
slowly  and  gradually.  If  it  be  very  concentrated,  the  phenomenon  is 
not  observed,  or  it  passes  so  quickly  into  complete  stoppage  of  blood,  as 
to  be  imperceptible.  Although  we  cannot  see  these  changes  in  man 
under  the  microscope,  certain  facts  indicate  that  the  same  phenomena 
occur.  The  operations  of  the  mind,  for  instance,  as  fear  and  fright,  and 
the  application  of  cold,  produce  paleness  of  the  skin,  an  effect  which  can 
only  arise  from  contraction  of  the  capillaries,  and  a diminution  of  the 
quantity  of  blood  they  contain.  In  the  majority  of  instances,  also,  this 
paleness  is  succeeded  by  increased  redness,  the  same  result  as  follows 
from  direct  experiment  on  the  web  of  the  frog’s  foot,  and  wdiich  con- 
stitutes the  second  step  of  the  process.  In  other  cases,  the  redness  may 
arise  primarily  from  certain  mental  emotions,  or  from  the  application  of 
heat ; and  in  both  instances  depends  on  the  enlargement  of  the  capillaries, 
and  the  greater  quantity  of  blood  which  is  thus  admitted  into  them.'^ 

The  variation  in  the  size  of  the  capillaries,  and  of  the  amount  of 
blood  in  them,  is  conjoined  with  changes  in  the  movement  of  that  fluid. 
Whilst  the  vessels  are  contracted,  the  blood  may  be  seen  to  flow  with 
increased  velocity.  After  a time  the  blood  flows  more  and  more  slowly, 
without,  however,  the  vessel  being  obstructed  : it  then  oscillates,  that  is, 
moves  forwards  and  backwards,  or  makes  a pause,  which  is  evidently 
synchronous  with  the  ventricular  diastole  of  the  heart.  At  length  the 
vessel  appears  quite  distended  with  yellow  or  colored  corpuscles,  and  all 
movement  ceases. 

Again,  these  changes  in  the  movement  of  the  blood  induce  variations 
in  the  relation  which  the  blood  corpuscles  bear  to  each  other,  and  to  the 

* It  has  been  asserted  that  instead  ot  contraction  of  the  capillaries,  the  first 
changes  observable  are  enlargement  with  an  increased  flow  of  blood.  To  determine 
positively  the  question  of  contraction  or  dilatation,  I have  made  a series  of  careful 
observations  on  the  web  of  a frog’s  foot.  Having  fixed  the  animal  in  such  a way  that 
it  could  not  move,  I carefully  measured  with  Oberhaeuser’s  eye  micrometer  the  diameter 
of  various  vessels  before,  during,  and  after  the  application  of  stimuli.  The  results 
were,  that  immediately  hot  water  was  applied,  a vessel  which  measured  13  spaces  of 
the  eye  micrometer  contracted  to  10 ; another  that  measured  10  contracted  to  V ; a 
third  that  measured  7 contracted  to  5 ; a fourth,  which  was  a capillary  carrying  blood 
globules  in  single  file,  and  measured  6,  was  contracted  to  4 ; and  another  one  of  the 
smallest  size  which  measured  4 was  contracted  to  3.  With  regard  to  the  ultimate 
capillaries,  it  was  frequently  observed  that  if  filled  with  corpuscles,  they  contracted 
little,  but  if  empty,  the  contraction  took  place  from  4 to  2,  so  that  no  more  corpuscles 
entered  them,  and  they  appeared  obliterated.  This  was  especially  seen  after  the  ad- 
dition of  acetic  acid.  It  was  also  observed  that  minute  vessels  that  contracted  from 
4 to  3,  afterwards  became  dilated  to  6 before  congestion  and  stagnation  occur- 
red. The  smaller  veins  were  seen  to  contract  as  much  as  the  arteries  of  the  same 
size. 


INFLAMMATION. 


lo7 

walls  of  the  vessel.  In  the  natural  circulation  of  the  frog’s  foot,  the 
yellow  corpuscles  may  be  seen  rolling  forward  in  the  centre  of  the  tube, 
a clear  space  being  left  on  each  side,  which  is  filled  only  with  liquor 
sanguinis  and  a few  lymph  corpuscles.  There  are  evidently  two  cur- 
rents— one  at  the  centre,  which  is  very  rapid,  and  one  at  the  sides  (in  the 
lymph  spaces,  as  they  are  called),  much  slower.  The  colored  corpuscles 
are  hurried  forward  in  the  centre  of  the  vessel,  occasionally  mixed  with 


Fig.  135. 

some  lymph  corpuscles.  These  latter,  however,  may  frequently  be  seen 
clinging  to  the  sides  of  the  vessel,  or  slowly  proceeding  a short  distance 
along  it  in  the  lymph  space,  and  then  again  stopping.  Occasionally  the 
lymph  corpuscles  get  into  the  central  torrent,  whence  they  are  carried  off 
with  great  velocity,  and  accompany  the  yellow  corpuscles.  It  has  been 
said  that  these  corpuscles  augment  in  number,  accumulate  in  the  lymph 
spaces,  and  obstruct  the  flow  of  blood.  In  young  frogs,  their  number  is 
often  very  great ; but  then  they  constitute  a normal  part  of  the  blood. 

Fig.  135.  An  exact  copy  of  a portion  of  the  web  in  the  foot  of  a young  frog,  after 
a drop  of  strong  alcohol  had  been  placed  upon  it.  The  view  exhibits  a deep-seated 
•artery  and  vein,  somewhat  out  of  focus;  the  intermediate  or  capillary  plexus  running 
over  them,  and  pigment  cells  of  various  sizes  scattered  over  the  whole.  On  the  left 
of  the  figure,  the  circulation  is  still  active  and  natural.  About  the  middle  it  is  more 
slow,  the  column  of  blood  is  oscillating,  and  the  corpuscles  crowded  together.  On 
the  right,  congestion,  followed  by  exudation,  has  taken  place. 

а,  A deep-seated  vein,  partially  out  of  focus.  The  current  of  blood  is  of  a deeper 
color,  and  not  so  rapid  as  that  in  the  artery.  It  is  running  in  the  opposite  direc- 
tion. The  lymph  space  on  each  side,  filled  with  slightly  yellowish  blood  plasma,  is 
very  apparent,  containing  a number  of  colorless  corpuscles,  clinging  to,  or  slowly 
moving  along,  the  sides  of  the  vessel. 

б,  A deep-seated  artery,  out  of  focus,  the  rapid  current  of  blood  allowing  nothing 
to  be  perceived  but  a reddish-yellow  broad  streak,  with  lighter  spaces  at  the  sides. 

Opposite  c,  laceration  of  capillary  vessel  has  produced  an  extravasation  of  blood, 
which  resembles  a brownish-red  spot. 

At  (Z,  congestion  has  occurred,  and  the  blood  corpuscles  are  apparently  merged 
into  one  semitransparent  reddish  mass,  entirely  filling  the  vessels.  The  spaces  of 
the  web,  between  the  capillaries,  are  rendered  thicker  and  less  transparent,  j)artly  by 
the  action  of  the  alcohol,  partly  by  the  exudation.  This  latter  entirely  fills  up  tho 
spaces,  or  only  coats  the  vessel.  20U  diam. 


158 


PEmCIPLES  OF  MEDICINE. 


and  in  no  way  impede  the  circulation.  In  old  frogs,  on  the  other  hand, 
all  these,  and  subsequent  changes,  may  be  observed,  without  the  presence 
of  colorless  corpuscles.  When  the  capillaries  enlarge,  however,  the 
central  colored  column  in  the  smaller  vessels  may  be  seen  to  enlarge 
also,  and  gradually  approach  the  sides  of  the  tube,  thus  encroaching  on 
the  lymph  spaces.  The  slower  the  motion  of  the  blood,  the  more  the 
lymph  spaces  are  encroached  on,  until  at  length  the  colored  corpuscles 
come  in  contact  with  the  sides  of  the  vessel ; and  are  compressed  and 
changed  in  form.  The  vessel  is  at  length  completely  distended  with 
colored  corpuscles,  the  original  form  of  which  can  no  longer  be  dis- 
covered, so  that  the  tube  appears  to  be  filled  with  a homogeneous  deep 
crimson  fluid.  This  is  congestion.  If  the  morbid  processes  continue,  the 
vessel  may  burst,  causing  haemorrhage,  or  the  liquor  sanguinis  may  trans- 
ude through  its  walls,  without  rupture,  into  the  surrounding  texture. 
This  last  is  exudation. 

II.  Theory  of  Inflammation. — It  is  of  the  utmost  importance  in 
pathological  inquiries  to  separate  facts  from  theories.  Our  facts  may  be 
correct,  although  the  conclusions  derived  from  them  are  wrong.  This 
proposition,  however  generally  admitted,  is  seldom  adhered  to  in  prac- 
tice ; for,  in  medical  writings  and  statements,  we  frequently  find  fact  and 
hypothesis  so  mingled  together,  that  it  often  requires  considerable  critical 
and  analytical  power  to  separate  the  one  from  the  other.  We  are,  how- 
ever, in  all  cases,  insensibly  led  to  theorise — that  is,  to  attempt  an  ex- 
planation of  the  phenomena  observed,  in  order  that  we  may  derive  from 
them  some  general  principle  for  our  guidance.  Such  speculation  is 
always  legitimate,  so  long  as  we  consider  opinions  to  be  mere  generalisa- 
tions of  known  facts,  and  are  ready  to  abandon  them  the  moment  other 
facts  point  them  out  to  be  erroneous.  The  phenomena  of  inflammation, 
previously  described,  may  easily  be  demonstrated — they  constitute  the 
facts.  Let  us  now  examine  how  they  have  been  attempted  to  be  ex- 
plained— in  other  words,  what  is  the  theory. 

1.  The  contraction  and  dilatation  of  the  capillaries  are  explicable,  by 
supposing  them  to  be  endowed  with  a power  of  contractility  analogous 
to  that  existing  in  non-voluntary  muscles.  John  Hunter  thought  they 
were  muscular,  from  the  results  of  his  observations  and  experiments; 
and  they  may  be  shown  by  the  histologist  to  consist  of  a delicate  mem- 
brane, in  which  permanent  nuclei  are  imbedded.  Mr.  Lister  has  recently 
shown  that  much  of  the  contractility  is  dependent  on  fusiform  cells, 
which  have  the  property  of  shortening  themselves,  and  which  run  trans- 
versely round  the  vessels.  In  structure,  then,  they  possess  elements 
closely  resembling  the  muscular  fibres  of  the  intestine,  and  we  know 
that,  like  them,  they  may  be  contracted  or  dilated  by  emotions  of  the 
mind  (that  is,  through  the  nerves),  or  by  local  applications,  that  is 
directly.  The  narrowing  of  these  tubes,  therefore,  may  be  considered,  as 
Cullen  thought  it  was,  analogous  to  spasm ; while  their  dilatation  may 
be  referred  either  to  the  relaxation  which  follows  such  spasm,  or  to 
muscular  paralysis.  The  recent  observations  of  Cl.  Bernard  and  others 
as  to  the  effects  produced  by  dividing  the  large  nervous  trunk  of  the 
sympathetic  in  the  neck,  have  singularly  confirmed  this  theory. 


INTLAMMATIOX. 


159 


2 The  rapid  and  slow  movement  of  the  blood  is  explicable  on  the 
hydraulic  principle,  that  when  a certain  quantity  of  fluid  is  driven  for- 
ward with  a certain  force  through  a pervious  tube,  and  the  tube  is  nar- 
rowed or  widened,  while  the  propelling  force  remains  the  same,  the  fluid 
must  necessarily  flow  quicker  in  the  first  case  and  slower  in  the  second. 
It  has  been  supposed,  from  the  throbbing  of  large  vessels  leading  to  con- 
gested parts,  that  they  pump  a larger  quantity  of  blood  than  usual  into 
them.  This  was  called  “ determination  of  blood  ” by  the  older  patholo- 
gists, and  is  now  known  not  to  be  a cause,  but  a result,  of  the  changes 
going  on  in  the  capillary  vessels  and  tissues  of  the  affected  part.  The 
oscillatory  movement,  seen  later  in  the  transparent  parts  of  small  animals, 
has  not  been  observed  in  man,  and  probably  depends,  in  the  former,  on 
a weakened  power  of  the  heart. 

3.  It  is  the  stoppage  of  the  blood,  and  exudation  of  the  liquor  san- 
guinis, however,  which  is  most  difficult  to  explain ; for  why,  so  long  as 
there  is  no  mechanical  obstruction  (and  during  this  process  none  has  ever 
been  seen),  should  the  circulation  through  the  capillaries  of  a part  cease  ? 

In  reasoning  on  this  matter,  observation  must  ultimately  satisfy  us 
that  it  cannot  depend  upon  any  mechanical  impediment,  such'  as  the 
plugging-up  of  the  vessel  by  colored  corpuscles  (Boerhaave)  ; multipli- 
cation of  the  colorless  corpuscles  (Addison  and  Williams) ; change  in 
the  specific  gravity  or  viscidity  of  the  blood  in  a part  (Wharton  Jones), 
or  of  the  corpuscles  in  particular  (Bruecke) ; obstruction  of  the  venous 
circulation  (G.  Robinson) ; or  adhesiveness  of  the  blood  corpuscles  (Lister.) 
That  the  blood  corpuscles,  indeed,  have  a tendency  to  aggregate  together 
is  certain;  and  I have  frequently  seen  what  Mr.  Lister  has  described — 
namely,  a roll  of  them  projecting  from  a side  vessel  into  a larger  one,  and 
oscillating  in  the  current  without  separating.  But  that  this  is  produced 
by  a viscous  condition  of  these  bodies,  which  causes  their  surfaces  to  stick 
together,  as  he  appears  to  think,  is  negatived  by  the  fact,  that  not  unfre- 
quently  I have  seen  one  or  more  of  them  approach  rapidly  a vessel  in  the 
inflamed  tis.sue  not  yet  obstructed,  then  proceed  slowly,  oscillate  for  a 
while,  until  at  length,  getting  beyond  the  diseased  parts,  it  has  again 
darted  off  with  the  same  velocity  as  it  came.  Again,  it  may  frequently 
be  observed,  when  a vessel  is  so  full  of  colored  corpuscles  that  they  can 
no  longer  be  distinguished,  and  seem  to  have  melted  together,  that  on 
rupturing  it,  these  bodies  are  extravasated,  at  once  assume  their  original 
form,  and  arrange  themselves  just  the  same  as  they  do  on  coming  from  a 
healthy  structure.  I cannot  suppose,  therefore,  that  the  cause  of  stasis  is 
connected  with  adhesiveness  of  the  blood  corpuscles  ; indeed,  many  of  the 
valuable  observations  of  Mr.  Lister  himself  only  confirm  what  I have 
long  maintained — namely,  that  they  are  simply  drawn  together  and 
brought  more  closely  into  contact  by  some  external  force,  which  is  excited 
by  irritation  of  the  surrounding  tissue. 

The  only  theory  which  appears  to  me  capable  of  explaining  the  well- 
recognised  changes  in  inflammation,  is  one  which  attributes  them  to  a 
vital  force,  not  seated  in  the  blood  or  blood-vessels,  but  in  the  tissues  out- 
side the  vessels.  We  have  previously  seen,  when  speaking  of  secretion 
and  nutrition,  that  a power  must  exist  in  the  ultimate  molecules  of  the 
textures,  whereby  they  attract  and  select  materials  from  the  blood.  A 


160 


PRINCIPLES  OF  MEDICINE. 


modification  of  this  power,  whereby  the  attractive  property  is  augmented, 
and  the  selective  one  diminished,  at  least  offers  us  an  explanation  con- 
sistent with  all  known  facts,  and  seems  to  be  the  only  active  agency  to 
which  we  can  ascribe  the  aggregation  of  the  colored  particles  to  one  an- 
other in  the  inflamed  part,  their  approach  to  the  vascular  walls,  and  the 
passage  through  these  last  of  the  exudation.  This  increased  attraction, 
the  result  of  irritation  operating  on  the  nearest  blood-vessels,  producing 
in  vascular  parts  exudation,  constitutes  inflammation.  It  may  cause  other 
effects,  which,  as  we  shall  subsequently  see,  ought  to  be  distinguished 
from  that  morbid  state.  The  nature  and  mode  of  operation  of  this  attrac- 
tion may  be  illustrated  by  the  well-known  effects  which  an  electrical 
current  produces  when  passing  round  a piece  of  soft  iron.  Let  the 
chemical  action  on  the  metallic  plates  be  regarded  as  the  irritant,  the 
excited  electrical  stream  as  the  attractive  force  evolved,  then  the  adhesion 
of  a piece  of  iron  to  the  one  affected  by  the  induced  current  represents 
the  effects  on  the  blood.  So  long  as  this  current  influences  the  iron 
within  the  helix,  the  attractive  power  exists ; and  so  long  as  a certain 
amount  of  irritation  operates  on  the  tissue  does  inflammatory  congestion 
continue.  In  both  cases,  also,  the  increased  attractive  force  so  produced 
must  be  molecular — that  is,  must  depend  upon  the  altered  relations 
existing  among  the  ultimate  molecules  of  the  iron  in  the  one  instance, 
and  those  of  the  living  tissue  in  the  other. 

III.  The  necessity  of  giving  to  the  word  “ Inflammation  ” a de- 
finite MEANING. — On  this  point  Andral  has  >vell  observed  : — “ Created 
in  the  infancy  of  science,  this  expression,  altogether  metaphorical,  was 
destined  to  represent  a morbid  state  in  which  the  parts  appeared  to  burn, 
to  be  inflamed,  etc.  Received  into  general  language  without  any  precise 
idea  having  ever  been  attached  to  it — in  the  triple  relation  of  symptoms 
which  announce  it,  of  the  lesions  which  characterise  it,  and  of  its  intimate 
nature — the  expression  ‘ inflammation  ’ has  become  so  very  vague,  its 
interpretation  is  so  very  arbitrary,  that  it  has  recently  lost  its  value.  It 
is  like  an  old  coin,  without  an  impression,  which  ought  to  be  removed 
from  circulation,  as  it  only  causes  error  and  confusion.”  Magendie  says  : 
“ One  could  fill  an  entire  book  with  all  the  ideas  which  represent  the 
word  ‘ inflammation,’  for  it  is  synonymous  with  the  word  ‘ disease.’  ’’  To 
judge  of  the  correctness  of  these  statements,  let  us  for  a moment  attend 
to  what  has  been  called  inflammation,  and  the  contradictory  ideas  which 
prevail  on  this  matter. 

1.  Symptoms  have  been  supposed  to  constitute  inflammation,  and 
especially  pain,  heat,  redness,  and  swelling.  Yet  the  most  fatal  inflam- 
mations are  now  known  to  represent  only  one  or  two  of  these  symptoms, 
and  in  not  a few  no  single  one  of  them  has  been  recognised.  For  ex- 
ample, an  old  man  may  suddenly  lose  his  appetite  and  strength ; his 
respirations  become  hurried  and  feeble ; his  chest,  on  examination,  is  dull 
on  percussion ; mucous  rattles  are  heard  by  the  ear,  and  he  dies.  On 
opening  his  body  grey  hepatization  has  attacked  the  lungs,  which  are 
infiltrated  with  pus.  He  has  from  first  to  last  had  no  pain,  there  has 
been  no  heat,  on  the  contrary,  the  temperature  was  diminished ; no  red- 
ness nor  swelling  is  anywhere  detectable.  Such  cases  have  been  called 


INFLAMMATIOX. 


161 


latent  pneumonia,  and  latent  inflammations  of  every  viscus  are  very  com- 
mon and  very  fatal.  The  truth  is,  the  great  writers  on  the  subject  have 
been  surgeons,  who,  because  phlegmonous  abscesses  and  exte^-nal  inflam- 
mations are  usually  accompanied  by  these  signs,  have  supposed  them  to 
characterise  all  inflammations.  Modern  clinical  investigation,  however, 
has  demonstrated  that  in  the  brain,  lungs,  heart,  pleura,  kidneys,  and 
internal  organs,  inflammation  frequently  presents  no  such  symptoms.* 
Not  only,  therefore,  are  the  cardinal  symptoms  not  characteristic  of 
inflammation,  but  the  idea  that  such  is  the  case  has  led  to  the  most  mis- 
chievous results  in  practice. 

2.  Is  irritation  of  texture  inflammation  ? This  doctrine  has  long 
been  formularized  by  the  expression,  uhi  irritatio  ihi  affluxus.  Irritation 
may,  as  we  have  seen,  produce  inflammation,  but  very  often  it  does  not 
do  so.  It  may  simply  excite  the  nerves,  and  occasion  heat  and  redness 
for  weeks  without  causing  inflammation.  Even  when  textural  irritation 
is  excited  through  the  nerves  by  reflex  action,  the  vessels  immediately 
in  connection  with  such  nerves  are  not  more  disturbed  than  those  at  some 
distance,  showing  that  the  effect  must  be  produced  through  the  elements 
of  the  tissue.  When  applied  at  intervals  it  may  produce  induration  and 
hypertrophy  of  texture,  as  when  a corn  grows , but  this  is  not  inflam- 
mation. It  may  produce  cell-growth  and  cell-multiplication  in  any 
texture,  but  this,  also,  is  not  inflammation,  as  it  may  be  a fibrous  tumor 
or  a cancer.  We  cannot,  therefore,  characterise  inflammation  by  the 
cause  which  occasions  it:  we  must  look  for  something  significant  in  the 
parts  diseased. 

3.  Is  contraction  or  dilatation  of  the  blood-vessels  inflammation? 
We  see  paleness  and  redness  of  tissues,  in  consequence  of  these  alterations 
in  the  vessels  constantly  occurring  from  mental  emotions  or  exposure  to 
cold  and  heat,  friction,  etc. ; yet  no  one  would  say  of  a face  suffused  with 
ablush,  red  with  anger,  or  warm  from  exposure  to  heat,  that  it  is  inflamed. 
In  the  experiments  of  Bernard  on  the  sympathetic  nerves,  intense  redness 
and  excessive  heat  in  parts  have  been  maintained  for  weeks  without  inflam- 
mation. To  produce  it  something  evidently  must  be  superadded.  Mere 
congestion,  therefore,  ought  to  be  carefully  separated  from  inflammation. 

4.  Is  capillary  haemorrhage  inflammation  ? This  is  a result  of  con- 
gestion and  rupture  of  the  vessel  from  over-distension  with  blood.  It 
often  accompanies,  but  is  by  no  means  essential  to,  inflammations.  It 
may  also  occur  under  circumstances  where  inflammation  is  not  to  bo 
thought  of — as,  for  example,  in  menstruation.  This  periodical  congestion 
and  haemorrhage  from  the  capillaries,  though  frequently  accompanied  by 
all  the  so-called  cardinal  symptoms,  can  never  be  regarded  as  in  its  nature 
inflammatory.  It  is  not  a monthly  metritis  and  ovaritis.  Hence  capil-- 
lary  haemorrhage,  like  congestion,  requires  something  more  to  convert  it 
into  inflammation. 

5.  Is  serous  effusion  inflammation  ? This  constitutes  dropsy,  and 
is  always  dependent  on  venous  congestion.  Hence,  when  important 
organs— such  as  the  heart,  lungs,  liver,  or  kidneys — are  so  diseased 

* See  case  of  Edward  Campbell  (acute  pericarditis) ; of  John  Young  (adherent 
pericardium);  of  Peter  M’Guine  (acute  pleurisy) ; of  William  Dow  (pneumo-thorax), 
etc. 


11 


162 


Fi:iNCIPLES  OF  :S[EI)ICINE. 


as  to  prevent  the  return  of  blood  from  the  capillaries,  oedema  occurs. 
Meclianical  pressure  on,  or  internal  obstructions  of  veins  produce  the 
same  effect.  This  is  not  inflammation.  The  so-called  serum  of  a blister 
is,  in  truth,  an  exudation,  contains  fibrin,  and  coagulates  on  cooling.  It 
is  not  allied  to  the  dropsies,  but  is  truly  inflammatory. 

6.  Is  stoppage  of  the  blood  (stasis)  inflammation  ? On  this  point 
Mr.  Norris  has  recently  pointed  out^  that  stoppage  of  the  blood,  with 
aggregation  of  the  corpuscles,  may  arise — 1st,  from  constriction  of  the 
arteries,  atid  thus  shutting  off  the  cardiac  force  from  the  capillaries;  2d, 
from  weakening  the  heart’s  contractions;  and,  3d,  in  a limb,  from 
strangulation.  In  neither  of  these  cases  is  there  inflammation.  The 
experiments  of  Mr.  Lister  show  that  carbonic  acid,  applied  locally,  pro- 
duces such  congestion,  although  his  employment  of  the  term  “ inflamma- 
tory congestion  ” in  such  cases,  shows  that  he  has  not  distinguished  this 
(Condition  from  true  inflammation.  In  asphyxia,  the  blood-vessels  in 
the  lungs  are  highly  congested  and  the  circulation  arrested  ; but  there  is 
no  pneumonia. 

7.  Is  the  exudation  of  the  liquor  sanguinis  inflammation  ? To  this  I 
answer.  Yes.  It  is  in  truth,  the  only  morbid  phenomenon — the  only 
part  of  the  process,  which,  whenever  it  occurs,  unequivocally  charac- 
terises an  inflammation. t The  late  Dr.  Aiison  maintained,  that  what  was 
requisite  to  give  precision  to  the  general  notion  of  inflammation  was,  in 
addition  to  the  four  cardinal  symptoms,  to  include  in  it  a tendency  always 
observed  to  effusion  from  the  blood-vessels  of  some  new  products  capable 
of  assuming  the  form  of  coagulated  lymph  or  purulent  matter.  But,  as 
this  tendency  to  a certain  act  can  never  be  separated  from  the  act  itself, 
or  be  recognised  in  the  body,  it  cannot  give  the  precision  which  is  de- 
sired. Indeed,  it  is  only  when  the  exudation  has  occurred  that  we  can 
ever  feel  satisfied  that  even  the  tendency  existed.  It  follows  that  no 
one  of  the  preliminary  phenomena,  nor  all  of  them  combined,  constitute 
an  inflammation  unless  exudation  has  occurred ; so  that,  for  all  practical 
as  well  as  scientific  purposes,  it  may  be  said  that  this  morbid  state  con- 
sists essentially  of  an  exudation  of  the  liquor  sanguinis.  J 


^ Proceedings  of  the  Royal  Society,  vol.  xii.,  p.  258. 

f The  term  exudation  lias  been  introduced  into  pathology,  not  only  to  express  the 
act  of  the  liquor  sanguinis  passing  through  the  walls  of  the  blood-vessels,  but  also  to 
denominate  the  coagulation  of  the  fibrinous  portion  of  the  liquor  sanguinis  itself, 
upon  the  surface,  or  in  the  substance  of  any  tissue  or  organ  of  the  body.  Tlie  use  of 
this  term  removes  a difficulty  which  morbid  anatomists  have  long  experienced ; and 
hence  it  has  of  late  years  been  extensively  used  to  indicate  various  kinds  of  morbid 
deposits.  Thus  it  has  been  applied  to  all  those  processes  hitherto  termed  inflamma- 
tory, tubercular,  and  cancerous ; it  may  be  associated  with  every  form  of  morbid 
growth;  it  often  gives  rise  to  concretions,  and  frequently  constitutes  the  soil  in 
which  grow  those  parasitic  vegetations  or  cryptogamic  plants  of  a low  type,  which 
communicate  essential  characters  to  certain  diseases.  Under  the  head  of  exudation, 
indeed,  considered  as  a morbid  process,  is  comprised  the  greater  part  of  organic,  as 
distinguished  from  functional  diseases;  of  lesions  of  nutrition,  as  separated  from 
lesions  of  innervation. 

\ Mr.  Norris  even  argues  that  exudation  precedes  the  stoppage  of  the  blood, 
and  is  the  cause  of  it.  This  he  denominates  the  primary  exudation,  which,  by  causing 
increased  viscidity  of  the  blood,  produces  what  he  calls  homogeneous  stasis. 


INFLAMMATION. 


163 


The  objections  to  this  viow  are  of  two  kinds.  In  the  first  place,  it 
is  said  that  epithelium,  cartilage,  cornea,  and  non-vascular  parts,  maybe 
inflamed,  although  they  contain  no  blood-vessels,  and  consequently  can 
have  no  exudation  poured  into  them.  But  the  morbid  changes  which 
occur  on  irritating  these  structures  are  so  widely  diflPerent  from  those 
which  are  produced  in  vascular  parts  that  they  ought  never  to  be  con- 
founded together.  Thus,  on  irritating  non-vascular  structure,  such  as 
cartilage,  we  find  the  cells  nearest  the  injury  enlarge,  the  included  con- 
tents gradually  form  secondary  cells,  and  the  intercellular  substance  be- 
comes opaque  and  soft  from  deposition  of  molecules,  or  from  fibrillation. 
The  first  of  these  changes — namely,  enlargement  of  pre-existing  cells — is 
well  shown  in  a section  of  the  patella  into  which  an  incision  was  made 
by  Redfern  (Fig.  136) ; and  the  second,  or  molecular  deposition  and 
fibrillation,  in  Fig.  137.  The  same  occurs  in  epithelium  and  cornea 


Nothing  can  be  more  different  from  such  changes  than  that  which  occurs 
in  vascular  parts,  where  we  have  alteration  in  the  blood-vessels  and  blood, 


as  formerly  described,  always  followed  by  exudation,  and  the  production 
of  new  cells  from  a molecular  blastema,  rather  than  in  the  interior  of  old 
ones.  In  fact,  the  two  morbid  states  are  wholly  different. 

To  suppose,  indeed,  that  mere  irritation  always  produces  inflamma- 
tion, whatever  be  the  change  effected,  is  to  confound  morbid  processes 
widely  different  in  character  with  one  another.  Such  of  the  German 
pathologists  as  have  adopted  this  doctrine,  under  the  head  of  parenchy- 

Fig.  136.  Cartilage  on  each  side  of  an  incision  made  into  the  patella  of  a dog. 
Thirty  days  afterwards  the  cells  were  found  enlarged,  with  internal  multiplication  of 
nuclei,  as  seen  in  the  figure.  (Redfern.) 

Fig.  1.37.  Vertical  section  of  cartilage  from  the  surface  of  the  patella,  showing  at 
the  same  time  cell-growth,  histolytic  molecular  formation,  and  fibrillation.  250  diam. 


164 


PRINCIPLES  OF  MEDICINE. 


matous  inflammation,  sometimes  include  under  it  fatty  degeneration  of 
muscle,  sometimes  hypertrophy  of  texture,  and  sometimes  even  cancer. 
According  to  such  views,  the  term  inflammation  would  equally  well  apply 
to  an  encephaloma  as  to  the  pulpy  softening  of  cartilages — to  a corn  as 
to  a fibro-nucleated  growth.  We  argue  it  should  be  applied  to  none  of 
these,  but  only  to  that  perverted  alteration  of  the  vascular  tissues  which 
produces  an  exudation  of  the  liquor  sanguinis.  Should  different  results 
be  occasioned  by  irritation,  they  are  congestion  on  the  one  hand,  or  in- 
creased growth — that  is  hypertrophy — on  the  other. 

In  the  second  place,  it  is  now  known  that  exudations  occur,  and  are 
often  very  fatal,  under  circumstances  where  the  old  idea  of  inffammation, 
or  an  active  condition  attended  by  acute  symptoms,  cannot  apply.  In 
short,  the  modern  pathologist  and  the  senior  practitioner  are  widely 
divided  in  thought.  The  former  regards  the  essence  of  the  process;  the 
latter  the  occasional  phenomena  it  presents.  As  there  is  no  necessary 
relation  between  the  two,  it  follows  that  the  only  escape  from  the  con- 
fusion thus  arising  is,  as  Andral  suggested,  the  removal  of  the  word 
inffammation  from  medical  nomenclature.  No  doubt  the  future  employ- 
ment of  the  terms  congestion,  stasis,  exudation,  morbid  growth,  etc.  etc., 
would  remove  much  of  our  difficulties.  Those,  however,  who  continue 
to  use  the  term  inflammation  can  only  do  so  with  exactitude  in  the  sense 
of  an  exudation  of  the  liquor  sanguinis.  This  is  the  only  view  of  it 
which  is  consistent  with  all  known  facts,  and  it  possesses  the  further  merit 
of  having  led  in  recent  times  to  the  most  valuable  results  in  practice. 

Terminations  of  Inflammation. 

Once  established,  further  changes  occur  in  the  exuded  matter.  These 
have  been  called  the  terminations  of  inflammation,  and  were  considered 
by  John  Hunter  to  be  adhesive,  suppurative,  ulcerative,  gangrenous,  etc. 
I have  long  taught,  however,  that  we  should  distinguish  two  great  results 
of  the  exudation — viz.,  that  it  may  live  or  die.  If  the  exudation  lives, 
it  constitutes  a molecular  blastema,  in  which  new  growths,  temporary  or 
permanent,  spring  up  according  to  the  molecular  law  of  development,  such 
as  pus  and  adhesive  lymph.  When,  on  the  other  hand,  the  exudation 
dies,  three  things  may  result — 1st,  Rapid  death,  with  chemical  decom- 
position, producing  mortification  or  moist  gangrene;  2d,  Slow  death, 
with  disintegration  of  tissues,  causing  ulceration;  8d,  What  may  be 
called  a natural  death  of  the  transformed  exudation,  whereby  it  is  broken 
down,  liquefied,  and  at  length  absorbed.  This  is  resolution. 

IV.  Vital  Transformations  of  the  Exudation. — We  find  that  the 
peculiar  constitution  of  the  blood,  or  the  general  vital  power  of  the 
organism,  exercises  a very  powerful  influence  on  the  development  of  the 
exudation.  This  has  been  long  recognised  by  pathologists  in  certain 
conditions,  denominated  respectively  diathesis,  dyscrasia,  or  cachexia.  I 
propose  at  present  to  direct  your  attention  to  some  of  the  changes  which 
take  place  in  the  exudation  as  it  occurs  in  the  body  during  health. 
These  vary — 1st,  As  it  occurs  on  serous  membranes,  where  it  exhibits  a 
finely  fibrous  structure,  and  has  a strong  tendency  to  be  developed  into 


INFLAMMATION. 


165 


molecular  fibres ; 2d,  As  it  occurs  on  mucous  membranes,  or  in  areolar 
tissue,  where  it  is  generally  converted  into  pus  corpuscles ; 3d,  When  it 
occurs  in  dense  parenchymatous  organs,  such  as  the  brain,  where  it 
assumes  a granular  form,  and  is  associated  with  numerous  granular 
• orpuscles ; 4th,  As  it  is  poured  out  after  wounds  or  injuries,  and  occurs 
Oil  granuhicing  sores.  In  this  last  case  the  superficial  portion  is  trans- 
formed into  pus  corpuscles,  while  the  deeper  seated  is  converted,  by 
means  of  nuclei  and  cells,  into  nucleus  and  cell  fibres,  which  ultimately 
form  the  cicatrix. 

1.  O.i  examining  the  minute  structure  of  the  exudation  on  a serous 
surface  when  recently  formed,  and  when  it  presents  a gelatinous  semi- 
transparent appearance,  it  will  be  found  to 


be  made  up  of  minute  filaments  mingled  with 
corpuscles  (Fig.  138).  The  filaments  are  not 
the  result  of  the  development  of  either  a 
nucleus  or  a cell,  but  are  formed  by  the  simple 
precipitation  of  molecules,  which  arrange 
themselves  in  a linear  manner,  in  the  same 
way  as  they  may  be  seen  to  form  in  the  buffy 
coat  of  the  blood.  As  the  exudation  becomes 
firm,  the  filaments  appear  more  distinct 
and  consolidated,  varying  from  yj 
To  0 0 0^^^  of  an  inch  in  diameter.  Bundles, 
or  different  layers  of  them,  often  cross  each 

beco  nes  older  they  assume  more  and  more  the  character  of  those  in 
dense  fibrous  tissue.  The  corpuscles,  when  newly  formed,  are  delicate 
and  transparent,  but  in  a short  time  become  more  distinct,  and  are  then 
seen  to  be  composed  of  a distinct  cell-wall,  enclosing  from  three  to  eight 
granules.  They  vary  in  size  from  toVo^^j  enclosed 

granules  from  yy^ool-h  loooo^^  diameter.  On  the  ad- 

dition of  water  and  acetic  acid,  the  corpuscles  undergo  no  change,  al- 
though sometimes  the  latter  re-agent  causes  the  cell  wall  to  contract  and 
thicken  ; and  at  others,  to  be  somewhat  more  transparent.  In  1842,  I 


‘r.V.'.a 


Fig.  138. 

other  ; and  as  the  lymph 


Fig.  130.  Fig  140.  Fig.  141,  Fig.  142.  Fig.  143. 

separated  tliese  bod.es  from  pus  cells,  and  called  them  plastic  corpuscles, 
from  the  frequency  of  their  occurrence  in  plastic  lymph.  Lebert  in 


Fig.  138.  Molecular  fibres  and  plastic  corpuscles,  in  simple  exudation  on  a serous 
surface,  a,  The  latter  after  the  addition  of  acetic  acid.  250  diam. 

Fig.  139.  A portion  of  recent  lymph  from  the  pleura. 

Fig.  140.  Another  portion  of  the  same,  further  developed. 

Fig.  141.  Portion  of  firm  pleural  adhesion. 

Fig.  142.  Another  portion  of  the  same,  further  developed. 

Fig.  143.  The  last  acted  on  by  acetic  acid. — {Drummond.) 


180  diam. 


166 


PRINCIPLES  OF  MEDICINE. 


1845,  confirmed  my  description,  and  called  them  fyoid^  from  their  re- 
semblance to  pus. 

These  corpuscles  after  a time  melt  away  among  the  fibres,  but  several 
of  them  remain,  constituting,  as  shown  by  Dr.  Drummond,  permanent 
nuclei.  After  a time,  blood-vessels  grow  in  the  exuded  lymph  (see 
Vascular  Growths),  the  surface  of  which  becomes  villous.  Into  the  villi 
loops  of  vessels  penetrate,  and  by  these  the  fluid,  contained  in  the  interior 
of  shut  sacs,  is  absorbed.  The  fluid  thus  gradually  diminishes,  and 
when  the  villous  surfaces  are  brought  into  contact,  they  unite,  and  ulti- 
mately form  the  dense  chronic  adhesions  so  common  between  serous 
membranes.  (See  pp.  174-75.) 

2.  Exudation  poured  out  on  a mucous  membrane  sometimes  presents 
a fibrous  mass,  as  in  cases  of  croup  and  diphtheritis,  but  more  generally 
it  passes  into  an  opaque,  unctuous,  straw-colored  fluid,  long  known 
under  the  name  of  pus.  When  poured  into  the  meshes  of  areolar  tissue, 
and  occasionally  into  the  substance  of  the  brain,  the  same  transformation 
occurs,  and  then  forms  an  abscess.  On  examining  the  minute  structure 
of  pus,  it  is  seen  to  be  composed  of  numerous  corpuscles  floating  in  a 
clear  fluid.  These  corpuscles  are  globular  in  form,  and  vary  in  size 
from  the  of  an  inch  in  diameter.  Their  surface 

is  finely  punctated.  They  have  a regular  well-defined  edge,  and  roll 
_ freely  in  the  liquor  puris  upon  each  other. 
On  the  addition  of  water,  they  become  much 


increased  in  size  and  more  transparent,  their 


Fi^.  144 


finely  punctated  surface  disappearing.  Weak 
acetic  acid  partially,  and  the  strong  acid  com- 
Fig.  145.  plelcly,  dissolves  the  cell-wall,  and  brings  into 
view  ail  included  body,  generally  composed  of  two  or  three  granules  close 
together,  and  rarely  four  or  five,  each  with  a central  shadowed  spot. 
These  are  usually  about  the  g of  an  inch  in  diameter.  (Figs.  144, 

145 ; also  Figs.  66,  67.) 

In  some  cases  the  pus  corpuscles  now  described  are  surrounded  by 
an  albuminous  layer  closely  resembling  a delicate  cell-wall  (Fig.  68), 
which  I first  described  in  1847.  It  is  about  the  or  of  an 

inch  in  diameter,  and  is  highly  elastic,  assuming  different  shapes,  ac- 
cording to  the  degree  and  direction  of  the  pressure  to  which  it  is  sub- 
jected. Water  and  acetic  acid  cause  it  at  once  to  dissolve,  whilst  the 
included  pus  corpuscles  exhibit  the  usual  body  . ^ ....  . 

composed  of  two  or  three  granules. 

In  what  is  called  scrofulous  pus,  the  cor- 
puscles, instead  of  being  round  and  rolling 
freely  on  each  other,  are  misshapen  and  irre- 
gular (Fig.  69),  and,  on  the  addition  of  acetic  Fig.  146. 
acid,  the  granular  nuclei  are  found  to  be  ill  formed  or  absent  (Figs.  146, 
147). 

3.  In  parenchymatous  organs,  the  exudation  insinuates  itself  among 


O. 

•iS-O 


■'w' 


a:) 


Fig  HJ. 


Fig.  144.  Pus  cells.  Four  cells  have  been  acted  on  by  acetic  acid. 

Fig.  145.  Pus  cells  containing  fatty  molecules,  after  adding  acetic  acid. 

Fig.  146.  Sciofulous  pus  cells  after  the  addition  of  acetic  acid. 

Fig.  147.  The  same.  In  both  specimens  the  nuclei  are  irregular  or  absent. 


250  d.l 


IXFLxiMMATIOX. 


167 


Fig.  148. 


tliG  elementary  tissues  of  wliicli  they  are  composed,  so  that,  when  it 
coagulates,  these  are  imprisoned  in  a solid  plasma,  like  stones  in  the 
mortar  of  a rough  cast  wall ; thus  constituting  a firm  mass,  and  giving 
increased  density  to  certain  organs.  This  is  well  observed  in  the  lung, 
where,  however,  a mucous  surface  extensively  prevails,  and  where  the 
exudation  is  commonly  transformed  into  pus.  In  the  brain,  spinal  cord, 
and  placenta,  we  find  the  exudation  deposited  in  the  form  of  minute 
molecules  and  granules,  which  are  frecpently  seen  coating  the  ves.^^els 
externally,  and  filling  up  the  intervascular  spaces  (Fig.  148).  The 
granules  vary  in  size  from  the  73^0 
the  6 in  diameter.  They 

always  contain  among  them  round  transpa- 
rent globules,  varying  in  size  from  the 
;g^i(j-„th  to  of  ioch  in  diameter. 

These  are  the  nuclei  of  round  or  oval  cells 
which  may  frequently  be  observed  in  various 
stages  of  development.  When  fully  formed, 
the  cells  vary  greatly  in  size,  for  the  most 
part  measuring  from  the  joVo^^  ^0  -^igthof 
an  inch  in  diameter.  They  sometimes  con- 
tain a few  oil  granules  only,  at  others  they 
are  so  completely  filled  with  them  as  to  assume  a brownish-black  appear- 
ance. Water  and  acetic  acid  cause  no  change  in  them,  although  the  latter 
re- agent,  on  some  occasions,  renders  the  cell- walls 
more  transparent.  They  are  readily  soluble  in 
aether,  and  break  down  into  a molecular  mass  on 
the  addition  of  potash  and  ammonia.  These  are 
granule  cells  (149).  Masses  of  these  granules 
may  be  occasionally  seen  floating  about,  of  irreg- 
ular shape,  without  any  cell-wall.  They  are  pro- 
duced either  by  the  solution  of  the  cell-wall  in 
which  they  are  contained,  or  from  the  separation, 
rig  149.  or  peeling  off,  of  such  masses  from  the  external 

wall  of  the  vessels;  and  form  granular  masses  (Fig.  149  a).  Pressure 
causes  these  granules  to  coalesce,  or  the  oil  to  be  forced  through  the 
cell-wall  Occasionally  also  the  cell-wall  is  ruptured. 

The  granules,  masses,  and  cells  just  described  are  found  in  the 
colostrum  secreted  by  the  mammary  glands ; in  the  exudative  softening 
of  parenchymatous  organs;  on  the  surface  of  granulations  and  pyrogenic 
membranes;  in  the  pus  of  chronic  abscesses;  combined  with  cancerous, 
tubercular,  and  all  other  forms  of  exudation ; in  the  tubes  of  the  kidney 
when  affected  with  Bright’s  disease;  and  in  the  contents  of  encysted 
tumors.  In  fact,  there  is  no  form  of  cell-growth,  whether  healthy  or 
morbid,  that  may  not,  under  certain  conditions,  accumulate  oil  or  fatt^ 
granules  in  its  interior,  become  a compound  granular  corpuscle,  and  thus 
be  rendered  abortive.  The  granule  cells  in  an  exudation,  however,  are 
the  results  of  a vital  transformation  of  that  exudation,  and  not  of  mere 
fatty  degeneration  of  the  vessels,  as  some  have  supposed.  In  some 

Fig.  148.  Granular  exudation  and  granular  masses,  from  cerebral  softening. 

Fig.  149.  Granular  cells  and  masses  from  cerebral  softening.  50  di. 


1G8 


PKINCIPLES  OF  MEDICINE. 


instances  I have  seen  them  in  all  stages  of  development  coating  the  blood* 
vessels,  as  in  Fig.  150. 

That  softening  from  the  formation  of  granules  and  granular  cells  may 
occasionally  disappear,  and  the  new  structures  bo 
absorbed  is  rendered  probable  by  the  history  of 
several  well-recorded  cases;  but  the  changes  there- 
by produced,  especially  in  nervous  textures,  have 
not  hitherto  been  made  the  subject  of  special  in- 
vestigation. 

4.  If  a recently-formed  granulation  on  the 
surface  of  a healing  sore  be  examined,  numerous 
cells  will  be  observed,  of  various  shapes,  and  in 
different  stages  of  development.  Some  are  round, 
others  caudate,  spindle-shaped,  elcvngated  or  split- 
ting into  fibres,  as  originally  described  by  Schwann 
(Fig.  151).  In  many  cases  there  may  be  seen  a 
number  of  free  nuclei,  imbedded  in  a slightly 
fibrous  blastema,  elongated  at  both  ends,  becoming 
fusiform,  and  splitting  up  the  surrounding  exuda- 
tion, as  described  by  Henle.  Not  unfrequently 
the  liuclei  may  be  seen  developing  themselves  into 
elastic  fibres,  in  the  same  exudation  which  contains 
cells  that  are  passing  into  white  fibres.  Indeed,  the  process  of  cicatriza- 
tion in  its  various  stages  and  in  different  tissues,  offers  the  best  means 
of  studying  the  manner  in  which  nucleus  and  cell  fibres  are  respectively 
{ 'U'lned.  As  these  , . 

G 


1 bres  are  developed 
in  the  deeper  layers 
of  the  exudation, 
a,  villous  vascular 
! lasis  is  formed,  and 
t'le  superficial  pus- 
crorpuscles,  after 
1 aving  served  to 
jirotect  the  more 
permanent  growths 
are  thrown  off  in 
the  form  of  dis- 
charge. When  the 
fibrous  structure 
becomes  more  con- 


Fig.  151. 

sistent  and  dense,  the  amount  of  pus  diminishes,  and  a greater  tendency  is 
manifested  by  the  exudation  to  pass  into  permanent  t.ssue.  At  length  pus 
ceases  to  be  developed ; the  whole  remaining  exudation  is  transformed 


ri"  ] 50.  Two  vessels  coated  with  exudation  from  softening  of  the  ' 

Granular  cells  may  be  seen  forming  in  it.  "50  aiam. 

Fig.  161.  Vertical  section  of  a granulating  sore  Externally,  pns  corpuscles, 
deeper,  fibre  cells  in  various  stages  of  development  into  fibre.  The  looped  blood- 
vessels are  seen  enlarged  at  their  extremities,  magnified  100  diameters  linear.  On 
the  left  the  cells  are  magnified  250  diameters  linear. 


INFLAMMATIOX. 


169 


into  fibres;  a new  surface  is  produced,  which  after  a time  contracts  and 
forms  the  permanent  cicatrix. 

V. — Death  of  the  Exudation. — The  exudation  may  die  in  three 
ways — 1st,  Instead  of  passing  through  the  vital  transformations  we  have 
previously  described,  it  may  die  rapidly — constituting  what  has  been 
called  MorHfication  or  Moist  Gangrene ; 2d,  It  may  die  slowly — causing 
gradual  disintegration  and  loss  of  texture,  and  thereby  forming  what 
has  been  denominated  ulceration  ; 3d,  There  is  a natural  death  of  the 
exudation,  which  is  resolution. 

Mortification  or  Moist  Gangrene, 

Occasionally  a very  large  amount  of  blood-plasma  is  thrown  out;  a 
greater  or  smaller  number  of  capillaries  are  also  ruptured,  and  blood  cor- 
puscles more  or  less  mixed  up  with  the  liquor  sanguinis  exuded.  The 
exudation  thus  formed  compresses  the  part  into  which  it  is  thrown  out, 
paralyses  the  nerves,  obstructs  the  blood-vessels,  and  arrests  the  circula- 
tion in  them.  Under  these  circumstances,  instead  of  forming  a blastema 
for  the  production  of  new  structures,  it  undergoes  chemical  changes, 
whereby  decomposition  is  induced,  and  then  the  part  is  said  to  be  morti- 
fied, or  to  be  affected  with  moist  gangrene.  This  change  commences 
first  in  the  blood  extravasated,  which  becomes  of  a purple  color  more 
or  less  deep ; the  corpuscles  break  down  and  become  disintegrated;  their 
hseniatozine  dissolves  and  colors  the  serum ; and,  should  the  exudation 
have  coagulated,  it  forms  brown,  rust-colored,  purple,  or  blackish  masses. 
An  acid  matter  is  now  formed,  which,  acting  on  the  neighboring  tissues, 
produces  foetid  gases,  that  are  abundantly  given  off  from  the  afiected  part. 
[Sulphuretted  hydrogen  is  evolved,  which  causes  the  blackish  sloughs 
usually  observed  in  such  cases,  aud  discolors  silver  probes  and  the  pre- 
parations of  lead.  After  a time,  the  elementary  tissues  surrounding  or 
involved  in  the  exudation,  become  more  or  less  affected.  The  tranverse 
striae  in  the  fasciculi  of  voluntary  muscles  first  become  pale,  aud  are  then 
obliterated.  Cellular  tissue,  fat,  and  other  soft  substances  lose  their  con- 
nection,-and  fall  into  an  undefined  granular  mass.  The  tendons  and  fibrous 
tissues  retain  their  characteristic  structure  for  a long  time  after  the  other 
soft  parts  have  been  reduced  to  a softened  pulp.  The  bones  resist  the 
action  longest,  but  at  length,  commencing  externally,  they  become  rough, 
soft,  and  are  more  and  more  broken  down,  and  reduced  to  the  same  pulpy 
consistence  and  granular  structure  as  the  surrounding  parts. 

As  the  tissues  thus  become  broken  down,  and  fluid,  they  are  dis- 
charged from  the  system  in  the  form  of  an  ichorous  matter,  which, 
examined  microscopically,  presents  numerous  granules,  imperfect  or 
broken-down  cells,  blood  corpuscles,  and  fragments  of  filamentous  tissue 
or  of  the  other  structures  involved.  If  the  morbid  action  be  seated  in 
the  subcutaneous  tissue,  the  skin  soon  becomes  affected ; and  an  opening 
is  formed,  which  rapidly  enlarges,  and  gives  vent  to  the  discharge.  In 
a similar  manner,  gangrene  of  internal  organs,  by  destroying  the  inter- 
mediate parts,  at  length  enables  the  fluid  to  reach  the  surface,  or  to  find  its 
way  into  the  excretory  passages,  such  as  the  bronchi,  the  intestinal  canal, 
the  meatus  auditorius,  etc.  In  this  manner,  life  may  be  endangered,  by 


170 


PEINCIPLES  OF  MEDICINE. 


the  destruction  of  organs  necessary  for  its  continuance ; by  the  exhaustion 
resulting  from  the  discharge ; and  sometimes  by  the  absorption  of  the  ichor- 
ous matter,  which,  entering  the  circulation,  acts  as  a poison  to  the  economy. 
On  the  other  hand,  a favorable  termination  may  take  place,  either  by 
the  dead  substance  breaking  down,  and  bein  gevacuated  externally,  or  by 


Fig.  152. 

its  being  separated  en  masse  in  the  form  of  slough.  In  such  case  a process 
of  regeneration  and  healing  may  be  set  up  in  the  exposed  living  texture, 
which  may  produce  a cicatrix,  in  the  manner  formerly  spoken  of. 

It  may  be  asked  whether  mortification  is  the  result  merely  of  a 
greater  amount  of  the  exudation  ? or,  whether  it  is  dependent  besides  on 
other  circumstances,  such  as  a peculiar  state  of  the  atmosphere,  which 
favors  the  decomposition  of  the  exudation  poured  out  ? In  order  to 
answer  these  questions,  we  must  distinguish  between  ordinary  mortifica- 
tion arising  from  a variety  of  circumstances,  and  moist  gangrene  properly 
so  called,  which  is  undoubtedly  the  rarest  of  all  the  terminations  of  ex- 
udation. Mortification  may  be  produced  by  the  application  of  chemical 
or  mechanical  agents,  which  directly  destroy  the  tissues.  It  also  often 
arises  through  severe  and  complicated  injuries,  in  which  arteries  leading 
to  the  portions  of  structure  affected  have  been  divided  or  crushed.  In 
old  persons,  it  follows  obstruction  in  the  blood-vessels,  or  is  dependent 
on  circumstances  not  yet  ascertained.  In  none  of  these  cases  is  it  a result 
of  inflammation.  But  when  stasis  of  the  capillaries  is  produced  to  a con- 
siderable extent,  followed  by  the  exudation  of  a large  quantity  of  blood- 
plasma,  which,  instead  of  passing  into  organization,  undergoes  the  changes 
previously  described,  then  moist  gangrene,  properly  so  called,  is  produced. 
We  see  this  take  place  after  burns,  after  long  exposure  to  frost,  and  in 
certain  cases  of  erysipelas.  Here  the  amount  of  exudation  is  considerable, 
the  pressure  caused  by  it  extreme,  the  obstruction  to  the  circulation  in 
the  neighboring  parts  correspondingly  great ; so  that  these,  as  well  as 
the  exudation  itself,  is  destroyed.  In  this  sense,  therefore,  it  may  be 
said  to  depend  on  the  rapidity  and  amount  of  the  exudation ; but  not  in 
the  sense  of  those  who  consider  adhesion,  suppuration,  and  gangrene,  as 
different  stages  of  one  process.  Suppuration,  as  we  now  know,  has  no 
connection  with  adhesion ; it  is  opposed  to  it ; nor  is  it  in  any  way 
related  to  mortification,  which  must  be  considered  as  a primar}"  altera- 
tion of  the  exudation.  In  mortification  the  vitality  of  the  exudation  is 
lost,  and  instead  of  passing  into  organization,  it  becomes  subject  to  the 
chemical  laws  of  dead  matter,  and  undergoes  putrefaction. 

Fig.  162.  Moist  gangrene,  following  compound  fracture — all  the  injured  parts  in- 
filtrated with  exudation,  which  has  died  and  mortified. — Liston. 


INFLAMMATIOISr. 


m 


Now  in  order  that  organic  substances  may  enter  rapidly  into  putre- 
faction, it  is  necessary  that  they  find  sufficient  oxygen  and  water  for  all 
their  carbon  to  be  transformed  into  carbonic  acid,  all  their  hydrogen  into 
water,  and  all  their  azote  into  ammonia.  When  these  conditions  are  not 
completely  fulfilled,  transition  or  intermediate  substances  are  formed. 


Fig.  153. 

If  there  is  not  sufficient  oxygen,  for  instance,  an  excess  of  carbon  is  pro- 
duced in  the  debris.  There  is  also  often  developed  a species  of  destruc- 
tion by  contact,  which  causes  parts  undergoing  decomposition  to  excite 
it  in  neighboring  ones  [eremacamis  of  Liebig) ; which  does  not  take  place 
in  dry  gangrene.  A gangrenous  stomatitis  {Cayicrum  oj'is)  will  thus 
destroy,  in  a short  time,  a large  portion  of  the  soft  parts  of  the  lips  and 
face,  and  Noma  the  genitals  of  young  female  children.  This  appears  to 
depend  upon  the  quantity  of  destructive  fluid  or  mixture  generated  in 
the  process.  On  the  other  hand,  several  weeks  ma}^  occur  before  a dry 
gangrenous  foot  is  completely  separated  by  decomposition. 

There  are  sometimes  external  causes  also  which  seem  to  produce  mor^ 
tification,  independent  of  the  amount  of  exudation,  or  the  rapidity  with 
which  it  is  thrown  out.  During  the  summer  of  1836,  I watched  with 
great  care  the  progress  of  sloughing  gangrene,  prevalent,  not  only  in  the 
Infirmary  of  Edinburgh,  but  throughout  the  city  generally.  All  kinds 
of  sores  and  wounds  were  affected  by  it,  even  those  of  a specific  nature, 
such  as  chancres,  etc.  Neither  youth  nor  age  was  exempted  from  it. 
It  affected  not  only  those  who  were  debilitated  from  disease,  through 
intemperance  or  bad  diet,  but  those  also  apparently  in  the  most  robust 
health.  Thus  a servant  girl,  aged  16,  who  had  never  suffered  from  ill- 
ness, and  was  of  a robust  constitution,  fell  down  upon  some  glass  bottles, 
and  slightly  cut  her  left  thumb.  A week  after,  she  entered  the  Infirmary 
with  an  ulcer  the  size  of  a shilling,  filled  with  a brownish-black  slough, 
discharging  a foetid  and  sanguineous  fluid.  In  this,  as  well  as  other 
cases  which  occurred,  it  became  impossible  to  attribute  the  gangrene  to 
the  violence  of  the  injury,  the  amount  of  exudation,  a state  of  cachexia, 
or  indeed  to  any  circumstances  connected  with  the  individual.  It  could 
not  arise  from  contagion,  as  it  originated  simultaneously  in  different  parts 
of  the  city,  in  individuals  who  had  no  communication  with  each  other, 
and  was  not  confined  to  the  Infirmary,  where  the  system  of  dressing 
wounds  precluded  the  possibility  of  such  an  occurrence.  We  are,  there- 
fore, compelled  to  ascribe  the  cause  to  something  in  the  atmosphere. 

Most  writers  have  noticed  the  connection  between  a certain  state  of 
the  atmosphere  and  the  prevalence  of  hospital  gangrene  and  of  dysentery, 

Fig.  153.  Dry  gangrene  from  debility — being  death  of  the  pre-existing  tissues, 
unconnected  with  exudation.— Xwtort. 


172 


PEINCIPLES  OF  MEDICIXE. 


as  well  as  their  more  frequent  occurrence  in  summer  and  autumn — that 
is,  at  a period  of  the  year  when  increased  temperature  favors  the  de- 
composition of  animal  matter.  The  good  effects  which  result  from  change 
of  air,  when  every  kind  of  treatment  fails,  still  further  point  out  its  con- 
nection with  some  atmospheric  changes.  These  may  probably  depend 
upon  some  peculiar  electrical  state,  not  yet  explained,  powerfully  influenc- 
ing the  chemical  combinations  of  the  diseased  part,  and  ]n-eventing  cell- 
growth.  At  least  such  is  what  we  may  reasonably  suppose,  from  all  the 
facts  with  which  we  are  acquainted  on  this  head.  The  disease  is  similar 
to  blight  among  vegetables,  or  the  potato-disease. 

Ulceration, 

The  process  of  ulceration  is  somewhat  similar  to  that  of  mortification, 
but  is  more  chronic  in  its  progress;  the  exudation,  instead  of  undergoing 
decomposition,  exhibits  an  indisposition  to  pass  into  cell-formation.  In 
this  case  the  exudation  is  poured  out  slowly,  it  coagulates  and  presses 
upon  the  surrounding  parts,  more  or  less  obstructing  the  flow  of  blood  to 
them  and  acts  as  a foreign  body.  By  means  of  the  continued  pressure, 
the  circulation  is  obstructed,  and  death  of  the  portion  affected  results. 
This  dead  portion  is  sometimes  imprisoned  in  fresh  exudation,  as  the 
ulceration  extends,  and  the  whole  part  affected  at  length  becomes  disin- 
tegrated, All  this  time  the  exudation  exhibits  little  of  that  tendency, 
so  conspicuous  in  healthy  peisons,  to  undergo  changes  in  itself,  and  when 
examined  microscopically,  is  found  to  consist  principally  of  very  minute 
granules.  These  are  occasionally  mixed  with  irregularly-formed  cells, 
usually  more  or  less  angular,  containing  one  or  more  granules.  The 
cells  are  more  numerous  in  proportion  to  the  stage  of  the  ulceration,  and 
the  healthy  powers  of  the  constitution.  The  different  granules  and 
imperfect  cells,  with  the  structures  they  involve,  at  length  become 
broken  down  and  separated  from  each  other,  constituting  a semi-fluid 
mass,  which  has  a tendency  to  point  where  it  can  most  readily  be  dis- 
charged, that  is,  towards  the  surface  of  the  skin  or  mucous  membranes. 
Here,  on  account  of  the  less  degree  of  resistance  offered,  the  continued 
pressure  and  disintegration  of  tissue  first  causes  an  aperture  to  be  formed. 
Another  portion  of  solid  exudation  is  now  broken  down,  with  the  tissues 
involved  in  it,  and  in  this  way  the  opening  is  enlarged.  If  the  morbid 
process  continue,  a fresh  exudation  is  slowly  poured  out  below  the 
already  coagulated  blood- plasma,  which  supplies  the  loss  thrown  off  in 
the  form  of  discharge,  and  thus  chronic  ulcers  may  be  continued  in- 
definitely. The  whole  of  this  process  may  be  well  observed  in  scrofulous 
and  syphilitic  ulcers,  or  in  the  callous  sores  of  the  legs  in  weavers  and 
others  of  a cachectic  constitution.  Indeed  the  general  powers  of  the 
constitution  are  almost  always  in  such  cases  enfeebled,  and  hence  the 
indisposition  of  the  exudation  to  be  transformed  into  cells. 

Ulcers  produced  by  direct  pressure  are  occasioned  in  a similar 
manner;  only  in  such  cases  the  pressure  is  not  derived  in  the  first 
instance  from  the  solid  exudation  poured  out.  Thus,  in  stumps  not 
sufficiently  covered  by  soft  parts,  in  places  long  pressed  upon  by  lying, 
or  by  the  growth  of  tumors,  the  vitality  of  the  part  is  slowly  destroyed. 


INFLAMMATION. 


173 


At  the  same  time  an  exudation  is  poured  out  from  the  neighboring 
vessels,  which  becomes  broken  up,  and  assists  in  disintegrating  the 
textures  whose  vitality  is  destroyed.  The  finely  molecular  particles  are 
thus  absorbed,  whilst  the  grosser  portions  are  thrown  off  in  the  form  of 
discharge. 

All  ulcerated  surfaces  are  covered  with  a fluid,  which  varies  in 
character  according  to  the  nature  of  the  sore.  Healthy  granulations  are 
covered  with  laudable  purulent  matter,  the  corpuscles  m it  presenting 
their  normal  character.  In  chronic,  scrofulous,  and  syphilitic  sores,  the 
corpuscles  are  generally  of  an  irregular  form,  constituting  what  has  been 
denominated  unhealthy  purulent  matter.  Not  unfrequently  the  ulcer  is 
covered  with  a discharge,  either  of  a thin  dirty  yellowish  tint,  or  more 
or  less  sanguinolent  and  foetid.  In  the  latter  case  the  discharge  has 
received  the  name  of  sanies,  and  is  similar  in  character  and  constitution 
to  that  observed  in  the  fluid  accompanying  moist  gangrene — that  is  to 
say,  there  are  in  it  traces  of  imperfect  cell-formation  mixed  with 
numerous  molecules,  and  the  shreds  or  debris  of  the  structures  involved. 

Ulceration  has  by  most  writers  since  the  time  of  Hunter  been  re- 
garded as  the  result  of  a peculiar  operation,  which  he  denominated 
ulcerative  absorption.  No  doubt  the  process,  such  as  we  have  described 
it,  is  peculiarly  favorable  to  the  production  of  a fluid  containing  mole- 
cules so  minute  that  they  may  readily  permeate  the  neighboring  vessels 
by  endosinosis.  But  it  must  not  be  overlooked  that  much  of  the  sub- 
stance lost  in  ulceration,  especially  of  the  more  consistent  and  tough 
structures,  after  having  been  more  or  less  broken  up,  is  thrown  off  from 
the  surface  in  the  form  of  discharge.  This  is  proved  by  direct  observa- 
tion. In  either  case  all  such  parts  first  lose  their  vitality,  from  the 
pressure  to  which  they  are  subjected,  and  then,  being  disintegrated,  the 
fluid  and  finer  parts  may  be  absorbed,  whilst  the  coarser  are  thrown  off 
from  the  surface. 

In  bones  the  processes  corresponding  to  mortification  and  ulceration 
in  soft  parts,  are  generally  denominated  Necrosis  and  Caries, 

Resolution. 

When  pus  is  not  evacuated  externally,  the  cells  ultimately  dissolve, 
their  walls  disappear,  the  included  nuclei  and  granules  separate,  and  are 
converted  into  a fluid.  This  passes  into  the  blood,  increases  for  a time  its 
effete  constituents,  but  is  at  length  excreted  by  the  emunctories.  Mean- 
while the  original  abscess,  or  collection  of  matter,  is  said  to  be  resolved. 

Numerous  observations  have  satisfied  me  that  this  is  tlie  process 
which  a pneumonia  undergoes  on  its  removal.  In  this  disease  the  exuda- 
tion is  infiltrated  into  the  air  vesicles  and  minute  bronchi,  and  between 
the  fibres,  blood-vessels,  and  nerves  of  the  parenchyma,  imprisoning  the 
whole  in  a soft  mass,  which  coagulates  and  renders  the  spongy  texture 
of  the  lung  more  dense  and  heavy,  or  what  is  called  hepatized.  This 
accomplished,  no  air  can  enter,  the  nerves  are  compressed,  the  circulation 
is  in  great  part  arrested;  and  the  object  of  nature  is  now  to  convert  the 
solid  exudation  once  again  into  a fluid,  whereby  it  can  be  partly  evacuated 
from  the  bronchi,  but  principally  reabsorbed  into  the  blood,  and  excreted 


174 


PRINCIPLES  OF  MEDICINE. 


from  the  economy.  This  is  accomplished  by  cell-growth.  In  the 
amorphous  coagulated  exudation,  granules  are  formed ; around  groups  of 
these  cell-walls  are  produced,  and  gradually  the  solid  amorphous  mass  is 
converted  into  a fluid  crowded  with  cells.  This  is  pus.  The  cells,  after 


exudation  is  again  reduced  to  a condition  susceptible  of  absorption 
through  the  vascular  walls,  and  once  more  mingles  with  the  blood,  but 
in  an  altered  chemical  condition.  In  the  blood  the  changed  exudation 
(now  called  fibrin)  undergoes  further  chemical  metamorphoses,  whereby, 
according  to  Liebig,  it  is  converted  by  means  of  oxygen  into  urate  of 
ammonia,  choleic  acid,  sulphur,  phosphorus,  and  phosphate  of  lime. 
The  urate  of  ammonia,  by  the  further  action  of  oxygen,  is  converted  into 
urea  and  carbonic  acid;  the  choleic  acid  into  carbonic  acid  and  carbonate 
of  ammonia ; the  sulphur  and  phosphorus  into  sulphuric  and  phosphoric 
acids,  which,  combining  with  an  alkali  or  earth  form  sulphates  and 
phosphates.  If  it  should  happen  that  the  quantity  of  oxygen  taken  is 
not  sufficient  completely  to  accomplish  this  cycle  of  changes,  then, 
instead  of  urea,  either  urate  of  Ammonia  appears  in  the  urine,  or  if  the 
ammonia  have  entered  into  any  other  combinations,  pure  crystals  of  uric 
acid.  In  consequence  of  these  or  similar  changes,  the  exudation  is 
finally  removed  from  the  economy. 

The  same  process  takes  place  in  abscesses,  and  is  frequently  seen  in 
buboes,  which  instead  of  being  opened  become  harder  and  harder, 
smaller  and  smaller,  until  at  length  they  disappear. 

In  a pleurisy  or  pericarditis,  the  transformations  occurring  in  the 
exudation  are  different.  We  have  previously  described  the  changes  which 
follow  pleurisy  (pp.  1G5-66).  Let  us  now  follow  them  in  the  case  of  peri- 
carditis. When  a severe  inflammation  of  the  pericardium  occurs,  the  liquor 
sanguinis  is  exuded  in  considerable  quantity,  separating  the  serous  layers 
to  a greater  or  less  extent.  After  a time  the  fibrin  coagulates  and  forms 
a layer  which  attaches  itself  to  the  membrane,  whilst  the  serum  of  the 
blood  accumulates  in  the  centre.  The  coagulated  fibrin  at  first  assumes 
the  form  of  molecular  fibres,  plastic  or  pyoid  cells  are  formed  in  it  (Fig. 
138),  others  throw  out  prolongations,  so  as  by  their  union  to  form  a 
})lexus,  which,  communicating  with  the  vessels  below  the  serous  mem- 

Fig.  154.  Three  air  vesieles  of  a pneumonic  lung,  filled  with  exudation  in  different 
stages  of  development,  a,  Molecular  exudation  recently  poured  out ; 6,  Cells  form- 
ing in  the  exudation;  e.  Cells  (pus-cells)  fully  formed.  See  case  of  Alexander  Walker 
among  Diseases  of  the  Nervous  System.  250  diam. 


INFLAMMATION. 


175 


brane,  renders  the  exudation  vascular  (Fig  254).  Gradually  the  surface 
assumes  the  appear- 
ance of  a villous 
membrane  (Fig. 

155),  which  possesses 
also  the  absorbent 
functions  of  one. 

The  enlarged  villi 
frequently  contain 
vacuoles  or  spaces, 
reminding  me  strong- 
ly of  the  general 
structure  of  the  pla- 
cental tufts,  than 
which  nothing  can 
be  imagined  more 
perfectly  adapted  for 
the  purposes  of  ab- 
sorption (Fig.  156). 

In  consequence,  the 
serum  now  disap- 
pears, the  two  false  Fig.  155. 

membranes  are  brought  into  contact,  and  thus  the  absorption,  as  soon  as 


Fig.  156. 

Fig.  165.  Layers  of  lymph  in  pericarditis,  presenting  the  form  of  large  villi. — 
( CruveUhier.) — Half  the  real  size. 

Fig.  156.  Structure  of  the  villi  in  pericarditis.  On  the  left  of  the  figure  are  some 
villi  treated  with  acetic  acid,  and  thereby  rendered  very  transparent,  showing  the 
elongated  nuclei  of  the  fibre  cells  of  which  tliey  are  principally  composed,  a.  The 
vacuoles  or  spaces  common  in  these  villi ; ft.  Group  of  epithelial  cells  which  in  many 
places  covered  the  villi ; c.  Cells  of  various  shapes,  easily  squeezed  from  the  soft  vil- 
lous structure,  undergoing  the  fibrous  and  vascular  transformations. — (See  Fig.  254.) 

200  diam. 


176 


PRINCIPLES  OF  MEDICINE. 


it  is  no  longer  required,  is  put  an  end  to,  and  adhesion  occurs.  The 
matters  absorbed  into  the  blood  pass  through  the  same  series  of 
changes  as  those  in  pneumonia  do,  and  are  eliminated  from  the  economy 
in  a similar  manner.  Such  is  the  natural  progress  of  pericarditis. 

The  two  kinds  of  processes  now  described  exhibit  the  same  wise  de- 
sign in  pathological  as  we  everywhere  find  in  physiological  actions.  In 
the  vascular  tissue  of  the  lung,  new  blood-vessels  are  unnecessary.  But 
in  the  nou-vascular  serous  membrane,  they  must  be  formed  to  bring 
about  removal  of  the  morbid  products.  In  the  one  case  the  entire 
exudation  is  transformed  into  cells  to  produce  rapid  disintegration  and 
absorption,  which  latter  is  easily  accomplished  by  the  already  formed 
numerous  vessels  of  the  lung.  In  the  other  case  the  exuded  liquor 
sanguinis  is  separated  into  solid  and  fluid  parts,  and  as  there  are  no 
vessels  in  the  serous  membrane,  they  are  formed  in  one  portion  of  the 
exudation  to  cause  absorption  of  the  other. 

VI.  General  Treatment  of  Inflammation. — ^The  foregoing  facts 
and  considerations  must  lead  us  to  the  conclusion,  that  practically  the 
medical  man  may  be  called  upon — 1st,  To  check  or  diminish  the  inflam- 
matory congestion ; 2d,  When  exudation  has  coagulated,  to  further  its 
removal  from  the  economy ; or,  3d,  If  this  cannot  be  accomplished,  to 
render  its  products  as  little  injurious  to  the  system  as  possible.  In  each 
case,  we  can  only  proceed  correctly  by  knowing  the  manner  in  which 
nature  operates,  and  assisting  those  curative  changes  which  she  invariably 
attempts  to  bring  about.  We  have  seen  that  exudation  follows  certain 
preliminary  alterations  in  the  capillary  vessels,  and  is  imn.ediately 
dependent  on  relaxation  or  paralysis  of  their  coats,  and  transudation 
through  them  of  the  liquor  sanguinis.  Once  formed,  it  passes  through 
certain  changes  or  developments,  which  vary  according  to  the  nature  of 
the  texture  in  which  it  occurs,  its  amount,  the  rapidity  with  which  it  is 
formed,  and  its  inherent  constitution.  The  exudation,  by  means  of  these 
changes,  is  rendered  soft,  is  more  or  less  disintegrated,  and  is  absorbed 
into  the  blood  to  be  excreted  from  the  economy.  A correct  treatment, 
therefore,  will  be  influenced  by  the  stage  and  nature  of  the  inflamma- 
tion. 

1.  To  check  or  diminish  the  inflammatory  congestion,  we  must  adopt 
measures  to  restore  the  capillaries  to  their  normal  condition,  prevent 
their  distension  with  blood,  and  lessen  the  attractive  power  (whatever 
that  is)  which  draws  the  blood  into  the  irritated  textures.  This  is  ac- 
complished— 1st,  By  local  applications  of  cold  and  astringents,  which 
stimulate  the  capillaries  to  contraction  ; 2d,  By  soothing  topical  applica- 
tions, such  as  warm  fomentations,  opiates,  etc.,  which  relieve  the  irrita- 
tion of  the  nerves  in  the  part.  Blood-letting,  local  or  general,  has  long 
been  supposed  capable  of  meeting  this  indication,  but  theoretically  it  can 
no  longer  be  defended,  and  practically  the  use  of  the  former  has  of  late 
years  been  confined  to  some  active  congestion  of  the  external  tissues, 
while  that  of  the  latter  has  been  abandoned. 

2.  Wh'Mi  the  exudation  has  coagulated,  it  constitutes  a foreign  body, 
which  either  becomes  organised,  or  is  removed  by  its  dying.  In  the  one 
case  it  acts  as  a blastema,  in  which  cells  are  developed  that  ultimately 


INFLAMMATION. 


177 


break  down,  and  so  render  it  capable  of  being  absorbed  (resolution),  or 
they  are  converted  into  a tissue  that  becomes  pennaneiit.  In  the  other 
case,  it  disintegrates  slowly,  constituting  ulceration — or  putrefies,  forming 
moist  gangrene,  when  it  is  separated  from  the  economy  in  discharge  or 
as  a slough.  It  is  by  regulating  the  formative  power  of  the  exudation 
that  we  check  or  favor  resolution ; and  we  can  only  do  this  by  employ- 
ing those  means  which  lessen  or  advance  cell-growth  in  all  living  organ- 
isms. Thus  locally,  cold,  dryness,  and  pressure  check — while  heat, 
moisture,  and  room  for  expansion  favor — growth.  And  as  regards  the 
general  system,  the  increase  or  diminution  of  food,  nutrients  and  stimuli, 
act  for  or  against  this  object. 

With  a view  of  diminishing  the  general  excitement  that  prevails, 
tartar  emetic  has  been  recommended,  and  to  assist  the  absorption  of  the 
exuded  matter,  calomel  has  been  a favorite  remedy ; but  the  manner  in 
which  these  act  has  been  disputed,  and  whether  it  be  as  a solvent  of  the 
effete  matters  in  the  blood,  or  by  operating  on  the  excretions,  is  yet  un- 
determined. The  former  probably  acts  in  both  these  ways — the  use  of 
the  latter,  as  an  antiphlogistic,  has  of  late  years  been  almost  abandoned. 
The  action  of  counter-irritants,  although  undoubtedly  useful  in  removing 
pain  and  in  causing  absorption  of  chronic  exudations,  is  little  understood, 
and  belongs  to  the  most  mysterious  department  of  therapeutics. 

3.  In  order  to  favor  the  excretion  of  the  effete  matters  in  the  blood, 
purgatives,  diaphoretics,  and  diuretics,  alone  or  combined,  will  occa- 
sionally be  found  very  useful.  The  influence  of  these  remedies,  indeed, 
is  not  confined  merely  to  removing  matters  which  have  been  absorbed  as 
the  result  of  the  secondary  digestion  ; but,  by  their  depurating  equalities, 
they  favor  indirectly  the  rapid  absorption  of  the  exudation. 

Formerly  it  was  supposed  that  the  essential  phenomenon  of  inflam- 
mation consisted  of  the  alteration  in  the  blood  and  blood-vessels^  The 
views  previously  detailed  seek  to  establish  that  this  process  really  con- 
sists in  irritation  of  the  extra-vascular  elements  of  the  textures,  pro- 
ducing exudation  of  the  liquor  sanguinis.  The  former  doctrine  naturally 
ted  its  upholders  to  maintain  an  antiphlogistic  treatment;  the  latter  one 
as  naturally  led  to  an  opposite  practice.  There  is  no  inflammation  so 
well  capable  of  testing  the  value  of  any  particular  treatment  as  a pneu- 
monia : first,  because  there  is  none  that  can  be  more  accurately  deter- 
mined by  functional  symptoms  and  physical  signs;  secondly,  because 
the  perturbation  of  the  system  and  importance  of  the  organs  involved 
have  ever,  and  must  always,  attract  strongly  the  attention  of  medical 
men ; thirdly,  because  it,  perhaps  more  than  any  other,  has  been  sup- 
posed to  be  amenable  to  blood-letting  and  antiphlogistics.  It  is  now 
eighteen  years  since  a careful  investigation  into  the  pathology  of  inflam- 
mation induced  me  to  doubt  the  value  of  the  then  universal  practice  in 
these  cases,  and  this  for  the  following  reasons  : — 

In  the  first  place,  the  cause  of  the  inflammation  is  an  irritation  of  the 
textures — of  the  ultimate  molecules  of  the  part — in  consequence  of 
which  their  vital  power  of  selection  is  destroyed,  and  that  of  their  attrac- 
tion is  increased.  The  removal  of  blood  by  venesection  cannot  alter  this 
state  of  matters — neither  can  other  lowering  remedies.  If  the  inflamma- 
tion be  superficial  and  limited,  local  bleedieg  may  relieve  the  congestion, 
12 


178 


PKINCIPLES  OF  MEDICIXE. 


as  in  conjunctivitis,  but  if  exudation  has  occurred  it  cannot  remove 
that. 

In  the  second  place,  an  exudation  or  true  inflammation  having  oc- 
curred, it  can  only  be  absorbed  by  undergoing  cell-transformation.  Now, 
tliis  demands  vital  force  or  strength,  and  is  arrested  by  weakness.  Hence 
inflammations  in  healthy  men  rapidly  go  through  their  natural  course  : 
in  weak  persons  this  is  delayed  ; hence  their  fatality. 

In  the  third  place,  the  strong  pulse,  fever,  and  increased  flow  of 
blood  in  the  neighborhood  of  inflamed  parts,  have  been  wrongly  inter- 
preted by  practitioners.  They  are  the  results,  and  not  the  causes,  of 
inflammation,  and  show  that  the  economy  is  actively  at  work  repairing 
the  injury.  So  far,  therefore,  from  being  interfered  with  and  interrupted, 
they  should  be  encouraged — locally  by  warmth,  which  also  relieves  pain, 
and  internally  by  nutrients. 

It  follows,  fourthly,  that  if  these  views  be  correct,  our  object  in  the 
treatment  of  internal  inflammation  should  be  directed  towards  bringing 
the  disease  to  a favorable  conclusion,  by  supporting  rather  than  diminish- 
ing the  vital  strength  of  the  economy,  and  this  not  by  over-stimulating, 
as  was  done  by  Dr.  Todd,  but  simply  by  attending  to  all  those  circum- 
stances which  restore  the  nutritive  processes  to  a healthy  condition. 

Having  been  guided  by  thes'e  views  in  my  practice  for  the  last  six- 
teen years,  and  having  seen  that  gradually  they  have  been  adopted  by 
the  profession,  it  is,  I think,  in  my  power  to  offer  you  the  most  convinc- 
ing proof  of  their  correctness,  by  contrasting  the  results  of  an  antiphlo- 
gistic treatment,  as  formerly  practised  in  pneumonia,  with  those  furnished 
by  the  cases  that  have  been  carefully  recorded  by  my  various  clinical 
clerks  in  the  Royal  Infirmary. 

For  the  details.  I must,  in  order  to  prevent  repetition,  refer  you  to 
section  III.,  in  which,  under  the  head  of  “ the  diminished  employment 
of  blood-letting,  etc.,”  the  facts  and  arguments  on  this  subject  are  fully 
detailed.  The  cases  also  are  given  under  the  head  of  Pneumonia.  All 
that  need  be  said  here  is,  that  the  mortality  of  this  disease,  which  used 
to  exist  ill  large  hospitals,  varying  fi  om  1 in  3 to  1 in  7 cases,  is  in  my 
wards  of  the  Royal  Infirmary  almost  nil.  Cases  of  simple  pneumonia, 
single  or  double,  always  recover ; while  the  few  cases  that  die  owe  their 
fatality  to  severe  complications. 

From  these  facts  I conclude — 1st,  That  simple  pneumonia,  if  treated 
so  as  to  support  instead  of  lower  the  nutritive  processes,  so  far  from  being 
a fatal  disease,  almost  invariably  recovers. 

‘2d,  That  the  cause  of  mortality  in  these  cases  is  exhaustion,  cither 
before  they  come  under  medical  supervision,  or,  as  formerly  practised, 
from  an  antiphlogistic  or  a lowering  treatment.  All  bleedings  that  do 
not  exhaust  must  be  regarded  as  palliative,  rather  than  as  curative. 

3d,  That  the  same  rule  applies  to  all  inflammations,  the  amount  of 
danger  bring  in  direct  ratio  to  the  weakness  of  the  system  and  the  exist- 
ence of  complications  in  the  disease,  especially  blood-poisoning. 

I need  not  dwell  at  length  on  what  it  appears  to  me  are  these  im- 
portant results.  I shall  only  remark,  in  conclusion,  that,  in  my  opinion, 
Ihev  arc  not  the  elfect  of  chance ; of  empirical  experiment ; of  a change 
in  the  nature  of  inflammation,  or  of  the  force  of  the  pulse  in  man  and 


TUBERCULOSIS. 


179 


animals  ; of  an  alteration  in  diet  or  of  drink,  or  of  nervous  susceptibility; 
nor  of  a change  in  the  type  of  disease;  all  of  which  have  been  supposed 
by  some  to  be  explanatory  of  facts  which  can  no  longer  be  denied.  The 
more  I consider  this  subject,  the  more  am  I convinced  that  it  is  to  the 
advance  of  medical  science  only  that  it  can  be  rightly  attributed,  and 
that  it  is  our  highest  privilege  and  honor  so  to  consider  it.  Indeed,  no 
stronger  proof  can  be  offered  of  the  improvement  in  practice  that  has 
resulted  from  a more  correct  pathology,  than  the  diminished  mortality 
and  great  success  wliich,  it  has  been  shown,  now  attend  our  treatment  of 
acute  inflammations. 


TUBERCULOSIS. 


I propose  in  this  place  to  speak  of  that  very  common  and  important 
morbid  condition  denominated  Struma,  Scrofula,  and,  in  recent  times, 
Tuberculosis — that  is  to  say,  the  formation  of  Tubercle. 

The  term  “ tubercle”  literally  implies  a little  swelling,  and  in  that 
sense  still  serves  to  distinguish  a class  of  skin  disease,  under  the  name 
of  “ tuberculae.”  Its  unfortunate  application  to  the  rounded  and  other 
masses  so  frequentl3r  f^mid  in  the  lungs,  bones,  and  other  textures,  renders 
it  imperative  upon  us  to  define  what  we  now  understand  by  it.  At 
present,  therefore,  tubercle  may  be  regarded  as  an  exudation  possessing 
deficient  vitality,  sometimes  grey,  but  more  frequently  of  a yellowish 
color,  varying  in  size,  form,  and  consistence,  essmtially  composed  of 
molecules  and  irregularly-formed  nuclei. 

Forms  of  iiibercle, — These  may  be  distinguished  as — 1st,  Miliary 
titbercle,  existing  in  small  grains  like  millet-seeds,  and  which  may  be 
yellow  or  grey,  hard  or  soft ; 2d,  Infiltrated  tubercle,  existing  in  masses 
or  patches  more  or  less  extensive  ; 3d,  Encysted  tubercle — that  is,  masses 
of  tubercle  surrounded  by  a fibrous  cyst ; 4th,  Cretaceous  and  calcareous 
tubercle — that  is,  tubercle  loaded  with  mineral  matter,  sometimes  break- 
ing down  under  the  finger,  and  at  others  of  stony  hardness.  In  this  way 
tubercle  not  only  varies  in  form,  but  in  extent,  color,  and  consistence. 
It  may  be  diffluent,  soft,  cheesy,  wax^q  indurated,  chalkjq  and  calcareous. 

Minute  structure  of  tubercle. — A small  portion  squeezed  between 


& 

0>p'0 


o» 


Fig.  157.  Fig.  158.  Fig.  159. 

glasses,  and  examined  under  the  microscope,  presents  a number  of  irregu- 
larly-shaped bodies,  approaching  a round,  oval,  or  triangular  form,  and 


Fig.  157.  Corpuscles  from  firm  tubercular  exudation  into  the  lung,  a,  After  the 
addition  of  acetic  acid. 

Fig  158.  Corpuscles,  granules,  and  debris,  from  soft  tubercular  exudation  into  the 
cerebellum. 

Fig.  159.  The  same,  from  tubercular  infiltration  of  a mesenteric  gland.  250  dlam. 


180 


PRINCIPLES  OF  MEDICINE. 


varying  in  their  longest  diameters  from  the  2/00  to  inch. 

These  bodies  contain  from  one  to  seven  granules,  are  unaffected  by  water, 
but  rendered  transparent  by  acetic  acid.  They  are  what  have  been  called 
tubercle  corpuscles.  They  are  always  mingled  with  a multitude  of  mole- 
cules and  granules,  which  are  more  numerous  the  softer  the  tubercle. 
Occasionally,  when  softened  tubercle  resembles  pus,  constituting  scrofu- 
lous purulent  matter,  we  find  the  corpuscles  more  rounded,  and  approach- 
ing the  character  of  pus  cells.  They  do  not  always,  however,  on  the 
addition  of  acetic  acid,  exhibit  the  peculiar  granular  nuclei  of  pus  cells. 


Fig,  leo. 


Fig.  161. 


The  grey  granulations  described  by  Bayle  may  seem,  on  careful 
management  of  the  light,  and  after  the  addition  of  acetic  acid,  to  contain 
similar  bodies  to  those  described  as  tubercle  corpuscles,  being  closely 
aggregated  together,  having  indistinct  edges,  and  containing  few  granules. 
Cretaceous  and  calcareous  tubercles,  on  the  other  hand,  contain  very 

few  corpuscles,  their  substance 
being  principally  made  up  of 
numerous  irregular  masses  of 
phosphate  of  lime,  and  a 
greater  or  less  number  of  mi- 
neral molecules  and  crystals 
of  cholesterine. 

Tubercle  corpuscles  may 
be  associated  with  pus  and 
granule  cells,  as  well  as  with 
cells  peculiar  to  glandular 
organs  or  mucous  surfaces  in 
various  stages  of  fatty  trans- 
Fig.  162.  formation  and  disintegration. 

With  all  these  they  have  frequently  been  confounded. 

Everything  that  I have  seen  of  tubercle  tends  to  convince  me  that  it 


^00 

‘So 


Fig.  160.  Section  of  a firm  miliary  tubercle  of  the  lung. 

Fig.  161.  Section  of  a grey  granulation  in  the  lung,  showing  the  pulmonary 
vesicles  filled  with  tubercle  corpuscles. 

Fig.  162.  Molecular  structure  of  a calcareous  pulmonary  tubercle. — {liadchjffe 
Hall.)  260  diam. 


TUBERCULOSIS. 


181 


consists  of  an  exudation  wLicli  has  little  tendency  to  pass  into  cell-forms. 
The  original  albuiniiious  molecular  matter  melts  into  nuclei,  which  con- 
stitute the  tubercle  corpuscles,  and  are  developed  no  further.  It  has 
been  regarded  by  some  pathologists  as  a breaking-down  of  pre-existing 
textures,  and  by  Virchow  as  forming  in  the  interior  of  connective  tissue 
corpuscles.  The  former  view  is  based  upon  the  circumstance  that  cells 
in  the  act  of  breaking  down  may  be  observed  in  a certain  stage  to  present 
irregularly-shaped  nuclei  with  numerous  molecules,  which  closely  resemble 
those  found  in  tubercle,  as  in  chronic  pneumonia  and  in  the  reticulum  of 
cancer.  I feel  persuaded,  however,  that  tubercle  is  a histogenetic,  and 
not  a histolytic  process,  and  that  as  such  it  may  easily  be  demonstrated 
in  every  organ  v/hich  it  attacks.  That  it  is  caused  by  a pre-existing 
growth  in  the  so-called  connective  tissue  corpuscles,  is  open  to  the  same 
objections  that  I made  to  the  supposed  origin  of  pus  in  the  same  bodies. 
In  no  case  can  it  be  demonstrated. 

Clmnical  com/position  of  tubercle. — Tubercle  has  been  analysed  by 
numerous  chemists.  The  general  results  are  as  follows: — 1st,  That 
tubercle  consists  of  an  animal  matter,  mixed  with  certain  earthy  salts. 
2d,  That  the  relative  proportion  of  these  varies  in  different  specimens  of 
tubercle.  That  animal  matter  is  most  abundant  in  recent  and  earthy  salts 
in  chronic  tubercle.  3d,  That  the  animal  matter  consists  almost  wholly 
of  albumen,  mixed  with  a minute  quantity  of  fibrin  and  fat.  4th,  That 
the  earthy  salts  are  principally  composed  of  the  insoluble  phosphate  and 
carbonate  of  lime,  with  a small  portion  of  the  soluble  salts  of  soda. 
5th,  That  very  little  difference  in  ultimate  composition  has  been  detected 
between  recent  tubercle  and  other  albuminous  compounds. 

Pathology  cf  tubercle. — In  endeavoring  to  determine  the  nature  of 
tubercle,  we  must  remember  that  it  occurs  in  young  persons  in  whom 
the  nutritive  functions  are  deficient  in  energy,  whether  from  poverty  and 
incapacity  of  obtaining  food,  from  deficient  stamina,  or  from  causes  of 
whatever  kind  which  induce  exhaustion.  Hence  its  frequency  among 
the  ill-fed  poor,  in  orphan  and  foundling  institutions,  among  badly- 
nursed  children  or  weak  and  dyspeptic  young  persons,  and  after  acute 
inflammations,  whooping-cough,  eruptive  fevers,  and  other  disorders  that 
weaken  the  body.  When,  under  such  circumstances,  exudation  occurs 
in  one  or  more  textures,  it  does  not  undergo  those  changes  we  observe 
following  inflammation  in  healthy  persons.  The  vital  changes  are  slow, 
and  easily  arrested.  Instead  of  cells  and  perfect  textures  being  produced, 
the  efforts  at  vital  transformations  are  abortive.  The  whole  remains 
molecular  and  granular,  or  at  most  ill-formed  nuclei  are  produced,  which 
have  received  the  name  of  tubercle  corpuscles. 

It  is  rare,  however,  that  this  weakness  of  the  constitution  acts 
uniformly  at  all  times  and  in  all  textures.  Hence  it  may  frequently  be 
observed  that  tubercle  is  more  or  less  associated  with  pus  and  granule 
ceils,  or  fibrous  and  other  growths ; with  the  exception  of  cancer,  with 
which  it  is  rarely  combined. 

I regard  tubercle,  therefore,  as  an  exudation,  which  may  be  poured 
out  into  all  vascular  textures  in  the  same  manner  and  by  the  same 
mechanism  as  occurs  in  inflammation,  only  from  deficiency  of  vital 
power  it  is  incapable  of  undergoing  the  same  transformations,  and 


182 


PRINCIPLES  OF  MEDICINE. 


exhibits  low  and  abortive  attempts  at  organisation,  and  more  frequently, 
as  a result,  disintegration  and  ulceration.  For  the  same  reason  we 
observe  that  whenever  an  undoubted  inflammation  becomes  chronic  with 
weakness,  the  symptoms  and  general  phenomena  become  identical  with 
those  of  tuberculosis.  Hence  there  is  little  difterence  between  a chronic 
pneumonia  of  the  apex  of  a lung  and  a phthisis ; the  one,  indeed,  pass- 
ing into  the  other. 

When  ve  endeavor  to  discover  the  origin  of  the  weakness  produc- 
ing this  effect  on  the  exudation,  we  must  ascribe  it  to  imperfect  nutrition ; 
indeed,  it  is  impossible  for  any  observant  practitioner  to  avoid  noticing 
throughout  the  whole  course  of  the  disease  the  derangement  that  occurs 
in  the  digestive  system.  All  writers  refer  to  the  deficiency  and  irregu- 
larity of  the  appetite,  and  the  functions  of  the  whole  alimentary  canal 
will  be  found  from  first  to  last  in  an  abnormal  condition : the  tongue  is 
either  furred  and  furrowed,  or  glazed  and  unusually  red ; the  teeth  are 
carious;  the  stomach  capricious — sometimes  rejecting  food,  at  others 
retaining  it  an  unusual  time,  with  accumulation  of  flatus.  There  is  a 
general  indisposition  to  eat  fat  or  fatty  substances  ; and  the  appetite  is 
feeble,  absent,  or,  in  rare  cases,  voracious.  In  the  former  case  there  is 
thirst  and  eructation  of  acid  matters  into  the  mouth ; flatulence  and 
tympanitis  of  the  bowels  are  frequently  complained  of;  the  alvine 
discharges  and  egesta  are  as  irregular  as  the  food  and  ingesta.  Some- 
times there  is  constipation,  at  others  diarrhoea.  The  stools  are  only 
slightly  tinged  with  bile,  and  in  children  often  consist  of  white  glairy 
matter,  like  white  of  egg.  It  may  also  be  invariably  observed,  that 
wdien,  by  proper  regulation  of  the  diet,  of  exercise,  or  other  circumstances 
which  regulate  the  nutritive  functions,  the  alimentary  canal  performs  its 
duty,  the  health  improves,  and  the  tubercular  formations  diminish. 

These,  indeed,  according  to  their  excess  or  progress  in  particular 
organs,  communicate  to  the  disease  more  or  less  of  a local  character.  In 
systematic  w'orks  they  have  been  described  at  length  as  separate  diseases, 
although,  in  truth,  they  are  only  manifestations  of  one  disease. 

After  a time  the  continuance  or  violence  of  the  local  disease  reacts 
upon  the  constitution,  and  a state  called  hectic  fever  is  established,  the 
which,  inducing  exhausting  diaphoresis  and  emaciation,  ultimately  de- 
stroys the  patient. 

Natural  progress  of  tuberculosis. — In  tracing,  therefore,  the  natural 
progress  of  tuberculosis,  we  observe  it  to  commence  in  debility  caused 
by  impairment  of  nutrition.  This  leads  to  local  congestions  and 
exudations.  The  latter  remain  abortive,  and  consist  of  molecules, 
granules,  and  imperfect  nuclei,  which  soften  and  cause  ulceration,  with 
more  or  less  disorganisation.  The  great  contribution  of  M.  Louis  to  the 
pathology  of  this  subject  was  the  establishment  of  a law,  that  whenever 
tubercle  occurred  in  ihe  body  it  also  existed  in  the  lungs,  and  whenever 
it  occurred  in  the  lungs  it  appeared  first  at  the  apex.  This  law,  though 
now  known  to  be  subject  to  several  exceptions,  is  still  so  generally 
correct  as  to  be  of  the  utmost  service  in  diagnosis.  Now,  in  the  lungs, 
it  was  long  supposed,  and  the  opinion  is  still  very  general,  that  tubercle 
almost  always  proceeded  onwards  to  a fatal  termination;  }^et  so  far  is 
this  from  being  the  tact  that  it  can  easily  be  shown  that  tubercle  is 


TUBERCULOSIS. 


183 


arrested  spontaneously  in  one-third  of  all  the  persons  in  whom  it  occurs. 
Nothing  is  more  common  in  examining  dead  bodies  than  to  meet  with 
crectaceous  and  calcareous  concretions  at  the  apices  of  the  lungs  more  or 
less  associated  with  cicatrices.  Of  seventy-three  bodies  which  I ex- 
amined consecutively  some  years  ago  in  the  Royal  Infirmary,  I found 
these  lesions  in  twenty-eight.  Of  these,  puckerings  existed  with  indura- 
tion alone  in  twelve,  with  cretaceous  or  calcareous  concretions  in  sixteen. 
Since  then  I have  examined  many  hundred  lungs  at  the  inspections  in 
the  Infirmary,  and  am  satisfied  that  these  proportions  exist  pretty 
constantly.  At  the  Salpjtriere  Hospital  in  Paris,  Roger  found  them  in 
fifty-one  bodies  out  of  a hundred ; at  the  Bicetre  Hospital,  in  the  same 
city,  Boudet  found  them  in  116  out  of  135  bodies.  Both  these  institu- 
tions are  establishments  for  persons  above  seventy  years  of  age. 

These  lesions  are  so  frequent,  therefore,  that  it  is  important  to 
determine  whether  they  are  really  proofs  of  arrested  tubercle.  This 
seems  to  be  established  by  the  following  facts : — 

1.  A form  of  indurated  tubercle  is  frequently  met  with,  gritty  to  the 
feel,  which,  on  being  dried,  closely  resembles  cretaceous  concretions. 
2.  These  concretions  are  found  exactly  in  the  same  situation  as  tuber- 
cular deposits  are.  Thus  they  are  most  common  in  the  lungs,  and  at 
their  apices.  3.  When  the  lung  is  the  seat  of  tubercular  infiltration 
throughout,  whilst  recent  tubercle  occupies  the  inferior  portion,  and 
older  tubercle  and  perhaps  caverns  the  superior,  the  cretaceous  and 
calcareous  concretions  will  be  found  at  the  apex.  4.  A comparison  of 
the  opposite  lungs  will  frequently  show,  that  whilst  on  one  side  there  is 
firm  encysted  tubercle,  partly  transformed  into  cretaceous  matter,  on  the 
other  the  transformation  is  perfect,  and  has  occasionally  even  passed  into 
a substance  of  stony  hardness.  5.  The  puckerings  found  without  these 
concretions  exactly  resemble  those  in  which  they  exist.  Moreover, 
whilst  puckering  with  grey  induration  may  be  found  at  the  apex  of  one 
lung,  a puckering  surrounding  a concretion  may  be  found  in  the  apex  of 
the  other.  6.  The  seat  of  cicatrices  admit  of  the  same  exceptions  as  the 
seat  of  tubercles,  and  in  about  the  same  proportion.  There  can  be  no 
question,  therefore,  that  these  cicatrices  and  concretions  for  the  most 
part  indicate  the  arrestment,  disintegration,  and  transformation  of  pre- 
existing tubercular  exudations  into  the  lungs. 

The  arrestment  of  tubercle  in  the  lung  is  not  confined,  however,  to 
its  early  stage.  It  may  be  stopped  at  any  period,  and  numerous  cases 
are  now  known  where  even  vast  tubercular  caverns  have  healed  and 
cicatrised.  I here  show  you  a series  of  preparations,  which  must  con- 
vince the  most  sceptical  of  the  truth  of  this  statement."^ 

Treatmsnt. — It  follows,  therefore,  that  if  we  can  succeed  in  support- 
ing the  nutritive  functions,  there  is  no  reason  why  tubercle  once  formed 
should  not  be  gradually  absorbed,  and  a tendency  to  subsequent  deposits 
completely  checked.  Formerly  this  was  rarely  accomplished,  in  conse- 
quence of  the  idea  that  phthisis  pulraonalis  ought  to  be  treated  by  paying 
attention  especially  to  the  lungs  and  respiration.  Hence  cough  mixtures, 
sedatives,  a warm  atmosphere,  tar  vapor,  and  other  substances  to  influ- 

* See  the  author’s  work,  “ The  Pathology  and  Treatment  of  Pulmonary  Con- 
sumption,” 2d  edition.  Figs.  21  to  26. 


1S4 


PEINCIPLES  OF  MEDICINE. 


ence  the  local  lesion.  Other  symptoms  had  their  special  treatment,  such 
as  sulphuric  acid  to  relieve  sweating,  acetate  of  lead  and  opium  to  check 
haemoptysis,  tonics  to  give  strength,  astringents  to  check  diarrhoea,  and 
so  oil ; while  so  far  from  any  vigorous  effort  being  made  to  improve 
nutrition,  the  diet  was  kept  low»  consisting  of  farinaceous  substances,  or, 
at  most,  milk;  and  to  avoid  irritation,  the  patients  were  confined  to  bed 
or  their  rooms,  which  were  kept  at  an  equable  tempei'ature. 

Our  present  knowledge  has  led  to  a complete  revolution  in  our  prac- 
tice. Thus,  moderate  exercise  to  stimulate  respiration,  cold  sponging, 
nutritious  diet,  and  a bracing  system,  have  been  found  more  beneficial; 
at  the  same  time  avoiding  anodynes  and  cough  mixtures,  which,  by 
diminishing  the  appetite  and  inducing  weakness,  interfere  with  nutrition. 
Indeed,  it  has  been  proved  that  the  best  method  of  lessening  cough,  ex- 
pectoration, and  sweating,  are  the  means  which  produce  increase  of  gene- 
ral strength  ; so  that,  if  we  can  carry  out  the  general  indication,  the  local 
symptoms  may  be  safely  left  to  themselves. 

In  doing  this,  we  have  now  the  advantage  of  possessing  a remedy 
which,  in  cases  of  tuberculosis,  is  of  the  highest  nutritive  importance,  as 
it  gives  to  the  system  that  fatty  element  in  which  it  is  so  defective,  and 
in  a form  that  is  more  easily  assimilated,  and  more  capable  of  adding  to 
the  molecular  element  of  the  body,  than  any  other.  I allude  to  cod- 
liver  OIL. 

And  now,  you  cannot  fail  to  perceive  how  the  molecular  doctrine  of 
organization  and  of  growth  not  only  explains  the  known  facts  in  physi- 
ology and  pathology,  but  constitutes  the  basis  for  a true  therapeutics. 
Fatty  particles,  as  we  have  seen,  form  the  molecular  fluid  of  chyle;  while 
out  of  chyle,  blood,  and  through  it  all  the  tissues,  are  formed.  Impair- 
ment of  digestion  in  scrofula  and  tuberculosis  renders  chylifieation  im- 
perfect ; the  fatty  constituents  of  the  food  are  not  separated  from  it  and 
assimilated ; the  blood  consequently  abounds  in  the  albuminous  elements, 
and  when  exuded  forms,  as  we  have  seen,  tubercle.  To  induce  health, 
it  is  necessary  to  restore  the  nutritive  elements  which  are  diminished, 
and  this  is  done  directly  by  adding  a pure  animal  oil  to  the  food.  While 
an  inflammatory  exudation  in  previously  healthy  persons  should  be  treated 
by  supporting  the  vital  powers  generally,  so  as  to  permit  its  molecules 
going  through  the  transformations  necessary  for  their  growth  and  elimin- 
ation ; in  tuberculosis  we  add  the  constituent  of  food  necessary  for  the 
formation  of  the  molecules  themselves.  By  so  doing,  we  form  good  chyle 
and  blood  , we  restore  the  balance  of  nutrition  which  has  been  disturbed  ; 
respiration  is  again  active  in  the  excretion  of  carbonic  acid  gas;  the 
tissues  once  more  attract  from  the  blood  the  elements  so  necessary  for 
their  sustenance.  The  entire  economy  is  renovated ; so  that,  while  the 
histogenetic  processes  are  revived,  the  histolytic  changes  in  the  tubercle 
itself  also  are  stimulated,  and  the  whole  disappears.  When,  in  184i, 
I first  announced  the  virtues  of  cod-liver  oil  as  an  analeptic  or  nutrient 
in  this  class  of  cases,*  so  little  was  the  substance  known,  that  linseed  oil 
was  furnished  to  the  Eoyal  Infirmary  of  this  city  instead  of  it,  when  I 
induced  I)r.  Spittal  to  try  it  in  his  wards.  At  present,  I need  scarcely 

* On  the  Oleum  Jecoris  Aselli:  Edinburgh,  1841.  See  also  the  same  work,  with 
Appendix  by  the  Author,  1848. 


MORBID  GROWTHS. 


185 


say,  whole  fleets  are  engaged  in  transporting  the  oil  from  the  extensive 
flsheries,  where  it  is  manufactured  for  medicinal  purposes  ; and  its  bene- 
ficial results  are  universally  recognised. 

In  1852,  Dr.  Wood  of  Philadelphia  remarks  of  it,  in  his  Practice 
of  Physic  (see  vol.  ii.,  p.  95,  note),  that  in  Philadelphia,  during  the  ten 
years  from  1840  to  1849  inclusive,  the  average  proportion  of  mortality 
from  phthisis  was  1 in  about  6'76  from  all  causes,  or  14‘8  per  cent,  and 
the  same  average  existed  in  previous  years.  Cod-liver  oil  was  then  gene- 
rally used  in  its  treatment,  and  the  mortality  sank  in  this  disease  during 
1850-51  to  1 in  8-33,  or  about  12  per  cent,  and  in  1851  it  was  only 
11'86  per  cent. 

In  1862,  Dr.  C.  J.  B.  Williams,  in  one  of  the  Lumleian  Lectures 
delivered  to  the  London  College  of  Physicians,  observes,  that  the  experi- 
ence of  Louis  and  Laennec  gave  an  average  duration  of  two  years’  life 
in  phthisis,  after  it  was  decidedly  developed,  but  that  since  cod-liver  oil 
was  introduced,  he  infers,  from  7000  cases,  that  the  average  duration  of 
life  has  been  four  years — that  is,  doubled. 

My  own  conviction  is,  that  innumerable  cases  which  formerly  would 
have  died  rapidly,  now  rally,  live  for  years,  and  many  of  them  ultimately 
recover.  The  hopelessness  which  used  to  seize  upon  many  consumptive 
persons,  and  on  their  friends,  is  also  now  removed,  and  the  resolution 
to  combat  the  disease  by  appropriate  diet,  exercise,  and  other  hygienic 
means,  has  added  further  success  to  our  treatment. 

I venture  then  to  say,  that  in  the  same  manner  that  in  recent  times 
we  have  diminished  the  mortality  in  cases  of  acute  inflammation,  so  we 
have  diminished  the  mortality  and  increased  the  duration  of  life  in  cases 
of  tuberculosis,  and  more  especially  in  that  most  fatal  form  of  it— phthisis 
pulmonalis.  In  the  one  disease,  as  in  the  other,  the  improvement  can 
only  justly  be  ascribed  to  the  advance  of  physiology  and  pathology ; to 
our  superior  knowledge  of  the  nature  of  the  disease,  and,  as  a conse- 
quence, to  our  treatment  of  it  on  more  scientific  and  successful  principles. 


MOEBID  GEOWTHS  OF  TEXTUEE— THEIE  GENEEAL 
PATHOLOGY  AND  TEEATxMENT. 

The  exclusive  study  of  morbid  growths,  according  as  they  affect  in- 
ternal or  external  parts,  has  led  to  limited  views  of  the  subject.  The 
surgical  tendency  to  speak  of  them  as  tumors,  and  to  regard  them  in 
reference  to  the  great  practical  question  of  excision,  has  interfered  with 
the  true  pathological  doctrine — namely,  that,  however  or  wherever  pro- 
duced, they  are  essentially  the  same.  No  doubt  they  are  very  common 
in  external  parts,  simply  because  all  growth  proceeds  best  on  surfaces 
where  there  is  room  for  expansion,  but  this  accidental  circumstance  should 
not  induce  us  to  suppose  that  they  are  peculiarly  matters  for  surgical 
consideration.  In  truth,  their  study  belongs  to  pathology — that  science 
which  constitutes  the  basis  of  all  branches  of  the  medical  art. 

The  line  which  separates  health  from  disease  is  not  always  to  be 
determined,  when  certain  tissues  or  organs  have  increased  in  size  dispro- 
portioned  to  the  rest  of  the  body.  Exercise,  within  certain  limits,  may 


186 


PRINCIPLES  OF  MEDICINE. 


cause  the  size  of  particular  parts  to  be  relatively  increased,  as  the  legs 
of  the  dancer,  and  arms  of  the  blacksmith.  In  these  cases,  however, 
such  enlargement  is  consistent  with  health.  So  when  the  uterus  enlarges 
and  its  walls  thicken  during  pregnancy,  we  recognise  that  the  departure 
from  the  normal  type  is  absolutely  necessary  for  the  purpose  it  is  required 
to  carry  out;  and  when  this  is  accomplished,  it  returns  to  its  natural 
condition.  In  like  manner,  other  hollow  viscera  enlarge  when  they  have 
an  obstruction  to  overcome.  Thus  the  urinary  bladder  becomes  greatly 
thickened,  in  consequence  of  a stricture  in  the  urethra ; and  the  left 
ventricle  of  the  heart  becomes  hypertrophied  from  disease  of  the  aortic 
valves.  But  in  these  last  cases,  the  increased  growth,  though  a wise 
adaptation  of  nature,  and  even  necessary  for  the  continuance  of  life,  must 
be  regarded  as  evidence  of  permanent  disease.  Again,  a blow  on  the 
breast,  on  the  skin,  or  over  a bone,  may  cause  the  injured  parts  slowly 
to  enlarge,  inducing  swellings,  which  may  produce  inconvenience  from 
their  size,  or  from  their  pressure,  on  neighboring  nerves.  In  this 
manner,  no  tissue  or  organ  of  the  body  is  exempt  from  more  or  less 
increase  of  its  extent  or  magnitude,  and  there  are  none,  consequently, 
which  may  not  occasionally  present  morbid  or  excessive  growth. 

Increased  growth  of  tissues  may  assume  various  forms.  The  organ 
or  structure  may  gradually  become  enlarged  in  whole  or  in  part,  still 
maintaining  more  or  less  of  its  original  texture,  shape,  and  function,  con- 
stituting hj'pftrtrophj.  Membranes  may  become  preternaturally  thickened, 
causing  more  or  less  induration^  whereby  the  movements  of  parts  nmy  be 
affected,  or  the  calibre  of  t,ubes  and  ducts  may  be  diminished,  producing 
stricture.  The  results  of  the  healing  process  may  give  rise  to  new  tissues 
exactly  resembling  those  previously  existing  in  other  parts  of  the  body, 
as  in  cicatrices^  callus,  etc. ; or  such  growths  may  assume  the  form  of 
tumor.  Lastly,  we  must  not  overlook  the  fact  that  certain  transforma- 
tions in  the  exudation,  formerly  noticed,  lead  to  increase  of  texture,  and 
produce  morbid  growths  altogether  foreign  to  the  healthy  frame. 

A cultivation  of  histology  excited  the  hope  that,  by  studying  the 
ultimate  structure  and  mode  of  development  of  morbid  growths,  distinc- 
tive elements,  and  thereby  a new  foundation  for  their  classification, 
would  be  discovered.  But  extensive  researches  long  ago  convinced  me 
that  this  hope  was  vain,  and  in  a special  work,  published  in  1849,^  I 
pointed  out  what  were  the  ultimate  elements  of  all  morbid  growths,  and 
that  not  one  of  these  was  characteristic  of  any  special  kind  of  organic 
formation.  The  structural  elements  of  morbid  growths  may  be  reduced 
to  six,  viz. — 1st,  molecules  and  granules;  2d,  nuclei;  3d,  cells;  4th, 
fibres  ; 5th,  tubes  (especially  vascular  ones) ; and  6th,  crystals  or  irregular 
masses  of  mineral  matter.  Now  no  combination  of  these  elements  will  serve 
to  characterise  morbid  growths,  such  as  fibro-molecular,  fibro-nucleated, 
fibro-cellular,  fibro-vascular,  etc.,  for  the  simple  reason  that  tumors  very 
unlike  in  their  external  characters  and  natures  may  be  composed  of  the 
same  elements.  For  instance,  cystic,  glandular,  cartilaginous,  and  can- 
cerous growths,  are  all  fibro-cellular.  It  is  not  then  from  its  showing 
the  existence  of  one  or  more  elementary  structures,  but  from  its  pointing 
at  their  mode  of  arrangement,  that  the  microscope  is  destined  to  be  of 
* On  Cancerous  and  Cancroid  Growths.  Edinburgh,  1849. 


CLASSIFICATIOX  OF  MOEBID  GKOWTHS. 


187 


infinite  importance  in  pathology  and  diagnosis.  Neither  will  chemical 
composition  furnish  us  with  trustworthy  means  of  distinguishing  morbid 
growths,  as  many  of  them  contain  albuminous,  fatty,  pigmentary,  and 
mineral  principles  conjoined,  although  in  variable  proportions. 

The  best  classification,  therefore,  is  one  founded  on  our  knowledge 
of  the  compound  textures  of  the  growths  themselves,  assisted  as  far  as 
varieties  are  concerned  by  their  similitude  to  well-known  objects,  which 
have  long  been  received  in  pathology  as  standards  of  comparison.  Thus 
the  following  arrangement  appears  to  me  capable  of  embracing  all  the 
known  primary  classes  of  morbid  growths 


I.  Fibrous  growths 

II.  Fatty  growths 

III.  Cystic  growths 
lY.  Glandular  growths  . 

V.  Epithelial  growths  . 

VI.  Vascular  growths 

VII.  Cartilaginous  growths 

VIII.  Osseous  growths 

IX.  Cancerous  growths  . 

All  these  primary  divisions  aia 
according  to  the  presence  of  particul 
blances  which  have  received  names. 


Fibroma^  or  Inoma. 
Lipoma. 

Cystoma. 

Andenoma. 

Epithelioma. 

Angionoma. 
Enchondroma. 

Osteoma. 

Carcinoma, 
susceptible  of  being  subdivided 
r substances,  or  to  fancied  resem- 
Thus  the  varieties  of  the  above 


kinds  of  growth  have  long  been  determined  by  their  substance  present- 
ing greater  or  less  similitude  to  well-known  objects,  such  as  water,  lard, 
flesh,  brain,  etc.  etc.,  as  follows 


1. 

Like  water 

Hygroma. 

2. 

u 

black  pigment  . 

Melanoma. 

3. 

a 

green  pigment  . 

Chloroma. 

4. 

u 

blood 

Haem  atom  a. 

5. 

u 

glue 

Colloma. 

6. 

u 

lard 

S tea  tom  a. 

7. 

u 

gruel 

Atheroma. 

8. 

a 

honey 

IMeliceroma. 

9. 

u 

cholesterine 

Cholesteatoma. 

10. 

u 

flesh 

Sarcoma. 

11. 

({ 

nerve 

Neuroma. 

12. 

ti 

brain 

Encephaloma. 

13. 

u 

marrow 

Myeloma. 

14. 

marble 

Schirrhoma,  etc. 

It  is  easy  to  understand  how  varieties  may  in  this  way  be  multiplied, 
and  how  new  names  may  be  scientifically  given  to  rare  forms  of  tumor, 
for  instance  Syphonoyna,  or  tubular  growth,  described  by  Henle;f  Cylin- 
droma^ by  Billroth  Keter adenoma^  by  Bobin,<^  etc.  etc. 


* The  word  Fibroma,  though  composed  of  a Latin  root  with  a Greek  termination, 
and  therefore  barbarous,  is  here  given  in  consequence  of  its  having  been  already  em- 
ployed in  medicine.  Those,  however,  who  may  object  to  it  on  this  ground,  can 
employ  the  more  correct  novel  term  of  Inoma,  from  is-ivos,  a fibre, 
f Zeit  fiir.  Ration.  Med.  3 Bd.  1 Heft. 

X Ueber  die  Entwicklung  der  Blutgefasse,  Berlin,  1856. 

§ Traite  d’Anat.  Pathologique,  par  Lebert,  p.  339,  ct  seq. 


188 


PEINCIPLES  OF  MEDICINE. 


Further  varieties  have  been  made  to  express  one  or  more  combina- 
tions of  these  elements,  and  hence  the  terms  Fihro-cijstic,  Filro  cartilagi- 
nous^ Fihro- Sarcoma^  Osteo- Sarcoma^  and  so  on.  Indeed,  this  kind  of 
nomenclature  admits  of  further  extension,  and  such  terms  as  Fihro- 
cpithelial,  Angio-cysticy  Cystic- adenoma^  Osteo-fihrous^  and  so  on,  might 
be  employed  with  advantage.  When,  also,  growths  have  a certain  re- 
semblance to,  or  largely  partake  of  the  character  of  the  structures  and 
substances  referred  to,  while  their  real  nature  is  not  absolutely  or  alto- 
gether the  same,  the  words  Fibroid^  Cgstoidy  Adenoid,  Chondroid, 
Osteoid,  Colloid,  Ilmnatoid,  Fungoid,  FncepTialoid,  Myeloid,  Cancroid, 
etc.,  have  been  employed. 

All  these  words  and  modes  of  expression,  as  they  are  founded  on 
anatomical  facts,  may,  if  carefully  applied,  be  useful  in  designating  the 
structure  and  nature  of  morbid  growths.  But  other  distinctions  founded 
on  presumed  vital  properties,  are  objectionable.  What  ideas,  for  instance, 
can  be  attached  to  the  terms  innocent  and  malignant  ? A fibrous  growth 
has  been  generally  classed  among  innocent  ones,  yet  the  terms  recurrent 
and  malignant  have  also  been  applied  to  it.  In  fact,  we  shall  afterwards 
see  that  almost  every  kind  of  growth  may  be  innocent  in  some  cases,  and 
malignant  in  others.  The  distinctions,  therefore,  sought  to  be  established 
from  such  theoretical  considerations  are  not  oi  ly  erroneous,  but  have 
proved — as  we  shall  subseque  ntly  show — most  ii  jurious  in  practice.  I 
have  known  innocent  growths  never  operated  on  by  the  surgeon,  and 
allowed  to  kill,  in  consequence  of  his  believing  them  to  be  malignant, 
and  really  malignant  ones  not  touched  at  that  early  period  when  their 
removal  was  likely  to  be  beneficial,  in  the  hope  that  they  would  go  away 
of  themselves.  This  point  will  be  more  especially  dwelt  upon,  after 
giving,  as  it  is  now  proposed  to  do,  a short  sketch  of  the  nine  distinct 
kinds  of  morbid  growths. 

Fibrous  Growths. — Fibroma  or  Inoina, 

The  pathological  formation  of  fibrous  growths  is  the  most  common 
^ and  universal  which  occurs  in  the 

body.  It  is  essentially  of  two  kinds — 
1st,  a simple  increase  by  division  or 
enlargement  of  pre-existing  fibrous 
tissue  ; 2d,  a new  formaiiou  of  fibres 
in  an  exudation. 


I.  As  examples  of  the  first  kind  of 
increased  fibrous  growth,  we  may  refer 
to  what  takes  place  in  voluntary  and 
involuntary  muscle,  in  simple  hyper- 
trophy.  In  voluntary  muscle,  the  fas- 
ciculi and  fibrillae  increase  in  breadth, 
and  there  is  a tendency  to  fissiparous 

Fig.  IGo.  Structures  in  hypertrophied  heart,  a,  A muscular  fasciculus  dividing 
dichotoinously ; b,  a slender  fasciculus  dividing ; c,  anastomosing  fasciculi ; d,  con- 
centric ; e,  smooth  colloid  (amyloid  ?)  bodies.—  ( Wedl.)  250  diam. 


FIBROUS  GROWTHS. 


189 


division  whereby  they  become  more  numerous.  There  may  be  also 
observed  fasciculi  varying  greatly  in  size,  but  without  cells  such  as  are 
visible  in  embryonic  muscular  formation.  The  same  thing  occurs  m 
hypertrophy  of  non-voluntary  muscle,  where,  in  addition  to  great  increase 
of  bulk  in  individual  cells,  other  smaller  ones  in  various  stages  of  devel- 
opment may  also  be  detected.  In  the  uterus  during  pregnancy  this  is 
easily  observable,  but  in  the  thickening  of  organic  muscular  fibre  ot  the 
stomach  and  other  hollow  viscera,  the  large  elongated  fusiform  cells  are 
not  discoverable. 


Fig.  164.  Fig.  165. 

II.  With  regard  to  the  second  kind  of  increased  fibrous  growth,  it 
may  be  said  to  present  various  forms. 

We  have  previously  seen  that  the  coagulation  of  liquor  sanguinis 
often  occurs  in  the  form  of  filaments  (Fig.  138),  which  become  more 
and  more  dense.  These  are  molecular  fibres.  Occasionally  when  the 
exudation  coagulates,  it  presents  a tendency  to  fibrillate  or  split  up, 


Fig;  166,  Fig.  167.  Fig.  168.  Fie.  16P, 

owing  apparently  to  the  formation  of  nuclei,  which  become  more  or  less 
elongated.  These  are  nuclear  fibres.  At  other  times  cells  are  formed, 
which  elongate,  become  fusiform,  split  up,  and  so  produce  fibres  in  the 
manner  described  by  Schwann  in  healthy  tissues.  These  are  cell  fibres. 
In  these  three  ways,  there  may  be  produced  all  kinds  and  forms  of  fibrous 

Fig.  1 64.  Fibrous  structure  of  the  uterus. 

Fig.  165.  The  same,  hypertrophied  from  great  increase  in  size  of  its  fusiform  cells. 

Fig,  166.  Cell  fibres  and  fibre-cells  from  a fibro-cellular  growth  in  the  coats  of  tlie 
stomach. 

Fig.  16Y.  Fusiform  cells  from  a sarcomatous  growth  in  the  kidney.  (See  also 
Fig.  213.) 

Fig.  168.  Fibro-nucleated  structure,  from  a so-callcd  medullary  sarcoma  of  the 
humerus. 

Fig.  169.  Fibrous  stroma  of  a tumor  acted  on  by  acetic  acid. 


250  diam. 


190 


PRINCIPLES  OF  MEDICINE. 


element,  from  tlie  finest  and  most  delicate  areolar  tissue,  to  one  resembling 
in  consistence  ligament  or  fibro-cartilage.  Hence,  as  far  as  structure 
is  concerned,  we  may  have  fibro-ynolecular^  fibro-nucleated^  and  Jihro- 
cellidar  fibrous  growths. 

1.  One  of  the  most  common  forms  of  pathological  fibrous  tissues  is 
that  of  cicatrix^  which  is  generally  produced  in  the  same  manner  in  every 
tissue  and  organ.  The  exudation  in  such  cases  is  partly  transformed 
into  filaments,  and  partly  into  pus.  The  former  are  in  connection  with 
the  deep-seated  tissues  and  capillaries,  and  are  covered  and  protected 
by  the  latter.  On  examining  a fungous  granulation  on  the  surface  of  a 
wound,  it  may  be  seen  to  contain  round,  oval,  caudate,  and  fusiform  cells, 
in  all  stages  of  their  development  towards  fibres.  As  these  increase  in 
amount  and  become  approximated,' the  formation  of  pus  gradually  ceases. 
At  length  the  new  growth  reaches  the  surface  of  the  healthy  tissue,  con- 
tracts, causing  more  or  less  puckering  of  the  surrounding  structures,  and 
becomes  dense  like  ligament.  (See  Fig.  151.) 

2.  Another  form  of  pathological  fibrous  growth  occurs  after  the  sub- 

cutaneous  section  of 

1 liA  ill[  lii 


■■ 


‘^1  '']f ! 1^1  viscera. 


Fig.  170. 


Fig.  171. 


Fig.  172. 


tendons,  and  in  the 
coats  of  some  hollow 
In  this 
case  the  exudation 
thrown  out  fibril- 
lates,  oval  or  fusi- 
form nuclei  are 
formed,  which  are 
scattered  irregularly 
through  the  mass, 
and  the  whole  often 
have  seen  the  coats  of 


assumes  a remarkable  degree  of  toughness.  We 
the  stomach  above  an  inch  thick  from  this  cause,  entirely  independent  of 
cancerous  formation.  (Fig.  170.) 

3.  A third  form  of  pathological  fibrous  growth  is  the  result  of  chronic 
exudation  on  serous  membranes.  The  white  patches  so  frequently  seen, 
more  especially  on  the  pericardium,  pleura,  and  peritoneum,  are  owing  to 
this  cause  (Fig.  171).  Occasionally  such  membranes  are  connected  by 
bands  of  firm  fibrous  tissue,  or  closely  united  and  hypertrophied  into  a 
dense,  white  ligamentous  substance,  upwards  of  half  an  inch  thick,  as 
may  frequently  be  seen  in  the  pleurae  over  chronic  tubercular  lungs. 

4.  A fourth  form  of  pathological  fibrous  growth  is  seen  in  an  increase 
of  the  areolar  tissue  of  the  skin,  or  other  organs,  and  also  results  from 
exudation.  Thus  we  observe  peculiar  thickening  and  indurations  of  the 
skin,  owing  to  this  cause,  in  the  adult,  and  in  the  hide-bound  skin  of 
certain  foetuses.  Atrophy  of  parts  may  arise  as  a consequence,  through 
pressure  thereby  produced ; for  instance  muscle  may  be  converted  into 
a ligamentous  substance.  So  called  cirrhosis  of  the  liver,  lung,  and 
kidney,  are  owing  to  a similar  cause. 

Fig.  I'ZO.  Fibres,  from  induration  of  the  stomach,  with  embedded  nuclei. 

Fig.'  171.  Fibrous  tissue,  with  free  nuclei  and  fusiform  cells,  from  a white  patch 
on  the  peritoneum. 

Fig.  172.  The  same,  after  the  addition  of  acetic  acid.  250  atam. 


FIBROUS  GROWTHS. 


191 


5.  A fifth  form  of  pathological  fibrous  growth  is  that  of  tumor. 
Under  this  head  must  be  classed  a number  of  growths,  hitherto  denomi- 
nated  sarcoma  and  neuroma,  as  well  as  those  usually  called  fibrous. 
They  all  consist  of  a fibrous  structure,  in  difierent  stages  of  development, 
the  softer  and  more  vascular  forms  being  such,  even  when  their  substance 
has  not  yet  completely  passed  into  perfect  fibres.  For  tins  reason  they 
have  been  made  to  constitute  a distinct  group  by  Lebert,  under  the  name 
of  fibro  plastic  tumors,  ■ and  may  bj  fibro-nuclear  or  fibro-cellular  in 
str’icture.  Such  growths,  however,  may  always  be  seen  passing  into  true 
fibrous  tissue.  In  some,  whilst  one  part  of  a tumor  is  sarcomatous,  or 
fleshy,  another  is  truly  fibrous;  but  the  difference  is  only  one  of  develop- 
ment, and  cannot  therefore  constitute  a good  ground  of  distinction. 
Other  kinds  of  fibrous  tumors  resemble  tough  ligament  and  fibro- 
cartilage,  and  present  a variety  of  intermediate  conditions  of  form  be- 
tween the  areolar  and  elastic  tissues.  Fibrous  tumors,  tiiei'efore,  may 
be  divided  into — 1st,  Sarcomatous;  2d,  Dermoid;  and  3d,  Neuromatous 
Fibrous  Tumors. 

Sarcomatous  or  soft  fibrous  Tumors. — These  tumors  are  either 
spherical  or  more  or  less  lobulated  (panci-eated  sarcoma  of  Abernethy). 
The  first  are  of  the  consistence  of  muscular  tissue,  or  very  soft  cartilage, 
and  are  generally  surrounded  by  a distinct  cyst.  On  section,  they  pre- 
sent a smooth  or  finely  granular  surface.  Their  color  varies  from  a 
yellowish-white  to  a rose  pink  or  deep  red,  and  is  dependent  on  their 
degree  of  vascularity.  Occasionally  a section  presents  different  colors, 
the  external  portion  being  more  vascular  than  the  internal;  or  it  is  more 
or  less  mottled,  the  red  tint  alternating  with  the  yellow.  At  other  times 
the  section  presents  several  ecchymotic  spots,  varying  in  size,  caused  by 
extravasation  of  blood  from  the  capillaries.  Ov/ing  to  the  vascularity  of 
these  tumors,  there  is  a disposition  in  them  to  exudation,  and  to  a 
breaking  down  of  their  substance,  with  formation  of  purulent  fluid. 

For  the  most  part,  they  increase  in  size  slowly,  and  only  cause  in- 
convenience from  their  bulk,  or  by  pressure  on  neighboring  nerves  and 
tissues.  Owing  to  this  pressure,  they  may  induce  absorption  or  ulcera- 
tion of  the  parts  around  them. 

Not  unfrequently  these  tumors  are  more  soft  and  lobulated,  and 
have  in  consequence  been  frequently  mistaken  for  encephaloma.  The 
lobules  vary  greatly  in  size,  and  present  externally  a papillary,  or  cauli- 
flower form,  sometimes  resembling  the  pancreas,  and  hence  the  name 
given  to  them  by  Abernethy.  Occas’onally  the  lobules  are  surrounded 
by  a more  or  less  dense  layer  of  areolar  tissue.  They  are,  for  tlie  most 
part,  of  a greyish,  yellowish,  or  rosy  color,  their  tint  varying  with  their 
amount  of  vascularity. 

These  tumors  are  found  in  many  places,  as  below  the  skin,  richly 
supplied  with  cellular  and  fibrous  tissue.  They  are  not  unfrequently 
observed  in  the  mamma,  where  their  separation  from  schirrus  constitutes 
one  of  the  nicest  points  of  surgical  diagnosis.  They  may  occur  in  bone, 
and  have  received  the  name  of  osteosarcoma.^  although  many  tumors 
that  have  received  this  name  have  been  shewn  to  be  cancerous.  They 
constitute  small  mushroom-like  growths  on  the  conjunctiva  (Lebert).,  and 
may  destroy  the  eye  from  the  pressure  cau.-.ed  by  their  enlargement. 


192 


PRINCIPLES  OF  MEDICINE. 


The  minute  structure  of  these  sarcomatous  tumors  is  essentially 
fibrous,  but  many  of  the  fibres  are  seen  to  be  made  up  of  congeries  of 
fusiform  cells  closely  applied  together  (Figs.  175,  213)  These  cells  are 
of  a spindle  shape,  varying  in  length  and  breadth,  and  are  for  the  most 


part  distinctly  nucleated.  Many  of  them  may  be  seen  branched  at  their 
extremities,  and  passing  into  fibres,  according  to  the  mode  of  develop- 


Fig.  177. 


■mwmm 

; S'*'.?  r\\o‘  r j ■ b ■ 


(!)  fe'T  ' 

Fig  178. 


Fig.  179. 


ment  of  fibrous  tissue  described  by  Schwann.  In  some,  the  nucleus  has 
disappeared.  Other  of  the  cells  are  round  or  oval,  or  only  slightly 
elongated.  All  these  stages  of  a fibro-cellular  growth  may  be  observed 
in  the  same  tumor.  In  the  softer  parts,  isolated  cells  and  nuclei 
abound  (Fig.  173),  whereas,  in  the  harder  and  denser  parts,  the  develop- 
ment into  fibrous  tissue  is  perfect  (Figs.  175,  176). 

At  other  times  associated  with  the  fibres  we  find  a multitude  of 
oval  nuclei,  without  cells  of  any  kind.  These  I described  in  1849 


Fig.  173.  Cells  in  the  soft  part  of  a fibrous  tumor  removed  from  the  neck  by  Mr. 
Syme. 

Fig.  174.  The  same,  after  the  addition  of  acetic  acid. 

Fig.  176.  Fibres  in  various  stages  of  development  from  a harder  nodule  of  the 
same  tumor. 

Fig.  176.  Perfect  fibrous  tissue  from  another  nodule  of  considerable  density. 

Fig.  177.  Corpuscles  scraped  from  the  surface  of  a fibro-nucleated  growth  of  the 
thigh,  excised  by  Mr.  Miller. 

Fig.  178.  The  same,  after  the  addition  of  acetic  acid. 

Fig.  17‘J.  Appearance  of  a thin  section  of  the  tumor. 

Fig.  180.  Another  section  treated  with  acetic  acid. 


FIBROUS  GROWTHS. 


193 


as  fibro-nucleated  growths.  They  may  be  hard  or  soft,  and  present  the 
structure  represented  Figs.  177  to  180,  and 
168. 

Some  tumors  of  this  kind  are  so  soft, 
as  to  be  pu’py  in  their  consistence,  and 
contain  between  the  meshes  of  their  fibro- 
cellular  structure  a certain  amount  of 
serous  liquid.  These  are  soft  polypi. 

For  the  most  part,  they  constitute  pro- 
minences on  the  mucous  membrane,  to 
which  they  are  attached  by  a neck,  which 
may  be  broad  or  narrow  (Fig.  181).  Ex- 
ternally, they  are  covered  with  mucous 
membrane,  more  or  less  hypertrophied  and 
thickened  (Fig.  184). 


Fig.  182. 


Fig,  183. 


Fig.  184. 


Fig.  185. 


Dermoid  or  hard  fibrous  tumors. — These  tumors  are  generally  of 
a white  color,  more  or  less  tough  and  elastic,  resembling  the  well-known 

structure  of  the  dermis.  This,  indeed,  is 
not  so  apparent  in  examining  the  compara- 
tively thin  human  dermis;  but  on  looking 
at  that  of  some  of  the  larger  animals,  and 
more  especially  of  the  whale,  the  analogy  in 
structure  at  once  becomes  evident.  These 
tumors  are  of  a rounded  or  oval  form, 
frequently  embedded  in  a cyst,  composed 
of  the  indurated  structures  in  which  they 
He.  They  are  of  considerable  density,  vary- 
ing from  that  of  tendon  to  that  of  ligament 
or  fibro-cartilage,  and  on  section  present 
numerous  w'liite  glistening  fibres,  intimately  interwoven  together,  or 
arranged  in  bundles  constituting  circles,  or  loops  intercrossing  with 


Fig.  181.  Soft  polypi  growing  from  the  Schneiderian  mucous  membrane — {Liston). 
— Half  natural  size. 

Fig.  182.  Fibre  cells  and  fibres  from  the  pulpy  interior  of  a polypus  removed  by 
Mr.  Syme. 

Fig.  183.  The  same,  after  the  addition  of  acetic  acid. 

Fig.  184.  Ciliated  epithelial  and  pus  cells  from  the  exterior  of  the  tumor. 

Fig  185.  The  same,  after  the  addition  of  acetic  acid.  ‘loO  diam. 

Fig.  186.  Section  of  a dermoid  fibrous  tumor,  embedded  in  the  uterine  walls. 
One-fourth  of  the  entire  growth  is  represented.  Natural  size. 

13 


194 


PRINCIPLES  OF  MEDICINE. 


eacli  other.  Occasionally  they  have  a calcareous  centre  or  nucleus. 
Their  color  is  generally  white,  but  sometimes  they  have  a yellowish 
tinge.  They  are  for  the  most  part  not  very  vascular,  although  there  is 
great  difference  in  this  respect,  some  approaching  the  pinkish  color  of 
sarcomatous  growths,  and  others  being  of  dead  white  and  of  extreme 
density,  containing  scarcely  any  vessels.  They  vary  greatly  in  size,  from 
that  of  a pin’s  head  to  a volume  measuring  several  feet  in  circumference. 

These  tumors  may  be  situated  in  various  tissues  and  organs,  as  in 
the  subcutaneous  and  submucous  cellular  tissue,  in  the  mamma,  and 
uterus,  in  which  last-named  organ  they  are  most  common.  When 

developed  in  the  uterus,  they  often 
push  the  mucous  membrane  before 
them.  In  this  way  they  grow  out- 
wards, forming  what  are  called  hard 
polypi.  At  other  times  they  grow  to- 
wards the  serous  or  internal  cavity, 
pushing  the  membrane  before  them  in 
a similar  manner,  so  that  it  ultimate- 
ly constitutes  a neck  or  pedicle,  by 
which  they  are  attached  to  the  uterus. 
Such  pedunculated  fibrous  tumors 
are  sometimes  found  in  the  peritoneum 
Fig.  1&7.  growing  from  the  uterus.  Occasion- 

ally the  pedicle  breaks  across,  and  the  tumor  becomes  free  in  the  serous 
cavity.  To  the  same  cause  are  owing  the  small  fibrous,  oval  or  round 
bodies,  called  loose  cartilages,  found  in  the  joints,  more  especially  that 
of  the  knee,  some  of  which  are  truly  osteo-cartilaginous.  Others  are 
found  in  the  veins,  and  denominated  phleholites. 

The  minute  structure  of  these  dermoid  tumors  is  found  to  consist 

of  fusiform  cells  more  or  less 
aggregated  together.  In  tie 
softer  portions  of  the  growth 
they  can  easily  be  separated  by 
needles,  but  in  the  indurated 
portions  they  are  so  dense  that 
this  is  impossible.  Sometimes 
the  filaments  are  more  or  less 
waved,  as  in  ordinary  fibrous 
tissue ; at  others,  they  are 
curled  and  brittle,  as  in  elastic 
tissue.  On  making  a thin  sec- 
tion, they  may  often  be  seen 
to  form  a concentric  fibrous  structure,  and  on  the  addition  of  acetic  acid, 
tlie  nuclei,  scattered  throughout  the  tissue,  are  made  very  apparent  (Fig. 
187).  Not  unfrequently  these  latter  are  collected  together  in  masses 

Fig.  187.  Section  of  a dermoid  fibrous  tissue  from  the  uterus,  after  the  addition 
of  acetic  acid,  sl'.owing  the  concentiic  direction  of  the  fibres.  250  diam.  ^ 

Fig.  188.  Section  of  hard  uterine-polypus,  which  had  been  boiled  in  dilute  acetic 
acid  and  dried ; a,  groups  of  nuclei,  surrounded  by  bundles  of  fusiform  fibres — 
{Wedl.)  250  diam. 


FIBROUS  GROWTHS. 


195 


(Fig.  188),  and  sometimes  they  are  isolated,  as  in  the  sarcomatous 
tumors ; but  then  the  proportion  of  them  to  the  fibrous  element  is 
generally  small.  The  bony  nuclei  of  such  tumors  are  composed  of 
amorphous  mineral  matter,  not  of  true  bone  (see  Fig.  368),  although  Le- 
bert  says,  that  on  two  occasions  he  has  seen  true  bone  produced.  Wedl  also 
has  figured  true  bone  in  the  interior  of  these  growths  (see  Fig.  282). 

The  two  forms  of  fibrous  growth  now  spoken  of  may  frequently  be 
found  associated  together  in  one  tumor.  Some  are  composed  of  several 
rounded  or  oval  masses  varying  in  size,  enclosed  and  separated  from  each 
other  by  a cyst,  or  layer  of  areolar  tissue.  The  external  surface,  under 
such  circumstances,  is  more  or  less  nodulated.  It  may  frequently  be 
observed  that  some  of  these  nodules  are  soft  and  pulpy — semi-gelatinous, 
with  a very  sparing  layer  of  fibrous  tissue ; whilst  others  may  be  seen 
more  or  less  tough,  gradually  passing  into  a fibro-cartilaginous  density, 
grating  under  the  knife.  Nay,  even  in  the  same  nodule  I have  frequently 
observed  some  parts  of  it  soft  and  others  hard,  and  have  shown  that  the 
softer  parts  are  mostly  cellular,  and  the  harder  fibrous,  and  that  between 
the  two  there  are  many  degrees  of  variation. 

Neuromatous  Fibrous  Tumors. — This  form  of  fibrous  tumor  is 
developed  in  the  nerves,  sometimes 
spontaneously,  at  others  as  the  result 
of  injuries,  and  especially  of  amputa- 
tion. In  the  museum  of  the  Rich- 
mond Hospital,  Dublin,  I examined  a 
most  remarkable  series  of  preparations 
taken  from  two  individuals,  in  whom 
almost  every  nerve  of  the  body  pre- 
sented knotty  swellings.  In  some 
places  these  were  developed  into  tu- 
mors, which  varied  in  size  from  a 
pea  to  that  of  the  human  head.*  A 
subcutaneous  tumor,  described  by 
the  late  Mr.  W.  VV  ood,  of  Edinburgh, 
must  be  referred  to  this  class  of  tumors,  f 

All  these  neuromata,  on  being  minutely  examined,  are  found  to  con- 
sist of  fibrous  texture,  more  or  less  dense,  the  filaments  often  arranged 
in  wavy  bundles  running  parallel  to  each  other,  but  occasionally  assum- 
ing a looped  form,  or  intercrossing  with  each  other,  as  in  Fig.  186.  I 
have  also  found  them  to  contain  groups  of  cells,  so  that,  on  the  addition 
of  acetic  acid,  they  closely  resemble  the  structure  represented  Fig.  188. 
Not  unfrequently  they  are  fibro-cartilaginous,  sometimes  with  the  cells 
closely  aggregated  together,  at  others  widely  scattered  (Fig.  190).  In 
some  of  the  neuromatous  swellings  described  by  Dr.  Smith,  of  Dublin,* 

*See  Smith’s  Treatise  on  Neuroma  ; Dublin,  1849. 
f Edin.  Med.  and  Surg.  Journal,  1812. 


Fig.  189.  Section  of  neuroma  connected  with  three  nervous  trunks. — Natural 
iize. — t^Smith.') 


196 


PRINCIPLES  OF  MEDICINE. 


I found  the  fibrous  tissue  to  present  wavy  bundles,  among  which  a few 


Fig.  190.  Fig.  191. 

granule  and  cartilage  cells  were  scattered  and  shrivelled,  apparently  from 
the  action  of  spirit  (Fig.  191). 

Fatiy  Growths. — Lipoma. 

The  morbid  increase  of  fat  is  frequently  so  imperceptible,  that  it  is 
impossible  to  separate  the  pathological  from  the  physiological  state. 
Obesity  may  gradually  increase,  either  locally  or  generally,  internally  or 
externally,  so  as  to  cause,  not  only  inconvenience,  but  actual  disease. 
Some  individuals  have  become  celebrated  from  their  excessive  fatness. 
(See  Polysarcia.) 

Fat  sometimes  occurs  in  masses,  being  only  an  exaggeration  of  the 
normal  texture  of  the  part,  as  when  it  collects  about  the  heart,  in  the 
omentum,  or  on  the  serous  membranes,  in  which  case  it  takes  the  exact 
form  of  the  included  viscera.  Fat  may  also  be  aggregated  in  masses  in 
unusual  situations,  and  then  form  the  so-called  fatty  tumor. 

Fatty  tumors  vary  in  size ; they  may  reach  a growth  weighing  up- 
wards of  30  lbs.  Sometimes  their  surface  is  lobulated,  at  others  smooth. 
They  are  of  a yellow  color,  resembling  adipose  tissue,  and  are  occasion- 
ally divided  into  bands  by  white  fibrous  tissue.  The  relative  amount 
of  these  two  elements  varies  greatly  in  different  specimens,  some  being 
soft,  oily,  containing  few  fibres,  others  being  hard  and  dense,  the 
areolar  tissue  preponderating.  For  the  most  part  they  are  very  sparingly 
sapplied  with  blood-vessels;  the  vessels  abound  most  in  the  fibrous 
varieties.  In  the  latter  case  they  are  liable  to  ulcerate,  and,  under  such 
circumstances,  have  frequently  been  mistaken  for  cancer.  Some  of  these 
growths,  indeed,  may  be  considered  as  fibrous  or  sarcomatous  tumors, 
combined  with  an  unusual  quantity  of  fat.  Occasionally  they  are  con- 
nected with  the  ordinary  adipose  tissue  of  the  body.  "We  see  this  in 
fatty  tumors  so  common  in  the  subcutaneous  tissue.  They  are  often 

Fig.  190.  Thin  section  of  a subcutaneous  tubercle,  composed  of  fibro-cartilage. 

Fig.  191.  Fibrous  structure  of  a neuromatous  swelling,  given  to  me  by  Dr.  Smith, 
from  one  of  the  cases  he  has  described.  250  diam. 


I 


FATTY  GROWTHS. 


197 


surrounded  by  a delicate  cyst  or  envelope;  but  in  others  this  is  not  per- 


Fig.  192. 


ceptible.  It  is  when  the  collection  of  fat  resembles  the  ordinary  adipose 
tissue,  that  the  tumor  has  received  the  name 
of  Lipoma.  When  it  is  more  lardaceous,  some 
have  applied  to  it  the  term  Steatoma,  in  the 
same  manner  as  when  the  substance  is  encysted. 

When  firm,  and  largely  mingled  with  fibres,  it 
may  be  called  Fibro-Lipomatous,  as  in  the  lobu- 
lated  tumors  that  constitute  so  frightful  a de- 
formity of  the  nose  (Fig.  192). 

The  minute  structure  of  these  tumors 
varies  according  to  the  amount  of  adipose  or 
fibrous  tissue  in  their  composition.  The  adi- 
pose matter  is  composed  of  vesicles  of  a 
round  or  oval  form,  more  or  less  liable  to 
undergo  alterations  in  shape  from  pressure  (Fig. 

191).  They  vary  from  the  yoV 3 of  an  inch  in  diameter;  are 
composed  of  a diaphanous  cell-wall,  which  frequently  includes  a nucleus. 


Fig.  ] 92.  Lobulated  Lipoma  of  the  nose. — {Bickersteth.) 

^ Fig.  193.  Smooth  Lipoma,  removed  from  under  the  tongue,  one-half  the  natural 
Tize. — ( Liston.) 


198 


PRINCIPLES  OF  MEDICINE. 


The  nucleus  is  generally  round  or  oval,  about  the  2 /o  otli  or  of 

an  inch  in  diameter.  Occasionally  it  is  stellate  or  penniform,  of  a crys 


talline  appearance,  from  the  formation  of  crystals  of  margarine  or  mar- 
garic  acid  around  it  (Figs.  195,  196  a).  On  rupture  of  the  cell-wall 

the  oil  may  be  made  to  flow  out,  and  the 
cell-wall  puckers  or  shrinks  up.  Such  col- 
lapsed cells  may  frequently  be  seen  among 
the  more  perfect  formations,  mixed  with 
globules  of  oil  and  fat  granules.  The  fi- 
brous tissue  presents  the  usual  appearance  of 
areolar  texture  running  between  groups  of 
the  adipose  cells,  being  denser,  and  occupy- 
ing greater  space,  according  to  the  propor- 
tion in  which  it  enters  the  tumor.  Steato- 
matous  and  melicerous  fatty  matter  may 
consist  of  the  cells  just  described,  mingled 
in  various  proportions  with  granular  miatter. 
In  some  melicerous  encysted  growths,  we  have  found  the  whole  to  be  com- 
posed of  granular  matter,  in  which  faint  traces  of  delicate  cell-walls  were 
seen  more  or  less  compressed  together.  In  all  such  productions  the  re- 
lative amount  of  the  vesicular  and  granular  elements  varies  greatly. 

An  excess  of  fat  may  cause  the  entire  disappearance  of  the  usual 
structure  of  a part,  and  its  conversion  into  adipose  tissue.  The  muscular 
system  is  very  liable  to  this  fatty  transformation  or  degeneration,  which 
often  occurs  in  the  heart,  and  in  muscles  which  have  not  been  much 
exercised,  owing  to  local  disease  or  paralysis.  In  this  case  adipose 
tissue  generally  springs  up  in  the  cellular  substance  surrounding  the 
muscular  fasciculi,  and  by  its  increase  and  pressure  upon  them,  causes 

Fig.  1 94.  Two  layers  of  voluminous  fat  cells,  varying  in  size,  from  a L\j>om  a.  2C0  (h. 

Fig.  195.  Fat  cells  from  the  same  Lipoma^  dried,  showing  crystalline  bundles  of 
Margaric  acid.  250  diam. 

Fig.  196.  Structure  of  a Fibro-Lipomaious  tumor;  a,  isolated  cells,  showing 
Stellate  crystals  of  Margaric  acid.  250  diam. 


CYSTIC  GROWTHS. 


199 


the  transverse  striae  to  disappear,  and  the  whole  to  assume  a granular 
appearance — (See  Fatty  Degeneration,  Fig.  328.) 

Cystic  Growths. — Cystoma. 

The  different  crypts  and  follicles  of  the  skin  and  mucous  membrane, 
as  well  as  several  of  the  excretory  ducts  of  internal  organs,  may  become 
obstructed,  and  as  a consequence  enlarged  and  hypertrophied.  It  is  true 
such  growths  usually  consist  of  one  or  more  elementary  tissues,  and  do 
not  therefore  properly  constitute  a class  of  themselves.  Their  importance 
in  a practical  point  of  view,  however,  as  well  perhaps  as  the  difficulty  of 
knowing  under  what  head  to  describe  such  compound  growths,  warrants 
our  speaking  of  them  separately. 

Encysted  growths  are  composed  of  a cyst  or  envelope,  enclosing 
various  kinds  of  contents.  They  differ  greatly  in  size,  situation,  and 
structure,  which  renders  their  arrangement  somewhat  difficult.  By 
some  they  have  been  divided  into  simple  and  compound.,  according  as  the 
tumor  is  formed  of  one  cyst,  or  is  composed  of  several.  By  others 
they  have  been  arranged,  according  to  the  nature  of  their  contents,  into 
hygromatous,  atheromatous^  melicerous,  and  steatomatous  growths.  The 
latter  mode  of  division  is  very  faulty,  as  many  of  these  varieties  are  only 
altered  forms  of  one  substance — fat ; whilst  some  compound  encysted 
tumors  contain  various  kinds  of  contents  in  separate  cysts.  But  as 
there  can  be  no  doubt  that  the  peculiar  contents  give  to  these  growths  a 
distinctive  character,  we  shall  first  speak  of  them  as  simple  or  compound, 
and  then  describe  their  different  kinds  of  contents. 

Simple  cystic  growths. — These  growths  are  formed  of  a cyst  generally 
composed  of  fibrous  tissue,  lined  by  a smooth  membrane.  Sometimes 
the  membrane  is  structureless,  or  only  composed  of  areolar  tissue.  At 
other  times  it  is  covered  with 
a distinct  layer  of  epithelial 
cells,  the  nuclei  of  which  are 
very  apparent  on  the  addition 
of  acetic  acid.  The  former 
kind  constitute  the  vesicles  so 
frequently  found  in  the  plexus 
choroides,  in  the  kidneys, 
ovaries,  etc.,  and'vary  in  size 
from  a pin’s  head  to  that  of 
a hazel  nut,  or  even  a walnut, 
and  usually  have  aqueous  con- 
tents. The  latter  kind  consti- 
tute the  cystic  growths  which 
arise  in  the  follicles  of  the  Tig.  197. 

skin,  in  the  mamma,  ovaries,  testicles,  etc. ; these  frequently  reach  the 
size  of  an  orange,  and  are  sometimes  much  larger,  and  vary  greatly  as 
to  the  nature  of  their  contents.  For  the  most  part  they  are  only  spar- 
ingly supplied  with  blood-vessels,  and  seldom  cause  inconvenience  except 
from  the  deformity  they  occasion  when  situated  externally. 

Fig.  197.  Simple  cyst  of  the  broad  ligament  of  the  uterus,  with  very  vascular 
walls,  a,  New  vessels  ; 6,  broad  ligament. — ( Wedl.)  30  diam. 


200 


PRINCIPLES  OF  MEDICINE. 


Compound  cystic  growths  are  of  two  kinds.  1st,  The  external  sr.c 
^ contain  on  its  internal  surface  secondary 
or  even  tertiary  cysts,  which  may  be  sessile 
or  pedunculated — or  the  growth  may  be  di- 
' vided  into  numerous  compartments  by  divi- 

■"yw  VL'  sions  of  the  fibrous  sac.  These  are  the  true 
multilocuiar  encysted  tumors.  The  external 
Fig,  199.  cyst  in  every  case  is  formed  of  fibrous  tissue. 
The  internal  surface  is  smooth,  sometimes  with,  at  others  without,  an 
epithelial  layer.  The  primary  as  well  as  the 
secondary  cysts,  are  for  the  most  part  richly 
supplied  with  blood-vessels,  and  hence  they 
are  peculiarly  prone  to  contain  exudation 
which  may  undergo  various  kinds  of  devel- 
opment. They  may  also  ulcerate.  In  the 
ovary  these  growths  frequently  attain  an 
enormous  size,  measuring  several  feet  in  cir- 
cumference ; tli3  cystic  internal  membranes 
often  secreting  more  or  less  rapidly  even  gal- 
lons of  fluid.  2d,  Numerous  cysts  may  be 
pedunculated  from  one  stock,  and  more  or 
less  crowded  together,  with  a tendency  to 
grow  outwards  instead  of  inwards ; as  happens  in  the  case  of  so-called 
uterine  hydatids,  which  is  a cystic  disease  of  the  chorion,  as  described 
by  Mitteuheimer,* 

The  contents  of  cystic  growths  are  very  various,  and  give,  as  we  have 
previously  stated,  a peculiar  character  to  them. 

1.  The  contents  may  be  a perfectly  colorless  fluid,  resembling  water, 
or  the  limpid  serum  so  frequently  secreted  in  the  lateral  ventricles  of  the 
brain.  It  is  structureless,  and  chemically  contains  a minute  proportion 
of  salts  and  a small  amount  of  albumen,  which  coagulates  on  boiling. 
Such  are  frequently  the  contents  of  so-called  serous  cysts,  or  false  hydatids 
of  the  plexus  choroides,  kidneys,  ovaries,  etc.  A Hyd/rocele^  and  other 
dropsies  of  shut  serous  sacs,  may  be  looked  on  pathologically  as  consti- 
tuting a form  of  hygromatous  encysted  growth. 

2.  The  contained  fluid  may  have  an  amber  or  golden  yellow  color, 
and  resemble  the  serum  formed  after  the  coagulation  of  the  blood.  It  is 
still  structureless,  but  contains  a large  amount  of  albumen,  as  is  proved 
by  the  action  of  heat  and  nitric  acid. 

3.  The  contents  are  more  or  less  gelatinous,  sometimes  slightly  so, 
like  weak  gelatin,  at  others  they  are  firm,  and  capable  of  being  cut  with 
a knife,  like  tolerably  strong  glue  or  firm  calves-foot  jelly.  The  color 
of  the  gelatinous  matter  may  vary  from  a slight  yellowish  tinge,  to  a 

* Muller’s  Archiv.  fur  Anatomic,  etc.,  1850,  p.  417. 

Fig.  198.  Diagram  of  compound  cystic  growth,  containing  secondary  and  tertiary 
cysts,  developing  themselves  endogenously. 

Fig.  199.  Diagram  of  compound  cy.stic  growth,  in  which  the  included  cysts  are 
formed  by  irregular  divisions  of  the  fibrous  sac. 

Fig.  200  Compound  cystic  sarcoma  of  the  mamma.  The  cysts  are  more  numerous 
at  a than  at  b. — [Sliller.)  One-fourth  the  natural  size. 


Fig.  200. 


Fig.  198. 


CYSTIC  GROWTHS. 


201 


deep  amber,  or  brownish-yellow  color.  Sometimes  this  matter  is  struc- 
tureless,  at  others  it  may  be  seen  to  contain  very  delicate  filaments,  com- 
bined with  pale  oval  bodies, 
the  outlines  of  which  become 
stronger  on  the  addition  of 
acetic  acid  (Fig.  202).  This 
re  agent  frequently  causes  the 
gelatinous  mass  to  coagulate 
into  a firm  white  fibrous  struc- 
ture, capable  of  being  separated 
by  needles,  and  presenting  the 
appearance  of  filamentous  tis- 
sue. This  kind  of  contents  is 
common  in  the  cysts  of  the 
thyroid  gland  and  ovary,  and  I 201. 

have  seen  it  in  the  kidney  and  other  organs.  On  one  occrslon  the  gelati- 
nous matter  in  the  kidney  contained 
^ numerous  granules  ; and  inoi-e  than 

^ have  found  in  the  centre  of 
the  clear  amber  masses  a creamy 
white  substance, either  wholly  gran- 
^ iilar  (Fig.  322),  or  in  the  process 
© % of  formation  into  pus  corpuscles. 

4.  The  cyst  may  be  distended 
with  epithelial  cells  which  have 
evidently  been  thrown  off  from  its 
Fig.  202.  Fig.  203,  internal  surface,  and  been  com- 

pressed together,  and  partially  broken  down.  Hence,  on  examination, 
clusters  of  such  scales  may  be  found 
mixed  with  numerous  debris,  and 
fat  granules  and  globules,  some- 
times with  crystals  of  choleste- 
rine.  (Fig.  208.)  The  contents 
of  the  cysts  are  usually  of  a white 
or  slightly  yellow  color,  sometimes 
fluid,  at  others  semi-solid.  The 
molluseum  contagiosvm  of  derma- 
tologists is  thus  constituted.  A 
small  pedunculated  simple  cyst,  dependent  from  the  peritoneal  rmrface  of 
the  ovary,  was  found  by  Wedl  to  contain  the  structures  represented 
Fig.  207. 

5.  The  contents  may  consist  principally  of  fat,  either  amorphous. 

Fig.  201.  Colloid  cystic  growths  ill  three  lobules  of  the  thyroid  gland. — {Wedl.) 
15  diatn. 

Fig.  202.  Delicate  oval  corpuscles  in  amber-colored,  transparent  colloid  matter  of 
the  ovary. 

Fig.  20H.  Round  and  oval  corpuscles  with  filaments  in  light  yellow,  semi-trans- 
parent gelatinous  colloid  matter  in  the  ovary. 

Fig.  204.  Oval  epithelial  cells  from  the  lining  membrane  of  an  ovarian  cyst. 

Fig.  205.  Polygonal  epithelial  cells  from  the  same  lining  membrane. 

Fig.  206.  Section  of  tlie  wall  of  the  same  cyst,  with  epithelial  cells  m situ.  250  di. 


202 


PRINCIPLES  OF  MEDICINE. 


crystallized,  or  orgaDized,  that  is  cellular.  If  amorphous,  they  resemble 
honey,  coustituting  the  melicerous  growths  of  morbid  anatomists.  In 

many  cases,  however, 
where  the  yellow 
color  is  uniform  and 
the  contents  closely 
resembling  honey  to 
the  naked  eye,  break 
down  under  the  fin- 
ger, faint  cell-walls, 
more  or  less  com- 
pressed together, 
may  be  observed  by 
the  microscope  in 
them.  At  other 
times  the  fatty  con- 
tents are  of  a whitish  color,  forming  masses  of  a pearly  aspect  and  smooth 
surface,  and  are  mingled  with  a roughened  yellowish,  and  more  granular 


Fig.  207. 


fatty  matter.  This  is  the  cJioJesteaioma  of  Muller.  This  white  matter 
consists  of  numerous  crystals  of  cholesterine  placed  in  a close  juxtaposi- 

Fig.  20V.  Cells  from  the  interior  of  a simple  cyst,  a,  c.  Cells  developing  endo- 
genously, independent  of  the  nucleus,  which  is  embedded  in  the  wall  of  the  parent 
cell ; d,  e,  the  same,  undergoing  the  fatty  degeneration  ; /,  ff,  cylindrical  epithelium, 
seen  sideways  and  from  above  : A,  polygonal  epithelium  cells  : i,  fibre  cells. — ( Wedl.) 
250  diam. 

Fig.  208.  Structure  of  cholesteatoma,  consisting  of  disintegrated  fat  vesicles  and 
epithelial  seales  with  numerous  crystals  of  cholesterine. — {Beale.)  diam. 

Fig.  209.  Encysted  tumor,  with  fatty  steatomatous  contents.  Natural  size. — 
(Liston.) 


CYSTIC  GROWTHS. 


203 


tion, — the  granular  fatty  matter  of  oil  globules  and  granules  mixed  with 
broken-up  crystals,  epithelial  scales,  and  sometimes  the  products  of  fibri- 
nous exudation  (Figs.  208,  210).  Such  is  the  general  structure  of  the 
atheromatous  encysted  growths  of  various  authors. 


Fig.  210. 


Fig.  211. 


Again,  the  fatty  matter  may  be  more  or  less  lardaceous  in  character, 
and  consists  of  beautiful  round  or  oval  cells,  some  of  which  are  distinctly 
nucleated.  Mixed  with  these  may  be  a granular  matter,  combined  with 
epithelial  cells  or  their  debris  (Fig.  211.)  At  other  times  no  distinct 
cells  can  be  observed,  only  a granular  or  amorphous  mass,  the  greater 
part  of  which  is  soluble  in  ether.  This  constitutes  the  steatomatous  en- 
cysted growth  (Fig.  209). 

6.  Many  encysted  growths  contain  hair  and  teeth.  The  hair  is  occa- 
sionally inserted  into  the  walls  of  the  cyst,  at  other  times  lies  loose  in  it, 
mixed  with  the  fatty  or  other  contents.  The  hair  has  exactly  the  same 
structure  as  the  hairs  in  other  parts  of  the  body,  having  distinct  bulbous 
roots.  When  attached  they  are  surrounded  by  a follicle  in  the  lining 
membrane  : when  loose  they  have  been  evidently  grown  in  follicles,  and 
been  afterwards  separated.  Their  apices  are  frequently  split  up  into 
several  fibres  in  the  longitudinal  direction.  The  teeth  belong  sometimes 
to  the  first,  and  sometimes  to  the  second  dentition.  They  present  on 
section  the  usual  structure  of  cav- 
ity, with  ivory,  enamel,  and  bone. 

Sometimes  they  are  found  em- 
bedded in  a follicle  of  the  lining 
membrane,  at  others  like  the  hairs, 
they  are  quite  unattached. 

7.  Occasionally  the  cysts  con- 

tain lymph,  or  softened  fibrin,  pre- 
senting the  structure  of  molecules  Fig.  212. 

(Fig.  212),  or  of  pus  and  granule  cells — this  is  the  result  of  exudation 
into  their  cavities.  Occasionally  there  is  a serous  fluid  more  or  less 


Fig.  210.  Contents  of  a large  atheromatous  cyst,  opened  by  Mr.  Syme,  consisting 
of  numerous  crystals  of  cholesterine,  oily  granules,  granule  and  pus  cells,  with  en- 
closed cysts  containing  oil  granules. — {MiircJmori.)  200  diam. 

Fig.  211.  Adipose  cells,  embedded  in  fatty  granular  matter  from  a steatomatous 
encysted  tumor  of  the  ovary.  250  diam. 

Fig.  212.  Cysts  in  cystic-sarcoma  of  the  mamma,  filled  with  molecular  matter. 


204 


PRIXCIPLES  OF  MEDICINE. 


mixed  up  with  extravasated  blood,  giving  to  the  contained  liquid  various 
colors  and  appearances,  according  to  the  age  of  the  extravasation.  Thus 
it  may  be  red,  dark  brown  (resembling  cofi'ee),  of  a dark-greenish  tinge, 
etc.  etc.  Sometimes  it  is  of  a dark  bluish  or  blackish  tint  from  excess 
of  pigmentary  deposit. 

8.  Sometimes  the  contents  of  the  cystic  growth  are  formed  of  a solid 
exudation, which  has  undergone  the  sarcomatous  trans- 
formation as  previously  described,  and  wholly  consists 
of  fusiform  cells  (Fig.  213).  The  exudation  poured 
into  such  cysts  may  pass  into  the  cancerous  forma- 
tion, and  then  the  characters  we  have  described  will 
be  associated  with  those  which  distinguish  cancer. 

9.  Some  cysts  contain  the  peculiar  secretion  of  the 
organ  in  which  they  are  found.  Thus  cysts  in  the  liver 
Fig.  213.  may  be  full  of  bile,  and  those  in  the  kidney  of  urine 

10.  Lastly,  cysts  may  contain  a greater  or  smaller  amount  of  mineral 
matter. 


The  mode  in  which  encysted  growths  are  developed  is — 1st,  By  the 
hypertrophy  of  pre-existing  tissues,  whereby,  from  the  accumulation  of 
materials  within,  canals  are  distended,  follicles  or  vesicles  enlarged,  and 
their  walls  thickened.  Thus  the  simple  cysts  in  the  plexus  choroides  are 
owing  to  effusion  of  serum 
into  the  areolar  spaces  in  the 
villi  of  the  membrane  and 
their  subsequent  distension. 

Those  in  the  kidney  may  be 
owing  to  the  dilatation  of  uri- 
niferous  tubes  above  an  acci- 
dental obstruction,  in  the 
same  manner  that  the  whole 
kidney  may  become  encysted 
from  obstruction  of  the  ureter. 

The  Malpighian  capsules 
also,  or  the  shut  sacs  of  the 
thyroid,  may  be  distended 
with  fluid,  which  thus  forms 
cysts.  In  like  manner  the 
crypts  of  the  skin,  the  blind 
sacs  of  conglobate  glands  or 
of  the  follicles  of  mucous 
membranes,  become  obstruct- 
ed at  their  orifice  ; and  their 
contents  gradually  accumu- 
lating,  distend  the  walls,  ^ 

which  become  enlarged  and  thickened.  Simple  cysts  in  the  ovary 
become  dilated  by  enlargement  of  isolated  Graafian  vesicles,  either 
Fig.  213.  Fibrous  tissue  composed  of  fusiform  corpuscles,  from  a sarcomatous 
encysted  growth  in  the  kidney.  . , , , 7 • 

j'i‘^  214.  Cystic-osteoma  of  the  femur.  One-eighth  the  nainral  size.-— ( jM 
Fig.  215.  Cystic-osteoma  of  the  tibia.  One-eighth  the  natural  size.  ( J/wter, 
from  the  preparations  referred  to.) 


CYSTIC  GROWTHS. 


205 


deep  in  the  stroma  of  the  organ,  or  on  the  surface,  when  they  grow  out- 
wards, and  become  pedunculated. 

This  mode  of  cystic  formation,  from  distension  by  material  that  can- 
not readily  find  an  escape,  is  remarkably  well  observed  in  bones,  in 
which  cysts  are  sometimes  produced  in  consequence  of  accumulated  pus. 
In  the  Edinburgh  University  Museum  is  a remarkable  preparation,  in 
which  a large  osseous  cyst  has  been  developed  in  this  manner,  at  the 
lower  end  of  the  femur  (Fig.  214) ; and  in  the  Edinburgh  College  of 
Surgeons’  Museum,  is  another,  which  has  formed  in  a similar  manner  in 
the  head  of  the  tibia  (Fig.  216).  In  the  first  specimen  the  osseous 
cystic  walls  are  thin,  in  the  second  they  are  greatly  thickened.  In  this 
respect  they  resemble  the  cranial  bones,  which  in  some  cases  are  ex- 
panded and  rendered  thin,  and  under  other  circumstances  become  pre- 
ternaturally  thick  through  disease. 

2d,  The  origin  of  compound  encysted  tumors  is  not  so  well  deter- 
mined. It  is  very  probable,  however,  that  in  most  cases  they  consist  of 
clusters  of  simple  cysts,  which  become  compressed  together,  assume  an 
increased  power  of  growth,  and  are  at  length  surrounded  by  a capsule. 
They  are  most  common  in  the  ovary ; and  here  we  can  readily  under- 
stand how  successive  growths  of  Graafian  vesicles  may  give  rise  either  to 
the  appearance  of  secondary  or  tertiary  cysts,  or  to  the  multilocular  form 
we  have  described.  Once  produced,  the  compound  cyst  enlarges,  the  in- 
dividual ones  grow  sometimes  inwards  and  sometimes  outwards,  accord- 
ing as  there  is  more  room  for  expansion  in  the  one  direction  or  the 
other.  In  the  former  case  they  open  into  each  other  by  ulceration. 
Hence,  in  very  old  compound  cystic  growths,  we  find  one  large  cavity 
with  the  traces  on  its  internal  wall  of  previously  existing  cysts,  or  bands 
and  divisions  with  pouches  between  them.  In  the  latter  case  they  grow 
outwards,  forming  clusters  of  cysts  more  or  less  pedunculated,  as  in  the 


so-called  hydatid  moles  of  the  chorion.  These  endogenous  and  exogenous 
modes  of  growth  are  sometimes  found  in  the  same  specimen. 

3d,  Another  mode  in  which  compound  cysts  are  formed  is  by  the 

Fig,  216.  Cysts  in  cystic-sarcoma  of  the  mamma,  crowded  with  cells;  a,  the  cells 
after  the  addition  of  acetic  acid. 

Fig.  217.  Fibrous  stroma  from  another  part  of  the  same  tumor,  with  commencing 
enlargement  of  the  areolar  spaces,  after  the  addition  of  acetic  acid.  250  diatn. 


206 


PRINCIPLES  OF  MEDICINE. 


gradual  enlargement  of  the  areolae  in  newly  formed  fibrous  tissue.  On 
examining  thin  sections  of  sarcomatous  growths,  we  observe  the  fila- 
mentous tissue  arranged  in  a circular  form,  enclosing  spaces  varying  in 
size.  These  spaces  are  often  lined  by  a distinct  epithelial  membrane, 
and  sometimes  contain  serum,  blood,  or  exudation,  either  in  a granular 
or  fibrous  state.  Such  growths  have  long  been  known  under  the  name 
of  cystic  sarcoma  (Figs.  216,  217,  and  also  Figs.  200,  212). 

4th,  The  glandular  or  epithelial  cells  of  an  organ  assume  an  in- 
creased power  of  development,  and  become  scattered  through  its  tissue 
in  great  numbers.  In  the  kidney  especially,  a cystic  disease  is  not  un- 
frequently  met  with,  in  which  the  cysts  vary  from  the  size  of  a pea  down 
to  the  ToVo^^  in  diameter,  as  may  be  accurately  traced  with 

the  aid  of  the  microscope. 

The  diagnosis  and  treatment  of  encysted  growth  belong  to  the 
special  pathology  of  each  organ  affected  by  them.  It  need  only  be 
mentioned  here  that  a knowledge  of  the  structure  of  these  tumors  is 
not  unimportant,  as  an  examination  of  the  fluid  discharged  from  them 
frequently  enables  us  to  speak  with  certainty  regarding  their  nature. 

Glandular  Growths. — Adenoma. 


Glandular  growths  are  essentially  hypertrophies  of  gland  texture,  in 
the  same  manner  that  fibrous  or  fatty  growths  are  an  increase  of  fibrous 


Fig,  218. 


or  fatty  tissues.  But  the  structure  of  a gland  is  compound,  and  embraces 
two  kinds  of  growth.  Strictly  speaking,  the  growths  are  fibro-epithelial, 
but  of  a kind  so  peculiar  as  to  warrant  Lebert  and  Birkett  in  constitut- 
ing them  into  separate  groups. 

Fig.  218,  Structure  of  a cystic  glandular  tumor  of  the  neck,  in  the  neighborhood 
of  the  thyroid  gland,  a,  Appearance  of  a portion  slightly  separated  and  viewed  by  a 
simple  lens,  presenting  a grape-like  bunch  of  lobules ; 6,  c,  ultimate  lobules,  com- 
posed of  single  or  branched  caecal  tubes,  distended  with  epithelial  cells ; e,  distended 
condition  of  these  on  the  addition  of  water ; /,  alteration  of  their  shape  on  pressure ; 
p-,  fusiform  cells  found  in  small  numbers. — {Redfern.)  250  di-im. 


GLAXDULA.R  GROWTHS. 


207 


Glandular  growths  may  be  regular  or  irregular,  that  is,  they  may  in- 
volve the  entire  gland  or  only  a portion  of  it,  and  in  the  latter  case  they 
may  assume  the  form  of  tumor.  They  may  also  be  perfect  or  imperfect, 
in  the  first  case  closely  resembling  the  gland  structure,  in  the  second 
differing  from  it  in  various  degrees,  and  passing  into  fibrous,  cystic,  fatty, 
and  other  forms  of  growth.  It  is  not  our  intention  to  enter  into  minute 
descriptions  of  the  various  appearances  and  modifications  of  structure 
they  present  in  the  several  glands.  Under  the  names  of  chronic  mam- 
mary tumor,  bronchocele,  enlarged  prostate,  and  hypertrophied,  in- 
durated, or  swollen  glands,  their  existence  was  recognized  before  their 
structure  was  known.  While  now  it  has  become  apparent  that  growths, 
which  are  truly  glandular  in  their  nature,  have  frequently  been  mistaken 
for  fibrous  and  even  for  cancerous  formations. 

These  growths  are  sometimes  lobulated,  with  the  lobes  more  or  less 
compressed,  and  the  interlobular  fibrous  t.ssue  varying  in  density  and 
amount.  They  may  reach  a considerable  size.  One,  removed  from  the 
female  breast  by  Mr,  Syme,  which  I carefully  examined,  was  larger  than 
the  human  adult  head,  and  weighed  upwards  of  eight  pounds.  To  the 
feel  they  vary  in  density,  are  lobular  or  smooth  externally,  and  in  the 
latter  case  are  not  unfrequently  surrounded  by  a fibrous  capsule.  On 
section  they  are  sometimes  smooth  and  glistening,  at  others  somewhat 
granular  and  dull.  The  cut  surface  varies  in  color,  sometimes  being 
almost  white,  at  others  of  a pale  yellow,  pink,  or  fawn  color,  apparently 
from  the  greater  or  less  amount  of  vascularity  of  the  particular  specimen. 
Their  mode  of  growth  is  by  no  means  uniform.  Sometimes  they  remain 


Figs.  219,  220,  and  221.  Structure  of  a glandular  tumor,  surrounded  by  a fibrous 
cyst,  removed  from  the  female  mamma.  Fig.  219.  Thin  section  transverse  to  the 
glandular  lobules,  after  the  addition  of  acetic  acid,  showing  the  condensed  epithelial 
lining  membrane  and  enclosed  epithelium  eells.  Fig.  220.  a.  Mass  of  epithelium 
separated  from  the  eut  lobule;  A,  cellular  contents.;  c,  the  same,  after  the  addition  of 
acetic  acid.  Fig.  221,  Longitudinal  section  of  one  of  the  duets  leading  from  the 
lobules,  after  the  addition  of  acetic  acid.  250  diam. 


208 


PRINCIPLES  OF  MEDICINE. 


at  one  time  and  rapidly  at  another.  Occasionally,  after  giving  rise  to 
much  anxiety,  they  gradually  disappear,  but  not  unfrequently  they  pre- 
sent all  the  external  cliaracters  and  symptoms  of  fibrous  or  sarcomatous 
tumors,  and  now  and  then  those  of  true  cancer. 

In  structure,  glandular  tumors  consist  of  gland  elements — that  is  to 
say,  of  a basement  membrane,  furnished  with  blood-vessels  on  one  side, 
and  nucleated  cells  or  nuclei  on  the  other.  Their  firmness,  softness, 
and  friability,  depend  upon  the  amount  of  fibrous  tissue  in  them,  and 
upon  the  number  of  cells.  The  follicles  are  frequently  much  distended, 
presenting  blind  sacs  apparently  without  ducts,  and  are  crowded  with 
epithelial  cells,  more  or  less  compressed  together.  If  ducts  do  communi- 
cate with  them,  these  are  similarly  distended,  as  seen  in  Fig.  221. 

The  thyroid  gland  is  especially  liable  to  a new  formation  of  tissue, 

first  described  by  Rokitan- 
sky, in  which  embedded  in  a 
lax  fibrous  stroma  are  round- 
ed vesicles,  sun  ounded  by  a 
layer  of  delicate  pavement 
epithelium,  and  containing 
colloid  substance,  which  es- 
capes when  one  of  these  is 
ruptured.  Fig.  222,  «, 
Whether  the  remarkable 
structure  denominated  by  M. 
Robin,  “ Tumeur  Heterade- 
nique,”  f in  any  way  resem- 
bles this,  it  is  difficult  for  me 
to  say,  never  having  had  an 
opportunity  of  examining  a 
specimen. 

Lymphatic  glands  are  very 
liable  to  enlarge  through  lo- 
cal irritation,  arising  from  a 
neighboring  ulcer  or  injury ; 
and  the  mesenteric  glands 
are  especially  so,  in  conse- 
quence of  the  various  ulcers  which  form  in  the  intestines.  In  typhoid  fever 
they  are  frequently  found  swollen  as  large  as  hens’  eggs,  presenting  a 
reddish  or  purple  hue  externally,  soft  and  spongy  to  the  feel,  on  section 
exhibiting  a granular  texture  and  greyish  hue,  and  on  pressure  yielding 
a dirty  white  juice.  This  juice  abounds  in  the  cell  elements  of  the  gland, 
which  exhibit  an  increased  power  of  development.  The  cells  enlarge, 
* Ziir  Anatomie  des  Kropfes,  Wien,  1849. 

f Lebert’s  Anatomie  Pathologique  General  et  Speciale,  Liv.  10,  11. 

Fig.  222.  New  formed  tissue  in  a follicle  of  the  thyroid  gland.  Areolar 
fibrous  tissue  surrounding  the  epithelial-like  lining  of  the  areolae.  Many  of  these 
have  been  removed  to  sliow  the  glandular  formations  within.  These  vary  in  shape, 
some,  i,  being  constricted,  others  round  or  oval — a,  c.  B,  Colloid  masses  of 
various  shape  from  the  interior  of  a.  Epithelium,  with  commencing  fatty  de- 
generation, seen  also  at  t/,  e,  and  /.  4,  Blood-vessels  containing  colorless  corpuscles 

of  the  glaml. — ( Wedl.)  250  diarn. 


Fig.  222. 


GLANDULAR  GROWTHS. 


209 


their  nuclei  divide  into  two,  these  increase  by  division  into  four,  or  a 
multiple  of  two,  and  often  form  a cluster  in  the  centre  of  the  cell,  as 
seen  in  the  accompanying  figures  (Figs.  223,  224). 

The  causes  which  excite  glandular  growths  are  not  always  apparent. 
They  may  be  constitutional 
and  local,  and  in  the  latter  *. 
case  the  irritation  exciting 
them  may  be  direct,  as  from  ^ 

a blow;  indirect,  as  from  a 


neighboring  sore ; or  reflex, 
as  when  uterine  disease  af- 
fects the  mamma.  Sometimes 
when  the  apparent  cause 
is  removed,  the  glandular 
growth  disappears,  but  at 


Fig.  225. 

The  laws 


Fig.  223. 

others  it  continues  to  grow  independently  of  any  such  cause, 
which  regulate  the  occasional  persistence  or  disappearance  of  these 
growths  have  not  yet  been  determined,  but  one  essential  and  hitherto 
unrecognized  condition,  with  regard  to  their  independent  growth,  admits 
of  being  explained  in  the  following  manner : — 

At  first  the  irritation,  however  communicated  to  the  gland,  whether 
direct  or  reflex,  operates  by  stimulating  it  to  increased  cell-growth,  and 
by  augmenting  the  flow  of  blood.  Hence  ensue  turgescence  and  enlarge- 
ment with  the  formation  of  cells,  often  in  such  numbers  that  they  can- 
not readily  escape.  This  is  especially  the  case  in  the  female  mamma  of 
young  women  not  pregnant,  in  whom,  while  this  morbid  action  is  pro- 
gressing, the  proper  function  of  the  organ  is  in  abeyance.  Hence  the 
follicles  enlarge  more  or  less  rapidly,  and  according  to  the  amount  of 
irritation  and  increased  nutrition  which  results,  is  the  consequent  amount 
of  growth.  It  frequently  happens,  however,  that  if  the  increased  amount 
of  cell  elements  can  find  a ready  exit,  they  retain  their  normal  type  for 
a certain  time,  and  on  the  cessation  of  the  cause,  they  cease  to  be  formed 
or  accumulated,  and  the  growth  disappears.  But  when  they  assume  a 
power  of  independent  development,  this  is  not  so  readily  accomplished. 
In  this  case  they  continue,  and  by  the  permanent  stimulation  to  growth, 
form  persistent  tumors. 

Again,  the  enlargement  of  glands  in  the  neighborhood  of  cancerous 
and  scrofulous  ulcers  or  growths,  is  not  necessarily  caused  by  the  presence 
of  cancer  or  tubercle  in  them.  I have  frequently  examined  enlarged 
axillary  glands,  which  have  been  removed  with  cancerous  breasts,  and 
found  nothing  but  simple  hypertrophy  of  those  glands.  In  the  case  of 
an  extensive  epithelioma  of  the  thigh,  for  which  amputation  was  per- 
formed by  the  late  Mr.  II.  Mackenzie,  the  inguinal  glands  on  the 
affected  side  were  greatly  enlarged.  After  the  death  of  the  individual, 
I found  no  epithelioma  in  those  glands,  but  again  only  simple  hyper- 
trophy. But  if  this  condition  be  allowed  to  remain  for  any  length  of 

Fig.  223.  Cells  in  fluid,  squeezed  from  a mesenteric  gland,  in  a case  of  typhoid 
fever. 

Fig.  224.  The  same  in  another  case. 

Fig.  225.  The  same  cells,  after  the  addition  of  acetic  acid. 

14 


250  diam. 


210 


PRINCIPLES  OP  MEDICINE. 


time,  epithelioma  as  well  as  cancer  does  form  in  them,  or  simple  and 
tubercular  exudations  are  thrown  out,  which  assume  the  character  of  pus 
or  tubercle.  It  follows  that  enlarged  glands  are  not  a necessary  proof 
of  the  extension  of  certain  growths  secondarily,  and  that,  as  we  shall 
subsequently  see,  their  commencement,  instead  of  discouraging,  ought 
perhaps  in  certain  circumstances  to  lead  the  surgeon  to  an  early  excision 
of  the  tumor. 

Einthelial  Gro wths. — Epithelioma. 

The  epidermic  and  epithelial  cells  are  continally  thrown  off  from  the 
skin  and  mucous  membranes,  and  new  ones  are  as  constantly  formed. 
Numerous  circumstances  may  arise,  which  induce  their  production  in 
greater  numbers,  or  their  accumulation  in  particular  parts.  In  this  case 
they  may  soften  and  give  a morbid  character  to  fluids,  as  that  of  the 
urine,  or  they  may  become  indurated,  causing  thickenings  or  swellings 
on  the  mucous  surfaces,  callosities,  or  tumors  of  the  skin.  Structures 
composed  of  epidermic  growths,  as  hair  or  horn,  may  become  excessive, 
or  arise  in  parts  which  are  unusual.  Lebert  was  the  first  to  point  out 
that  many  of  the  tumors  hitherto  called  cystic,  fibrous,  and  even  can- 
cerous, belong  to  this  class  of  growths.  In  all  cases  they  consist  of  an 
increased  number  of  epidermic  or  epithelial  cells,  more  or  less  compressed 
together,  frequently  united  by  filaments  of  fibrous  tissue,  and  supplied 
by  blood-vessels.  The  term  epithelioma.,  first  introduced  by  Hannover, 
may  be  appropriately  applied  to  the  entire  group. 

The  following  are  the  principal  forms  assumed  by  this  kind  of 
growth  : — 

1.  Corns  and  Callosities  consist  of  a local  hypertrophy  of  the  epider- 
mis, and  are  composed  of  numerous  epidermic  scales  condensed  into  an 
indurated  mass.  The  corn  is  a distinct  rounded  or  acuminated  tumor, 
varying  in  size  from  a barley-corn  to  that  of  a pea,  more  commonly  sur- 
rounded by  indurated  epidermis.  On  examining  a vertical  section  under 
high  magnifying  powers,  it  appears  irregularly  fibrous,  but  on  making  a 
horizontal  section  these  are  shown  to  be  the  edges  of  epidermic  scales, 
each  of  which  has  its  distinct  nucleus.  Occasionally  these  cells  soften 
and  separate  from  each  other,  constituting  the  soft  corn.  Callosities  of 
the  skin  exactly  resemble  corns  in  structure,  but  are  diffused  over  a 
greater  surface. 

Both  corns  and  callosities  are  occasioned  by  interrupted  pressure 
upon  any  part  of  the  skin.  To  a certain  extent  they  protect  the  deli- 
cate nervous  filaments  below.  At  other  times,  from  their  bulk  or  hard-, 
ness,  they  cause  increased  pain  whenever  the  pressure  is  modified  or 
increased.  Corns  are  common  on  the  feet  from  undue  pressure  of  the 
shoe ; callosities  occur  on  the  knees  of  housemaids,  on  the  hands  of 
handicraftsmen,  sempstresses,  etc.,  or  in  any  other  portion  of  the  surface 
exposed  to  pressure.  The  cure  consists  in  removing  the  cause.  We 
have  frequently  observed,  that  during  an  attack  of  fever  and  the  sub- 
sequent convalescence,  the  corns  and  callosities  on  the  feet  of  patients 
] ave  disappeared,  having  “ grown  out,”  as  it  is  called.  Changing  the 
shoe  or  bootmaker,  or  obtaining  another  last,  has  been  known  to  remove 
them. 


EPITHELIAL  GKOWTHS. 


211 


2.  The  scaly  shin  diseases  must  be  classified  among  epidermic 
growths.  Accuumlatioiis  of  epidermic  scales,  upon  a reddened  and 
indurated  surface,  constitute  their  characteristic  features.  In  psoriasis 
t ley  are  gathered  together  in  considerable  masses.  In  pityriasis  the 
ncales  are  sniiller  are  more  easily  separated  from  the  surface,  and 
frequently  associated  with  minute  cryptogamic  vegetations.  ^ The 
flattened  and  imbricated  iorm  of  ichthyosis  is  also  composed  of  similar 
accuiimlations  of  epidermic  scales,  but  without  the  reddened  surface. 
(Fig.  115). 

3.  Warts  and  Condylomata  are  also,  for  the  most  part,  composed 
of  epidermic  cells  condensed  together.  The  wart  consists  of  projections 
of  a papillary 


form,  varying  in 
size,  and  occurs 
under  circum- 
stances where 
pressure  does 
not  take  place. 
These  growths 
appear  to  be 
constitutional, 
or  associated 
with  peculiar 
states  of  the 


Fig.  226. 


Fig.  227. 


body.  Thus  condylomata  and  warts  are  frequently  found  round  the  mar- 
gins of  the  anus,  vulva,  and  penis,  in  syph- 
ilitic individuals.  Warts  assuming  the 
form  of  cauliflower  excrescence,  often  ar- 
rive at  a large  size  in  such  situations, 
weighing  even  several  pounds.  They  fre- 
quently form  on  the  hands  of  young  per- 
sons, and  are  sometimes  found  on  other 
parts  of  the  body,  earning  and  going  with- 
out any  obvious  cause. 

Condylomata^  when  closely  examined, 
seem  to  be  made  up  of  a congeries  of  pa- 
pillae  {papilloma)^  sometimes  flattened  at  (ok 
the  top  so  that  they  cannot  be  separated ; 
at  others,  presenting  fissures  or  sulci  which 
lead  down  to  a common  stalk.  Sometimes 
the  papillae  are  small  and  rounded ; at 
others,  elongated  and  enlarged  at  their 
extremities.  The  tumors  thus  formed 


may  be  only  the  size  of  a pin’s  head,  or  may  be  so  large 


weigh 


Fig.  226.  Warts  on  the  penis.  One-fourth  the  natural  size. — {Acton.) 

Fig.  227.  Summit  of  a papilla  from  a wart. 

Fig.  228.  Perpendicular  section  of  a papilla  from  an  acuminate  condyloma,  after 
the  addition  of  acetic  acid,  a,  Vascular  loop — internal  to  which  is  fibrous  tissue 
forming  the  axis  of  the  papilla — outside  are  nuclei.  6,  6,  Basement  membrane,  c,  c, 
Epidermic  cells. — ( Wedl.)  250  diam. 


212 


PEINCIPLES  OF  MEDICINE, 


several  pounds.  In  the  latter  case  the  central  portions  seem  to  consist 
of  a fibrous  structure,  probably  an  hypertrophy  of  the  dermis,  which 
is  supplied  with  blood-vessels  (Fig.  229).  Their  surface  sometimes 
is  smooth,  resembling  thickened  epidermis ; at  others  it  is  lobulated, 
composed  of  rounded  groups  of  papillae,  resembling  externally  a cauli- 
flower. These  tumors,  when  small,  are  almost  wholly  composed  of 
epithelial  scales,  which  assume  a square  or  elongated  form,  their  nuclei 

being  for  the  most  part  very  distinct. 
In  the  larger  growths  the  surface  is 
similarly  composed,  but  internally  we 
find  more  or  less  areolar  tissue,  supplied 
with  blood-vessels.  On  snipping  off 
a small  isolated  papilla  from  such  a 
tumor,  and  examining  it  entire,  it  pre- 
sents a conical  or  round  projection, 
covered  with  epidermic  scales,  as  in 
Fig.  227.  When  a vertical  section  of 
it  is  made,  we  observe  a vascular  loop, 
surrounded  by  basenmnt  membrane,  external  to  which  are  layers  of 
epithelial  cells  varying  in  thickness  (Fig.  228).  The  Verruca  Achro- 
cordon  is  a peculiar  epidermic 
tumor,  furnished  with  a cen- 
tral canal,  through  which 
blood-vessels  ramify  abun- 
dantly to  all  parts  of  the  tu- 
mor. The  central  parts  of  such 
tumors  are  composed  of  fibrous 
structure  (Fig.  229) ; exter- 
nally they  consist  of  epidermic 
scales,  arranged  concentrical- 
ly round  the  central  vascular 
part,  which,  if  cut  into,  gives 
rise  to  great  haemorrhage. — 

( Vogd.)  All  these  tumors  may 
soften,  and  ulcerate  on  the 
surface,  and,  under  such  cir- 
cumstances, give  rise  to 
purulent  and  ichorous  dis- 
charges. 

4.  Another  form  of  epithe- 
lioma is  one  wdiich  frequently 
commences  as  an  ulcer,  al- 
though sometimes  it  is  pre-  Fig-  2S0. 

ceded  by  slight  induration  of,  or  a small  wart  on  the  part  affected.  It  is 
common  in  the  under  lip,  in  the  tongue,  and  in  the  cervix  uteri.  In  the 
lip  there  may  be  often  observed  a furrow  or  groove  in  the  indurated  spot 
or  wart,  in  which  the  ulceration  commences.  This  slowly  extends,  with 
indurated,  thickened,  and  raised  margins,  is  circular  and  cup-shaped,  its 

Fig.  229.  Transverse  section  of  the  base  of  a condyloma.  The  dark  shading  in 
the  centre  and  radiating  lines,  represent  dense  fibrous  vascular  tissue. — {Wedl.) 

Fig.  230.  Ulcerated  epithelioma  of  the  lip. — {Liston.) 


EPITHELIAL  GROWTHS. 


213 


surface  sometimes  covered  with  a white  cheesy  matter,  at  others  with  a- 
thick  crust  or  scab  (Fig.  230).  It  slowly  extends,  until  it  involves  a 
greater  or  less  portion  of  the  lip  and  neighboring  parts,  pouring  forth 
a foul  ichorous  discharge.  In  the  tongue,  the  disease  follows  a similar 
course ; the  base  of  ttie  sore,  however,  is  generally  more  fungoid  or 
papillated  on  the  surface,  and  exceedingly  dense,  owing  to  the  close 
impaction  and  compression  to- 
gether of  laminae  of  epitheli- 
um, These  on  section  present 
a mass  having  a white  surface, 
with  a tendency  to  split  up 
and  separate,  are  dense  to  the 
feel,  and  do  not  yield  on  pres- 
sure a milky  juice  (Fig.  211). 

On  the  cervix  uteri  similar 
ulcers  are  very  common,  with 
hard  irregular  edges,  yielding  a copious  ichorous  discharge,  and  causing 
more  or  less  thickening  of  the  neighboring  textures.  The  so-called  cauli- 
flower excrescence  is  a form  of  epithelioma ; so  also  are  the  cancer  of  the 
scrotum  of  the  chimney-sweeper,  certain  forms  of  rodent  ulcer,  and  of 
noli  me  ian  jere.  An  epithelioma  of  the  hand  is  well  figured  by  Mr. 
Paget, and  so  also  is  a remarkable  one  in  the  interior  of  the  stomach 
by  Professor  A.  lietzius.f 


Fig.  232.  Fig,  233. 

In  all  these  cases,  the  ulcers,  when  examined  microscopically,  present 

* Surgical  Pathology,  vol.  ii.  p.  41 Y. 
f Museum  Anatomicum  Holmiense.  Sect.  Path.  Tab.  Y,  1855. 


Fig.  231.  Section  of  an  ulcerated  epithelioma  of  the  tongue.  Natural  size. 

Fig.  232.  Muscular  tissue  immediately  below  the  white  mass  Fig.  231. 

Fig.  233.  Concentric  laminae  of  condensed  epithelial  scales,  from  the  lower  por- 
tion of  the  white  matter  seen  Fig.  231,  with  epithelial  cells,  and  fragments  of 
muscular  fasciculi.  250  diarn. 


Fig.  231. 


214 


PRINCIPLES  OF  MEDICINE. 


on  the  surface  masses  of  epithelial  cells  in  all  stages  of  their  development. 
Some  spherical  and  nucleated  are  about  the  yo'oo^^ 
diameter,  others  are  much  larger ; both  often  resembling  cancer-cells 
when  isolated  or  viewed  alone,  but  associated  with  flattened  scales,  vary- 
ing in  shape  and  size,  sometimes  occurring  in  groups  adherent  at  their 
edges,  at  others  mingled  together  in  a confused  mass.  Many  of  the 
cells  and  scales  often  reach  an  enormous  size,  and  as  they  become 
old,  split  up  into  fibres.  These  elements  are  commonly  mingled  with 
.numerous  molecules  and  granules,  naked  nuclei,  fusiform,  granular,  and 
pus  cells.  Below  the  surface  the  epithelial  cells  may  be  seen  more  or 
less  compressed  and  condensed  together,  and  when  the  epithelioma  is 
chronic,  and  the  structure  dense,  these  present  concentric  laminae  sur- 
rounding a hollow  space  or  loculus,  evidently  owing  to  the  compression 
together  of  numerous  epithelial  scales.  This  peculiar  appearance,  some- 

Fig.  235. 


times  called  “cell  nests,”  is  characteristic  of  this  form  of  epithelioma 
(Fig.  233).  On  breaking  them  up,  they  exhibit  a variety  of  forms,  in 
which  their  epithelial  character  is  visible  on  the  one  hand,  and  the 
fragments  of  concentric  circles  are  seen  on  the  other  (Fig.  237.) 

The  lymphatic  glands  in  the  neighborhood  of  such  ulcers  have  a 
great  tendency  to  be  secondarily  affected,  in  which  case  they  enlarge, 
soften,  and  easily  break  down  under  the  finger.  Not  unfrequently  they 
contain  a yellow  cheesy-looking  substance,  which,  under  such  circum- 
stances, represents  fatty  degeneration,  analogous  to  the  reticulum  c»f 
cancerous  formations.  On  crushing  a portion  of  the  altered  glandular 
substance  between  glasses,  it  presents  the  appearances  represented  Fig. 
237.  If  the  concentric  masses  are  broken  down,  the  individual  epithelial 
cells  are  here  also  seen  to  be  of  various  fantastic  shapes,  in  which 
fragmentary  portions  of  circles  are  detectable  (Fig.  237).  In  the 

Fig.  234.  Ei)idermic  scales,  in  mass  and  isolated,  trom  the  surface  of  an  epitheli- 
oma of  the  scrotum,  in  a chimney  sweep. 

Fig.  235.  Group  of  deep-seated  cells,  in  the  same  case. 

Fig.  236.  The  same,  after  the  addition  of  acetic  acid. 


250  diam. 


EPITHELIAL  GROWTHS. 


215 


yellowish  portions  the  nuclei  are  composed  of  fatty  granules,  and  the. 


Fig.  237.  Fig.  238. 

cells  themselves  are  molecular,  and  mingled  with  numerous  oily  particles, 
(Fig.  238,  also  Fig.  122). 

A modification  of  this  form  of  epithelioma  occurs  on  mucous  surfaces, 
especially  in  the  urinary  bladder, 
and  has  been  variously  called 
villous  cancer,  dendritic  vegeta- 
tion (Zottenkrebs  of  Rokitans- 
ky). It  forms  a fungous  projec- 
tion, having  a fibrous  basis 
which  is  elongated  into  branched 
stems,  supporting  villi,  more  or 
less  ao-fjreo-ated  together,  and 
covered  with  a layer  of  epithe- 
lial cells.  It  is  soft,  and  readi-  24o. 

ly  breaks  down  under  the  finger,  the  pulpy  matter  exhibiting  under  the 
microscope  numerous  irregularly-shaped  cells,  partly  fibrous  and  partly 
epithelial,  in  various  stages  of  development  (Fig.  239). 

5.  Hairy  formations. — Great  varieties  exist  in  different  individuals 
regarding  the  amount  of  hair  on  their  body.  Some  men  have  been  known 
to  be  as  hairy  as  certain  of  the  lower  animals.  Patches  or  groups  of  hair, 
seated  on  a somewhat  indurated  base,  may  frequently  be  seen  scattered 
over  the  surface  in  parts  usually  smooth ; these  constitute  a form  of  so- 
called  mole  on  the  skin.  Hair  has  been  found  on  the  surface  of  the 
mucous  membrane,  and  even  in  the  lungs;  and  is  common  in  encysted 
tumors,  especially  of  the  ovary  and  testis.  In  several  such  cases  I have 
found  the  root  of  the  hair  implanted  in  a follicle,  at  other  times  loose, 
with  the  roots  of  a bulbous  form  exactly  resembling  those  on  other  parts 
of  the  body.  The  point  of  the  hair  is  generally  somewhat  tr.uncated, 
presenting  at  its  extremity  two  or  more  fibres,  produced  by  the  longi- 

Fig.  23Y.  Fragments  produced  by  breaking  up  the  concentric  masses  figured,  Fig. 
233,  from  a fymphatic  gland. 

Fig.  238.  Epithelial  cells,  in  yellow  cheesy  matter,  of  the  same  gland. 

Fig.  239.  Cells  in  pultaceous  white  matter,  from  a fungoid  epithelioma  of  the 
Urinary  bladder. 

Fig.  240.  The  same  after  the  addition  of  acetic  acid. 


250  diam. 


216 


PEINCIPLES  OP  MEDICINE. 


In  length  they  vary  from  one  i][narter 


tudinal  splitting  up  of  the  hair, 
of  an  inch  to  several  inches. 

6.  Horny  productions. — Under  this  head  may  be  classed  the  promi- 

neiit  growths  in  some 
forms  of  ichthyosis , tu- 
mors resembling  warts,  but 
so  indurated  as  to  resemble 
horn,  and  true  horny  ex- 
crescences growing  from  the 
surface. 

In  some  forms  of  ich- 
thyosis., the  growths  stand 
out  as  distinct  spines,  broad 
on  the  surface,  narrow  at 
their  insertions,  like  col- 
umns of  many  sides,  accu- 
rately fitting  to  their  neigh- 
bors. Horny  iumors  occa- 
sionally occur,  varying  in 
size  from  a bean,  or  extend- 
ing over  a space  the  size  of 
half-a-crown.  M any  cases 
are  on  record  of  true  horn 
having  grown  from  the  sur- 
face, especially  from  the 
head,  originating  in  some 
sebaceous  follicle.  They 
have  grown  several  inches 
long,  as  seen  in  Fig.  241. 
On  making  a section  of  these 
productions,  they  are  found 
to  be  identical  with  the 
structure  of  true  horn  in 
the  lower  animals,  or  with  that  of  the  nails  on  the  hands  and  toes. 
They  consist  of  condensed  epidermic  scales,  which  on  the  addition  of 
acetic  acid,  assume  all  the  characters  of  such  structures. 


Vascular  Growths. — Angionoma. 

Vascular  growths  are  formed  by  an  increase  in  the  dimensions  or 
number  of  the  arterial,  capillary,  or  venous  vessels.  Several  growths 
already  described,  as  well  as  such  as  arc  of  a cancerous  nature,  are  very 
vascular; — indeed,  so  much  so,  that  in  some  cases  the  slightest  touch 
causes  alarming  haemorrhage,  as  in  the  case  of  so-called  uterine  polypi, 
and  fungus  haematodes.  No  doubt  there  is  considerable  increase  of  vas- 

Fig.  241.  From  an  old  preparation  in  the  Edinburgh  University  Museum.  The 
medal  attached  to  it  bears  the  following  quaint  inscription  : — “ This  horn  was  cut 
hy  Arthur  Semple,  Chirurgeon,  out  of  the  head  of  Elizabeth  Low,  being  three  inches 
above  the  right  ear,  before  these  witnesses,  Andrew  Temple,  Thomas  Burne,  George 
Smith,  John  Smytone,  and  James  Tweedie,  the  14th  of  May,  1671. — It  was  growing 
seven  years  ; her  age  60  years.  Natural  size. 


VASCULAR  GROWTHS. 


217 


cular  growth  in  such  tumors,  but  their  basia  is  formed  of  other  materia^ — 
they  are  not  wholly  vascular.  This  term  is  more  properly  applied  to  those 
diseases  which  have  hitherto  been  denomi- 
nated aneurism^  erectile  tumors^  and  varix. 

1.  Aneurisfn  is  an  arterial  swelling,  which 
may  vary  in  size  from  the  slightest  possible 
dilatation  of  the  calibre  of  the  vessel,  either 
wholly  or  partially,  to  the  formation  of  enor- 
mous tumors,  Inr'ior  than  the  human  head. 


Fi2.  242. 

In  such  cases  we  find  the  growth  to  consist 
externally  of  the  dilated  and  hypertrophied 
structures  of  the  vessel  itself,  or  of  the  tissues 
in  its  immediate  neighborhood,  and  of  layers 
of  blood,  more  or  less  coagulated  within  it. 

The  varieties  of  aneurism  are  numerous,  but, 
the  principal  are—- 1.  Aneurism  hy  dilatition^ 
in  which  the  whole  circumference  of  the  vessel  fiet  243. 

is  dilated.  2.  Saccular^  also  called  true  Aneurism^  in  which  one  portion 
or  side  of  the  vessel  is  dilated  into  a sac.  3.  False  Aneurism^  in  which 
the  coats  of  a vessel  have  been  ruptured.  It  has  been  called  primitive 
when  all  the  coats  are  divided,  as  by  a wound,  and  consecutive^  when  it 
is  consequent  on  ulceration  or  rupture  of  the  internal  and  middle  coats. 
4.  Mixed  Aneurism^  in  which,  after  dilatation,  general  or  partial,  of  all 
the  coats  of  a vessel,  the  internal  and  middle  ones  burst,  and  a false 
aneurism  is  superadded.  5.  Dissecting  Aneurism^  in  which  there  is 
laceration  of  the  internal  and  middle  coots,  so  that  the  blood  becomes 
infiltrated  between  the  coats  of  the  vessel,  separates  them  for  a greater 
or  less  distance,  and  bursts  externally  at  some  distance  from  the  internal 
lesion.  6.  Hernial  Aneurism^  in  which  the  external  and  middle  coats 
are  lacerated,  and  the  internal  protrudes  through  them,  forming  a her- 
nial aneurismal  sac.  7.  Aneurism  hy  anastomosis,  in  which  an  artery, 
by  an  unnatural  communication  with  the  vein,  causes  a pulsating  tumor 
in  the  latter. 

The  tendency  of  these  growths  is  to  burst  externally  or  internally 


Fig.  242.  True  saccular  aneurism  of  the  aorta,  nearly  filled  with  coagulated  clot. — 
One-third  the  real  size. — {After  Hodgson,  slightly  modified.) 

Fig.  243.  Remarkable  spontaneous  varicose  aneurism,  formed  by  communication 
between  the  vena  cava  and  the  aorta  at  its  bifurcation.  A,  Aorta;  B,  Vena  cava; 
C,  Aneurism  ; D,  Situation  of  a round  aperture  somewhat  larger  than  a sixpence, 
through  which  the  communication  between  vein  and  artery  was  kept  up. — {Syme.) 


218 


PRINCIPLES  OF  MEDICINE. 


into  spaces  wliero  least  resistance  is  offered,  but  occasionally  tlie  clot  of 
blood  in  the  interior  coagulates  to  such  an  extent  as  to  close  up  the 


I'ig.  iit-4.  Aneurism  of  the  coronary  artery,  completely  filled  with  coagulated  clot. 
Natural  size. — {Peacock.) 

Fig,  245.  Section  of  erectile  tumor. — {Miller.,  after  ?) 


Fig.  244. 

cavity,  prevent  influx  of  fluid,  and  cause  spontaneous  cure — a result 
which  is  observable  in  the  figure  of  a very  rare  specimen  of  aneurism 
of  the  left  coronary  artery  described  by  Dr.  Pea- 
cock.* The  special  pathology  of  these  growths, 
however,  is  far  too  extensive  a subject  to  be 
entered  upon  in  this  place. 

2.  Erectile  growths  are  generally  soft ; for  the 
most  part  situated  in  the  subcutaneous  tissue,  the 
skin  covering  them  being  of  unusual  delicacy. 
When  compressed  they  may  be  gradually  emptied 
of  blood,  which  returns  like  water  into  a sponge 
on  removing  the  pressure.  For  the  most  part 
they  are  congenital.  When  the  arteries  are  numerous  in  them  they 
have  a brownish  or  reddish  color,  and  pulsate  during  life.  When  the 
veins  abound,  they  are  of  a blue  or  purple  color.  Their  texture  con- 
sists of  numerous  capillaries,  more  or  less  distended,  mixed  with  arteries 
and  veins,  the  interstices  of  which  are  filled  up  by  areolar  tissue.  A 
section  presents  a spongy  texture,  composed  of  fibrous  bands  closely 
resembling  the  appearance  of  the  corpus  cavernosum  penis,  with  areolm 
or  spaces  into  which  the  blood  enters  (Fig.  245).  The  section  of  a 
fresh  tumor  is  not  unlike  that  of  a sponge  soaked  in  blood.  In  struc- 
ture it  is  composed  of  vessels  of  all  sizes,  abounding  in  capillaries,  which 
are  more  or  less  sacculated  or  aneurismal,  and  anastomose  freely  with 
each  other.  In  one  case  of  erectile  growth  in  the  liver,  I found  the 
intervascular  structure  to  consist  of  caudate  and  branched  cells,  and  in 
another,  in  the  brain,  I found  it  loaded  with  earthy  salts. 

Varix  is  a permanently  enlarged  and  tortuous  vessel.  Swellings 
* Monthly  Journal  of  Medical  Science.  March,  1849. 


VASCULAK  GROWTHS. 


219 


from  this  cause  are  for  the  most  part  venous,  and  may  exist  in  various . 
parts  of  the  body,  but  are  frequent  in  the  saphena  veins  of  the  inferior 
extremities,  the  spermatic  veius  {varicocele)^  and  haemorrhoidal  veins 
[hcemorrhoids).  In  all  these  cases  the  veins  gradually  enlarge,  and  then 
become  distended,  tortu- 
ous, and  coiled  up.  Seve- 
ral of  these,  accumulated 
together,  may  produce 
knotty  swellings  in  the 
legs,  cause  the  testicle  to 
assume  an  unusual  size,  or 
produce  tumors  which, 
during  defgecation,  are 
protruded  beyond  the 
margin  of  the  anus.  Such 
growths  may  ulcerate,  and 
cause  death  by  haemor-  Fig.  246. 

rhage,  or  they  may  be  spontaneously  obliterated  by  the  formation  of  clots 
within  them.  An  artery  rarely  becomes  varicose. 

The  enlargement  of  vascular  growths,  for  the  most  part,  arises  through 
dilatation  of  the  vessels ; no  new  materials  are  produced  in  them,  with  the 
occasional  exception  of  such  as  arise  in  the  clot  of  blood  within  them, 
viz.,  fibrous  or  albuminous  laminae,  or  calcareous  masses.  Through  the 
presence  of  these,  the  vessel  becomes  obliterated,  and  gradually  assumes 
the  density  and  appearance  of  ligament. 

New  vessels  constitute  one  of  the  most  common  pathological  forma- 
Fig.  247 


tions.  In  the  embryo  the  capillaries  originate  in  independent  cells, 
which  throw  out  arms  or  prolongations  that  unite  with  one  another  (Figs. 
252  and  253).  The  larger  vessels  originate  in  globular  cells  which  be- 
come fusiform,  and  arrange  themselves,  some  longitudinally  and  others 
transversely,  to  constitute  the  different  coats  of  the  vascular  wall  (Figs. 


Fig.  246.  Yaricose  vessels  in  the  caput  trigonum  vesicce. — {Wedl.)  200  diam. 

Fig.  247.  Inner  layer  of  umbilical  artery  of  calf,  eight  inches  long. — {Drummond.) 

Fig.  248.  Succeeding  layer  in  the  same  vessel,  composed  of  spindle-shaped  cor- 
puscles.— {Drummond.) 

Figs.  249  and  250.  Layp^=;  more  external  in  the  same  vessel,  in  different  stages  of 
development  into  fibres  — ‘Drummond  ) 

Fig.  251.  Common  caiotil  artery  of  an  embryo  calf  two  inches  in  length,  showing 
d'ffjrent  directions  of  the  fibre  cells. — {Drummond.)  200 


220 


PRINCIPLES  OF  MEDICINE. 


247  to  251).  In  the  adult  the  observations  which  have  been  made  in 
connection  with  this  subject,  have  led  to  three  theories.  1st,  That  new 

vessels  are  of  independent  origin, 
and  that  they,  as  well  as  the  blood 
they  contain,  spring  up  in  a blas- 
tema according  to  the  general  laws 
of  cell  formation.  2d,  That  the 


blood 


, escaping 
a 


globules  of  the 

from  the  vessels,  channel  a way 
through  the  surrounding  exuda- 
tion, and  thus  form  new  vessels. 
3d,  That  the  walls  of  the  old  ves- 
sels themselves  at  particular  places 
present  bulgings  and  irregularities, 
which  become  pushed  out  more 
Fig.  253.  more  by  the  vis  a tergo^  and 

An  inquiry  into  this  subject  is  surrounded  with 
results  of  modern  research  tend  to  the  conclusion, 
that  in  exudation  new  vessels  for  the  most  part  have  an  independent 
origin,  being  formed  as  in  the  embryo ; although  old  vessels  may  occa- 


Fig.  252. 

SO  form  new  channels, 
difficulties,  but  all  the 


Fig.  254.  Fig.  255. 

sionally  throw  out  off-shoots  or  prolongations.  Thus  in  lymph  we  some- 
times observe  cells,  in  all  stages  of  development  of  the  spindle-shaped 
and  branched  forms,  which,  according  to  the  observations  of  Drummond,* 
and  more  recently  of  Billroth, f by  their  fusion,  or  by  their  arrangement 
side  by  side,  form  capillaries  of  various  magnitudes.  These  capillaries 
afterwards  unite  themselves  with  the  pre-existing  vessels. 


Cartilaginous  Groivths. — Enchondroma. 

Cartilaginous  growths  were  first  described  by  Muller,  under  the 

* Monthly  Journal  of  Medical  Science,  November  1854. 
f Billroth  Ueber  die  Entwicklung  der  Blntgefilsse,  Berlin,  1856. 


Fig.  252.  Stellate  cells  in  the  tail  of  the  tadpole,  developing  into  capillary  vessels. 
Fig.  253.  Capillary  vessels  in  dilferent  stages  of  formation  from  stellate  cells,  in 
the  eye  of  the  foetal  calf. — {Drummond.) 

Fig.  254.  Branched  cells  in  lymph  exuded  on  the  peritoneum. 

Fig.  255.  Vessels  in  an  early  stage  of  formation,  from  a colloid  tumor  of  the 
back.  250  diam. 


CARTILAGINOUS  GROWTHS. 


221 


name  of  Enchondroma  (Osteochondropliytes  of  Cravelhier).  In  the  soft 
parts,  they  are  surrounded  by  an  envelope  of  cellular  tissue,  and  in  the 
bones  by  a bony  capsule.  In  the  first  case  they 
occur,  althougli  very  rarely,  in  the  glands,  as  in 
the  parotid  or  mamma.  In  the  second  case  they 
are  most  common  in  the  bones  of  the  extremi- 
ties. The  tumors  may  be  round  and  smooth,  or 
rough  and  nodulated  from  several  of  them  being 
accumulated  together.  Though  hard  to  the  feel, 
they  often  present  a peculiar  elasticity.  They 
crunch  when  cut  with  the  knife,  usually  present 
a smooth,  glistening  surface,  and  are  not  unfre- 
quently  more  or  less  soft,  pulpy,  gelatinous,  and 
even  diffluent  in  some  parts  of  their  substance. 

They  are  rarely  met  with. 

In  structure,  enchondroma  presents  all  the  cha- 
racters of  cartilage — that  is,  nucleated  cells  vary- 
ing in  size,  isolated  or  in  groups,  situated  in  a 
hyaline  substance.  A network  of  filamentous  tissue  runs  through  the 
substance  of  the  tumor,  forming  areolae,  in  which  blood-vessels  ramify. 


Fig.  257.  Fig.  258.  Fig.  259. 


Within  the  areolae  so  formed,  the  cartilage  is  found.  These  two  elements 
vary  as  regards  amount  in  different  tumors.  Sometimes  the  cartilage  is 
in  excess,  resembling  that  in  young  animals,  or  that  in  the  foetus.  At 
others  the  fibrous  element  ab  >unds,  the  whole  being  similar  in  structure 
to  fibro-cartilage.  Between  these  two  extremes  there  is  every  gradation. 
Occasionally  it  presents  all  the  characters  of  articular  cartilage.  I have 
.seen  all  the^e  kinds  in  one  tumor.  The  c^lls  present  an  extraordinary 
variety  in  their  size  and  form,  being  sometimes  large  and  embryonic  (Fig. 
257),  at  others  small  (Fig.  260).  They  may  contain  from  one  to  twenty 


Fig.  2*36.  Enchondroma  of  the  hand  and  fingers.  The  tumor,  of  which  a section 
has  been  made,  is  enclosed  in  a bony  capsule.  Onc-fiflh  natural  size. — {Miller.) 

Fig.  257.  Structure  of  a firm  nodule  in  an  enchondroma  of  the  humerus.  The 
right  of  the  figure  represents,  above,  mineral  deposit  in  and  around  the  cells,  and 
below,  some  isolated  cartilage  corpuscles. 

Fig.  258.  The  same,  after  the  addition  of  acetic  acid,  rendering  the  whole,  and 
especially  the  nucleus,  more  transparent. 

Fig.  259.  The  cartilage  cells  and  fibrous  tissue  separated  and  broken  up,  with 
numerovis  molecules  in  a nodule  of  the  same  tumor  which  was  soft  and  in  some 
places  diffluent.  250  diain. 


222 


PRINCIPLES  OF  MEDICINE. 


nuclei.  In  shape  they  may  he  round,  oval,  irregular,  or  branched. 
They  may  also  be  associated  with  numerous  granule  cells,  as  in  Fig.  260, 

Fig.  260. 


Fig.  261.  Fig.  262.  Fig,  263. 

from  a specimen  of  enchondroma  removed  from  the  integuments  of  the 
neck  by  Mr.  Miller,  which  on  section  presented  the  smooth  and  moist 
surface  of  a cut  potato. — [Solanoma,)  (Figs.  260  to  263.) 

Not  unfrequently  a bony  nucleus  may  be  observed  in  a nodule  of 
enchondroma,  and  sometimes  all  stages  of  transformation  into  perfect 
bone  may  be  observed  in  them.  Some  of  the  exostoses,  to  be  spoken 
of  immediately,  are  owing  originally  to  an  excess  of  cartilaginous  growth. 


Fig.  264.  Fig.  265.  Fig.  266. 

Enchondromatous  tumors  are  continually  mistaken  for  cancerous 
growths,  a fact  pointed  out  by  Muller.  They  are  usually  denominated 

Fiej.  2G0.  Small  cartilage  with  round  granule  cells,  in  the  pulp  scraped  from  a 
scctio!!  of  an  enchondroma,  which  in  color,  density,  and  appearance,  closely  resembled 
a potato,  or  so-called  Solanomo.. 

Fig.  2G1.  The  same  cartilage  cells,  after  the  addition  of  acetic  acid. 

Fig.  2G2.  Thin  section  of  a firm  portion  of  the  same  tumor. 

Fig.  2Go.  Fine  filaments  which  interlaced  the  cells,  these  having  been  washed  out. 

Fig.  264.  Thin  section  of  an  enchondroma,  with  a bony  cap.sule,  growing  from  the 
ischium  and  pubis. 

Fig.  265.  Separated  cartilage  cells  from  a softened  portion  of  the  same  tumor. 

Fig.  266.  The  same,  rendered  more  opaque,  after  the  addition  of  acetic  acid.  250  di. 


CAKTILAGINOUS  GROWTHS. 


223 


osteosarcoma.  Not  uufrequently  they  soften,  and  under  such  circum- 
stances present  all  the  external  characters  of  what  is  called  soft  cancer. 
This  softened  portion,  even  when  examined  microscopically,  may  lead 
to  error,  as  the  cartilage  cells  which  then  float  loose,  mixed  with  granules 
and  the  debris  of  the  tumor,  very  much  resemble  those  in  cancerous 
growths.  They  may  be  distinguished,  however,  by  the  action  of  acetic 
acid,  which  affects  the  whole  corpuscle  alike,  instead  of  producing,  as  in 
the  case  of  cancer,  a marked  difference  between  the  external  cell-wall 
and  the  nucleus  (Figs.  258,  266). 

Another  form  of  cartilaginous  growth  is  observed  in  the  so-called 
pulpy  degenerations  and  ulcerations  seen  in  articular  cartilage.  Goodsir 


was  the  first  to  point  out  that  such  ulcerations  were  in  part  owing  to  an 
increased  growth  of  the  cells  ; avid  Rodfern,  whilst  he  has  confirmed  this 
statement,  has  described  and  figured  all  the  various  changes  observable 
in  tho>=ie  cells,  and  in  the  inter-hyaline  substance  in  the  different  diseases 
of  cartilage  in  man,  and  many  of  the  lower  animals.  In  consequence  of 


Fig,  267.  Diseased  human  articular  cartilage,  from  a scrofulous  joint,  showing  the 
enlargement  of  the  corpuscles,  the  increase  of  nuclei  within  them,  and  their  escape 
into  the  intercorpuscular  softened  substance. — {Redfern.) 

Fig.  268.  Similar  alteration  in  costal  cartilage  of  the  dog,  caused  by  the  passage 
of  a seton  thirty-four  days  before  death. — {Redfern.) 

Fig.  269.  Vertical  section  through  diseased  articular  cartilage  of  the  patella;  a, 
free  surface. — {Redfern.) 


224 


PEINCIPLES  OF  MEDICINE. 


as  Goodsir  pointed  out,  there  are  gradually  formed  within  them  a mass  of 
secondary  ones.  These  hurst  into  the  surrounding  hyaline  substance, 
give  it  unusual  softness,  and  cause  it  to  swell.  At  the  same  time  the 


hyaline  substance  fibrillates,  and  splits  up,  a change  best  observed  on  the 
villous  and  rough  abraded  surface  so  commonly  seen  in  diseased  joints. 


Fig.  271. 


Fig.  272. 


Mechanical  injury  inflicted  on  these  structures  produces  the  same  results, 
showing  that  both  it  and  disease  operate  by  stimulating  cell  nutrition  and 
growth  (Figs.  2GT  to  270,  and  136). 


Fig.  270.  Fibrous  projection,  from  the  flocculent  surface  of  a diseased  human  semi- 
lunar cartilage. — [Redfern.)  250  diam. 

Fig.  271.  Lateral  view  of  an  exostosis,  removed  from  the  posterior  and  inner  surface 
of  the  humerus  two  inches  from  its  head,  by  Mr.  Syme.  At  a,  a piece  of  the  tumor  has 
been  broken  off,  showing  the  cancellated  structure  of  the  interior. — {Lister.)  Real  stze. 

Fig.  272.  Part  of  a section  through  one  of  the  prominences  of  the  tumor,  a, 
Superficial  cartilage ; c,  a portion  of  deep-seated  cartilage  surrounded  by  dense 
bone ; 6,  and  f/,  c,  calcified  cartilage  not  so  dense  as  the  more  superficial  portions. — 
{Lister.)  Real  size. 

Fig.  273.  Section  of  a portion  of  the  tumor  at  the  line  of  junction  of  the  calcified 
cartilage,  and  the  cancellous  structure  of  the  interior,  the  earthy  matter  having  been 
removed  by  dilute  hydrochloric  acid,  a.  Cartilage  with  its  cells  changed  by  the  pro- 
cess of  calcification;/;,  c,  is  true  bone,  containing  laminae,  lining  the  excavations  in  the 
calcified  cartilage  ; d,  part  of  a spiculum  of  the  cancellous  structure ; c,  and  /’  spaces 
formerly  occupied  by  medullary  substance. — {Lister.)  200  diam. 


OSSEOUS  GROWTHS. 


225 


Osseous  Growths. — Osteoma. 

We  have  seen  that  in  many  of  the  cartilaginous  growths  deposit  of 
bone  may  take  place  to  a greater  or  less  extent.  In  such  cases  the  new 
cartilaginous  tissue  undergoes  the  true  bony  transformation,  in  the  same 
manner  that  normal  cartilage  becomes  ossihed  in  passing  from  the  foetal 
state  through  the  periods  of  youth,  manhood,  and  old  age.  This  we  must 
separate  from  the  numerous  forms  of  calcareous  concretH)iis  so  frequently 
met  with.  True  bone  may  bo  at  once  recognised  by  its  osseous  lacunao 
and  canaliculi.  Earthy  concretions  only  consist  of  an  amorphous  mass 
of  mineral  material.  (Compare  Figs.  277  and  d68.) 

Osseous  growths  may  affect  the  external  surface,  the  substance,  or  the 
internal  surface  of  bone.  In  the  first  case  they  are  denominated  exostoses. 
They  form  prominences  on  the  surface  of  the  bone  varying  in  size  from 
a small  point  to  that  of  a cocoa-nut.  There  is  no  part  of  the  osseous 
frame  free  from  them,  but  they  are  very  common  in  the  bones  of  the 
extremities.  They  may  arise  as  the  result  of  direct  local  injury,  asfronii 
a blow  or  fall,  or  they  may  be  connected  with  peculiar  constitutional 
diseases.  In  syphilitic  constitutions,  exostoses  more  especially  arise  on 
the  shafts  of  the  long  bones;  in  rheumatic  persons,  they  surround  the 
joints. 

Many  of  these  growths  on  the  surface  of  bones  have  not  been  shown 
to  originate  in  cartilage  as  the  bones  themselves  do.  But  in  others,  there 
can  be  no  doubt  that  such  is  their  mode  of  growth,  viz.,  matter  is  thrown 
out  from  the  blood,  which  is  converted  first  into  cartilage  and  then  into 
bone  (Fig.  273).  In  this  manner  enchondroma  may  be  converted  into 
osteoma.  The  growths  in  which  this  change  is  observable  generally 
present  roundish  masses.  They  may  be  intensely  hard  or  eburnated,  or 
comparatively  soft  and  cancellated.  This  is  owing  to  the  bone  texture 
being  more  compact  in  the  one  case  and  more  spongy  in  the  other. 
Externally  they  may  be  covered  with  a layer  of  cartihige  and  a smooth 
membrane. 

Bony  growths  may  more  especially  affect  the  substance  of  bones,  and 
this  in  two  ways.  An  exudation  may  be  poured  into  the  cancelli  of  the 
osseous  texture,  which  is  gradually  transformed  into  perfect  bone.  From 
this  cause  its  substance  becomes  much  indurated  and  of  great  density,  and 
the  cancelli  and  medullary  cavity  are  more  or  less  obliterated.  We  fre- 
quently observe  this  in  the  long  bones  of  the  inferior  extremity  as  well 
as  in  the  flat  bones  of  the  cranium.  Some  of  the  latter  have  thus  be- 
come upwards  of  an  inch  in  thickness,  and  on  section  presented  the  close 
texture  and  density,  although  not  the  structure,  of  ivory.  Sometimes, 
however,  the  bones,  instead  of  being  condensed  and  thickened,  become 
spongy,  the  cancelli  enlarge,  and  the  whole  assumes  unusual  lightness. 
In  this  case,  the  exudation  poured  into  the  cancelli  is  transformed  into 
pus,  and  acts  as  a distending  power,  and  sometimes  collects  in  a central 
cavity,  causing  at  the  same  time  expansion  and  hypertrophy  of  the  sur- 
rounding osseous  tissue  (Figs.  214,  215).  On  other  occasions  the  new 
osseous  growth  assumes  the  form  of  spicula,  radiating  from  the  shaft,  a 
result  most  common  in  cases  where  the  bone  is  the  seat  of  sarcomatous 
or  cancerous  formations,  through  which  they  ramify  (Fig.  274). 


226 


PKINCIl'LES  OF  ,\l  EDICFNE, 


Bony  growths  are  sometimes  thrown  out  on  the  internal  surface  of  the 
cranial  bones.  This  occurs  in  a peculiar  disease  first  described  by  Boki- 

tansky  in  puerperal  women.  I 
saw  this  formation  frequently 
in  Berlin,  on  the  internal  sur- 
face of  the  cranial  bones,  in  the 
numerous  dissections  which  oc- 
curred in  the  Maternity  Hospital 
of  that  city  during  an  ep.dcmic 
puerperal  fever  which  laged 
there  in  1840.  Unfortunately, 
they  were  not  examined  micro- 
scopically. The  internal  table 
of  the  skull  in  all  these,  cases 
ijHi-J  |J.  was  so  soft,  that  the  knife  could 
r penetrate  it.  These  de- 


posits, when  dry,  assume  a gra- 
nular laminated  aspect,  more  or 
less  curled  up  and  separated 
from  the  internal  lamina  of  the 
cranial  bones.  Very  fine  speci- 
mens of  this  lesion  are  to  be 
found  in  the  Pathological  Mu- 
seums of  Prague  and  Vienna. 

There  is  a form  of  growth 
generally  originating  in  bone, 
which  is  soft,  easily  breaking 
down  under  the  finger  like  rice- 
pudding or  marrow  (hence  called 
myeloid  by  Mr.  Paget).  It  has 
P'i„  274.  frequently  been  confounded  wuth 

soft  cancers,  as  pointed  out  by  Lebert,  and  in  addition  to  fibrous 
and  fusiform  cells,  contains  others  of  a round  or  oval  form,  ^ ary- 
ing  in  size  from  the 
the  3i;jth  of  an  inch  in  diame- 
ter, having  in  their  interior 
from  two  to  twenty  nuclei. 

These  growths  occur  in  va- 
rious situations,  but  are 
most  common  in  bones,  es- 
pecially of  the  jaw,  constitut- 
ing certain  forms  of  epulis 
(Figs,  275,  27G.)  The  large 
cells  often  contained  in  the 
friable  matter  of  such  growths  275. 

(Fig.  276,)  closely  correspond  to  the  many-nucleated  corpuscles  described 

Fig.  2T4.  Spiciilar  growth  of  bone,  in  an  osteo-carcinomatous  tumor  of  the  tibia. 
One-Jourfh  (he  natural  size. — (Syme.) 

fig.  275.  Epulis  removed  from  the  upper  jaw.  Natural  size. — {Syme.) 

Fig,  276.  Cells  with  many  nuclei  in  epulis.  250  diam. 


OSSEOUS  GROWTHS. 


227 


by  Kolliker  as  occurring  in  the  marrow  of  foetal  bones.*  A remarkab'e 
example  of  it  is  figured  by  Mr.  Paget,  occurring  in  the  bones  of  tbe 
cranium,  and  in  tbe  brain. f 

Tlie  growth  of  now  bone,  after  fractures  or  injuries,  takes  place  in 
the  folio ,ving  manner  : — An  exudation  is  poured  out  from  the  vessels  in 
the  neigbb  nmood,  which  at  first  unites  the  lacerated  edges  of  ruptured 
periosteain,  muiclc,  and  cellular 
tissue,  so  as  to  form  a capsule 
around  the  whole  of  tlie  denuded 
aid  injured  bone.  Tiiis  exuda- 
tion, at  first  granular,  is  partly 
transformed  into  fibrous  tissue 
and  partly  into  granular  corpus- 
cles, which  may  be  observed  to 
form  an  internal  coating  to  the 
capsule  just  alluded  to.  Tne 
blood  extravasated  is  rapidly  ab- 
sorbed, and  a gelatinous  exuda- 
tion, which  is  poured  out  from 
the  neighboring  capillaries,  col- 
lects between  the  capsule  and 
denuded  bone.  This,  at  first 
yellowish,  becomes  gradually  lac- 
tescent and  white,  and  assumes 
all  the  characters  of  fibro-carti- 
lage.  (Fig.  277, «).  This  carti- 
lage, in  its  turn,  is  transformed  into  bone,  by  exactly  the  same  process 
as  the  one  structure  passes  into  the  other  in  the  normal  state.  As  solidi- 
fication takes  place,  the  soft  parts  are  absorbed  and  contracted,  whilst 
the  bony  growth,  in  the  form  of  spicula,  forming  the  boundaries  of  large 
cancelli  (Fig.  277,  h),  insinuates  itself  between  and  around  the  fractured 
bones,  producing  complete  union. 

Certain  textures  have  been  occasionally  transformed  into  true  bone. 
I examined  the  preparation  of  an  eye  at  Munich,  in  the  possession  of 
Professor  Furg,  which  contained  an  osseous  mass,  attached  internally  to 
the  choroid  and  fibrous  structure  of  the  sclerotic,  and  encroaching  con- 
siderably  on  the  space  usually  occupied  by  the  vitreous  humor.  A 
thin  section  of  it  exhibited  numerous  bony  corpuscles.  A similar  osseous 
transformation  of  the  choroid  membrane  and  lens  has  been  described 


* Manual  of  Human  Histology,  vol.  i.  fig.  7. 

f Surgical  Pathology,  vol.  ii.  p.  222.  The  peculiar  character  and  structure  of 
these  growths  may  ultimately  warrant  their  being  classified  among  the  primary  divi- 
sion of  tumors,  under  the  name  of  Myeloma.  But  at  present  our  acquaintance  with 
them  is  limited ; and  the  many-nucleated  cells,  which  is  their  chief  characteristic,  I 
have  seen  in  growths  presenting  all  the  characters  of  sarcoma,  adenoma,  epithelioma, 
and  enchondroma. 


Fig.  277.  «,  Fibro-cartilage  formed  between  the  separated  portions  of  a fracturefl 
cervix  fem oris  ; b,  new  osseous  structure,  in  the  form  of  a bony  spiculum  or  trabecula 
between  the  large  cancelli,  from  the  same  fracture. — ( Wedl.)  250  diam. 


228 


PRINCIPLES  OF  MEDICINE. 


and  figured  by  Dr.  Kirk,*  in  a diseased  eye  of  thirty  years’  standing 
(Figs.  278,  279,  280).  I have  seen  true  bone  formed  in  the  substance 


Fig.  273.  Fig.  279.  Fig.  280. 

of  the  dura  mater,  where  it  has  been  exposed  after  removal  of  a portion 
of  the  cranium  by  the  trepan.  The  osseous  laminae,  sometimes  found 
on  the  surface  of  tho  spinal  arachnoid,  also  possess  the  true  bony  struc- 
ture (Fig.  281)o  Ligaments  have  occasionally  been  transformed  into 


Fig.  281.  Fig.  282. 


osseous  texture  (Ileule) ; the  calcareous  concretions  occasionally  found  in 
the  centre  of  fibrous  tumors,  though  generally  composed  of  amorphous 


* Monthly  Journal  of  Medical  Science,  November,  1853. 


Fig.  278.  Spieulum  of  bone  projecting  from  the  choroid  membrane. — {Kirk.) 

Fig.  270.  Section  from  tho  centre  of  the  crystalline  lens,  of  stony  hardness  from 
osseous  transformation.  In  the  centre  are  spheroidal  mineral  masses,  composed  of 
carbonate  mixed  with  phosphate  of  lime. — {Kirk.) 

Fig.  280.  Loose  membranous  matter,  like  the  collapsed  pith  inside  a quill,  found 
in  the  anterior  chamber  of  the  same  eye.  On  one  of  its  surfaces  were  projecting 
tubercles  with  a radiated  structure. — {Kirk.) 

Fig.  281.  Ossified  excrescence  on  the  arachnoid  of  the  thoracic  portion  of  the 
spinal  cord  ; at  a portion  is  cut  across. — ( Wedl.) 

Fig.  282.  a.  Bony  laminai  arranged  concentrically  ; 6,  others  arranged  irregularly 
in  partially  ossified  fibrous  tumor  of  the  uterus. — ( Wedl.)  250  diam. 


CANCEROUS  GROAVTHS. 


229 


mineral  matter,  are  sometimes  formed  of  true  bone  (Figs.  282,  h) ; and 
Dr.  Wilkinson  of  Manchester  communicated  to  the  Pathological  Society 
of  that  city  an  instance  where  numerous  muscles  of  the  body  had  un- 
dergone a like  transformation.  In  all  these  cases  the  osseous  structure 
is  formed  on  a hbrous  and  not  on  a cartilaginous  basis,  an  occurrence 
which  may  be  accounted  for  by  the  analogy  which  exists  between  carti- 
lage and  certain  forms  of  fibre  cells.  Many  kinds  of  morbid  fibrous 
growth  contain  cells  and  nuclei,  which  present  all  degrees  of  interme- 
diate formation  observable  in  those  of  fibrous,  cartilaginous,  and  osseous 
textures.'^  (Compare  Figs.  187,  277,  a,  281,  282). 

Of  earthy  depositions  which  to  the  naked  eye  frequently  resemble 
them,  whether  a, morphous  or  assuming  a regular  form  from  accidental 
circumstances,  I shall  speak  more  at  length  under  the  head  of  Concre- 
tions. 


Cancerous  Growths — Carcinoma. 

Cancerous  growths  present  three  principal  forms,  which  result  from 
the  relative  amount  and  arrangement  of  the  cells  and  fibres  forming 
t'lem.  1,  A very  hard  structure,  principally  formed  of  fibres  (scirrhus). 
2,  A soft  structure  containing  a copious  milky  fluid,  in  which  numerous 
corpuscles  swim  {encephaloma) . 3,  A structure  having  a fibrous  basis, 

so  arranged  as  to  form  areolae  or  loculi,  which  contain  a gelatinous  gum 
or  glue-like  matter  [coVoid  cancer). 


1.  Scirrhus  presents  to  the  naked  eye  a whitish  or  slightly  yellowish 
tinge,  is  dense  and  hard  to  the  feel,  and  offers  considerable  resistance 


* See  Memoir  on  Calcification  and  Ossification  of  the  Testicle,  by  Mr.  J.  S.  Gam- 
gee,  in  Researches  on  Pathological  Anatomy,  etc.,  8vo.  18.56. 

Fig.  283.  Section  showing  the  arrangement  of  cells  and  fibres  in  scirrhus  of  the 
mamma. 

Fig.  284.  The  same,  after  the  addition  of  acetic  acid. 

Fig.  285.  Isolated  cancer-cells,  from  the  same  growth. 

Fig.  286.  The  same,  after  the  addition  of  acetic  acid. 


250  diam. 


230 


PKINCIPLES  OF  MEDICINE. 


to,  aud  often  crunches  under,  the  knife.  On  making  a thin  section  of 
the  growth,  it  is  seen  to  be  composed  principally  of  filaments,  which 
vary  in  size,  and  run  in  different  directions,  sometimes  forming  waved 
bands,  at  others  an  inextricable  plexus,  among  which,  however,  nucleated 
cells  (cancer  cells)  may  be  seen  to  be  infiltrated.  Occasionally  the 
fibrous  structure  forms  loculi  or  cysts,  enclosing  similar  cells. 

The  so-called  cancer-cells  may  be  round,  oval,  caudate,  spindle  shaped, 
oblong,  square,  heart-shaped,  or  of  various  indescribable  forms,  produced 
by  pressure  on  their  sides.  In  size  they  vary  from  the  yVo  oth  to  the 
y^^th  of  an  inch  in  diameter.  The  cell-wall,  when  young,  is  smooth  and 
distended  ; when  old,  it  is  more  or  less  corrugated  and  flaccid.  Each  cell 
contains  at  least  one  nucleus,  often  two,  and  sometimes  as  many  as  nine. 
Most  commonly  there  is  only  one,  which  is  round,  or  more  generally  oval, 
and  contains  one  or  two  granules  or  nucleoli.  The  nucleus  also  varies  in 
size,  and  may  occupy  from  one-sixth  to  four-fifths  of  the  volume  of  the 


Fig.  287.  Fig.  288.  Fig.  289.  Fig.  290. 

cell.  Between  the  nucleus  and  cell-wall  there  is  a colorless  fluid,  which, 
at  first  transparent,  becomes  afterwards  opalescent,  from  the  presence  of 
molecules  and  granules.  On  the  addition  of  water  the  cell-w^all  becomes 
distended  by  endosmose,  and  is  enlarged.  When  acetic  acid  is  added,  the 
cell-wall  is  rendered  more  transparent,  and  in  young  cells  is  entirely  dis- 
solved (Fig.  288),  whilst  the  nucleus,  on  the  other  hand,  either  remains 
unaffected,  or  its  margin  becomes  thicker,  and  its  substance  more  or  less 
contracted. 

2.  Encephaloma  also  presents  a fibrous  texture,  wdiich,  however,  is 
very  loose  when  compared  with  that  of  scirrhus.  In  the  denser  parts  of 
the  growth,  indeed,  it  closely  resembles  the  scirrhus  form  of  cancer,  but 
often  where  it  is  pulpy  and  broken  down,  no  traces  of  fibres,  or  at  most 
only  some  fragments  of  them,  are  visible  to  the  naked  eye. 

The  whitish  cut  surface  is  often  more  or  less  mottled  with  a pinkish, 
reddish,  greyish,  yellowish,  or  black  color.  The  two  first  colors  are 
owing  to  different  degrees  of  vascularity.  The  reddish  spots  are  owing 
to  extravasations  of  blood,  and  are  of  greater  or  less  extent;  when  very 
large  they  constitute  what  has  been  called  fungus  hcematodes.  The  yel- 
lowish color,  when  it  surrounds  extravasations  of  blood,  is  owing  to 
imbibition  of  its  coloring  matter ; but  when  the  color  is  spread  in  a 
reticulated  form  over  the  surface,  or  over  masses,  it  generally  results 
from  fatty  degeneration  of  the  cancerous  tissue,  and  forms  the  so-called 
Tei\Q\x\\xm  {cancer  retmdare  of  Midler).  This  yellow  matter  is  usually 

Fig.  287.  Young  cancer-cells  from  the  lung. 

Fig.  288.  Tlie  snme,  after  the  addition  of  acetic  acid. 

Fig.  289.  Somcwha"  older  cells  from  the  testicle. 

Fig.  290.  The  sr.nie  after  the  addition  of  acetic  acid. 


250  <kam. 


CANCEKOUS  GiiOWTliJ. 


231 


of  clieese-like  consistence,  friable,  and  often  resembles  tubercle,  for  which 
it  has  been  mistaken.  The  blackish  tinge  is  owing  to  black  pigment 


%/-r 


iWiWK 


Fig.  291.  Fig.  292  Fig.  293 

infiltrated  among  the  cancerous  elements,  or  existing  within  the  cells, 
and  constitutes  the  malignant  melanosis,  or  melanic  cancer  of  authors. 
(See  Fatty  and  Pigmentary  Degenerations.) 

A small  portion  of  the 
cream-like  fluid  obtained  from 
cancer-masses,  when  examined 
with  a microscope,  presents  a 
large  number  of  the  cancer 
cells  formerly  described ; in 
some  specimens  of  encepha- 
loma  these  cells  reach  a higher 
degree  of  development  than 
in  other  forms  of  cancerous 
.ficrowth  (Figs.  293,  294). 

They  are  mingled  with  a 
large  number  of  molecules 
and  granules,  granular  cells, 
blood  corpuscles,  and  more  or 
less  of  the  fibrous  element. 

The  fibrous  structure  is  the 
same  as  that  in  scirrhus,  but  the  filaments  are  often  finer,  and  always  more 
widely  separated,  while  the  pulpy  matter  and  cells  contained  in  the  inter- 
stices, are  corre.spondingly  increased.  The  yellow  reticulum  is  sometimes 
composed  of  loose  granules  and  granular  cells,  at  others  of  granules  alone. 
Not  unfrequently  it  contains  nuclei,  disintegrated  and  altered  in  shape, 
with  crystals  of  margarine  or  of  cholesterine.  In  some  instances  the  en- 
cephaloma  is  more  or  less  impregnated  with  irregular  masses  of  mineral 
matter,  and  occasionally  is  almost  entirely  converted  into  a calcareous 
substance.  In  this  way  cancer  is  liable  to  undergo  the  fatty  and  cal- 
careous degenerations,  (See  Fatty  and  Mineral  Degenerations.) 


Fig.  294. 


Fig.  291.  Sill  older  cancer-cells  from  a tumor  in  the  duodenum. 

292.  The  same,  after  the  addition  of  acetic  acid. 

Fig.  293.  Highest  development  of  cancer-cells,  including  secondary  cells,  from  a 
tumor  of  the  toe. 

Fig.  294.  Simple  and  compound  cancer-cells  from  the  duodenum.  Several  con- 
tain fluid  from  endosmose,  which  strongly  refracts  light.  250  diam. 


PEINCIPLES  OF  MEDICIXE. 


232 


3.  Colloid  cancer  consists  of  a fibrous  structure  so  arranged  as  to 
form  areolas  or  loculi,  which  are  filled  with  a grey  or  amber-colored  glu- 
tinous matter,  sometimes  trans- 
parent, at  others  opalescent  or 
semi-opaque.  This  matter  is  oc- 
casionally found  quite  structure- 
less, or  exhibits  only  a finely  mo- 
lecular appearance  (Fig.  295) ; 
and  in  conse(|uence  the  terra  col- 
loid tissue  has  been  applied  to  it. 
At  other  times  numerous  nucle- 
ated cells,  pre  enting  all  the  cha- 
racters of  cancer-cells  in  various 
stages  of  development,  are  found  in 
it  as  a blastema  ; and  we  observe 
that  the  growth  has  a tendency  to 
spread.  In  this  colloid  cancer, 
Fisr.  295.  when  it  is  formed  on  a free  sur- 

ace,  as  on  the  peritoneum,  there  are  often  present  small  grains  of  a grey 
color,  resembling  coagulated  gum-arabic.  When  collected  in  masses, 


Fig.  298. 


Fig.  296.  Fig.  299.  Fig  297. 

these  grains  have  an  irregularly  nodulated  aspect.  I have  never  seen 
the  fibrous  structure  of  colloid  contain  permanent  nuclei,  or  aft'ord  any 
evidence  of  being  developed  from  nuclei  or  cells. 

All  the  three  forms  of  cancer  now  described  are  vascular,  but  in 
difierent  degrees.  Scirrhus  is  least  so,  but  is  still  rich  in  blood-vessels. 


Fig.  295.  Colloid  tissue,  with  the  loculi  filled  with  molecular  matter,  in  which  cells 
vre  commencing  to  form.  On  the  left  of  the  figure,  one  of  the  molecular  masses  has 
()een  scpieezed  from  the  fibrous  matrix.  Below  are  masses  of  mineral  matter. 

Fig.  296.  Colloid  cancer.  Appearance  of  the  fibrous  areolae  filled  with  cancer-cells. 
Fig.  297.  The  same,  after  the  addition  of  acetic  acid. 

Fig.  298.  Some  of  the  cells  isolated. 

Fig.  299.  Fibrous  stroma  deprived  of  the  cells  by  pressure  and  washing.  260  diam» 


GENERAL  PATHOLOGY  OF  MORBID  GROWTHS. 


233 


Encephaloma  is  always  very  vascular,  and  often  to  such  a degree,  that 
it  readily  bleeds  during  life  [fungus  licematodes).  Colloid  cancer  is 
also  well  supplied  with  vessels,  which  ramify  among  the  fibrous  tissue. 
I have  already  stated  that  these  forms  pass  into  each  other,  and  need 
only  remark  here,  that  this  is  often  so  gradual  in  many  specimens,  as  to 
render  their  classification  very  difficult.  This  is  especially  the  case  with 
scirrhus  and  encephaloma. 

General  Pathology  oe  Morbid  Growths. 

The  general  pathology  of  morbid  growths  comnrehends  a considera- 
tion of  their  origin,  development,  propagation,  and  decline.  It  is  impos- 
sible to  over-estimate  the  importance  of  this  subject,  as  only  through  a 
knowledge  of  it  can  we  arunve  at  correct  principles  of  treatment.  Doubt- 
less many  facts  are  yet  t)  be  discovered  as  to  the  structure,  chemical 
composition,  and  mode  of  formation  of  morbid  growths ; but  enough 
has  been  ascertained  of  late  years  by  combined  histolog'cal  and  clinical 
research,  to  necessitate  great  modificat'.ons  in  the  views  hit'ierto  held 
regarding  them.  The  following  account  is  derived  not  only  from  care- 
ful study  of  what  has  been  written  by  others,  but  from  a large  amount 
of  original  investigation. 

Origin  of  Ilorlid  Growths. — All  morbid  grov/ths  consist — 1st,  Of 
augmented  clevelopiiienb  of  pre-existing  textures  (the  so-called  homolo- 
gous or  homeomorphous  growths) ; 2d,  Of  new  elements  which  have  no 
pr^evious  existence  in  the  economy  (tlm  so-called  heterologous  or  hetero- 
morphous  growths) ; and  3d,  Of  these  two  sorts  of  growth  mingled 
together.  The  causes  which  induce  them  are  of  two  kinds — -1st,  Local 
irritation  excited  directly  or  indirectly ; and  2d,  Constitutional  or  un- 
known changes,  supposed  to  operate  through  the  blood.  Thus  the 
direct  stimulus  of  a blow  may  so  irritate  the  parenchyma  of  a part,  as 
to  excite  increased  nutritive  action,  and  cause  hypertrophy,  or  it  may 
give  rise  to  an  exudation;  and  irritation  at  a distance  may,  through 
the  nervous  system,  produce  like  elfects,  as  when  the  female  mamma 
is  influenced  by  the  state  of  the  uterus.  If,  on  the  other  hand,  the 
constitution  be  affected,  such  local  changes  may  assume  peculia,r  cha- 
racters. In  this  manner,  age,  sex,  hereditary  predisposition  and  various 
disorders,  as  syphilis  and  cancer,  not  only  modify  but  give  rise  to  mor- 
bid growths. 

It  has  been  a favorite  idea  with  pathologists  that  morbid  growths 
have  fixed  tendencies  from  the  beginning,  such  as  are  impressed  upon 
the  ova  of  various  animals,  in  virtue  of  which  they  are  necessarily  de- 
veloped in  certain  directions.  If  so,  this  is  not  traceable  to  any  pecu- 
liarity of  structure  or  chemical  composition.  In  this  respect  morbid 
growths  are  like  healthy  ones,  which,  however  different  in  ultimate  com- 
position, all  originate  in  a finely  molecular  blastema.  A commencing 
small  white  nodule  of  cancer  in  the  stomach,  about  the  size  of  a split 
pea,  was  ascertained  by  me  to  present  exactly  the  same  kind  of  molecular 
matter,  exuded  in  the  areolar  tissue  between  the  muscular  and  mucous 
coats,  as  occurs  in  simple  exudation.  A careful  observation  of  the  sub- 


234 


PKIJSCIPLES  OP  IIEDICIXE. 


Fig.  300, 


sequent  development  of  these  growths,  however,  seems  to  indicate  that 
specific  differences  are  not  impressed  upon  them  from  the  first — that  one 

does  not  as  a matter  of 


as  a 

course  exclude  the  other, 
but  that  any  of  the  clace- 
es,  into  which  they  have 
been  divided,  may  super- 
vene upon  pre-existing 
ones.  For  instance,  persons  may  have  a fibrous  or  glandular  growth, 
and  after  a time  its  blood-vessels  may  pour  into  it  a cancerous  exudar 
tion,  or  this  latter  may  undergo  a fibrous  or  fatty  transformation.  It 
is  only  in  this  manner  we  can  explain  numerous  cases,  which  arc  daily 
observable  in  practice,  where  indolent  fibrous  tumors  suddenly  assume 
increased  power  of  development  and  become  cancers,  or  where  these  last 
slough  out  and  subsequently  cicatrize. 

Besides  these  constitutional  causes,  locality  and  the  nature  of  pre- 
existing textures  have  a considerable  influence  on  the  formation  of  mor- 
bid growths.  Thus,  as  a general  rule,  fibrous  growths  are  common  in 
fibrous  textures,  cartilaginous  and  bony  growths  in  osseous  ones, 
epithelial  growths  on  epidermic  and  mucous  membranes,  and  so  on. 
Yet,  even  here,  the  particular  states  of  the  system  generally  occasion 
differences  in  their  modes  of  manifestation.  For  example,  osseous 
growths  in  rheumatic  constitutions  occur  at  the  extremities  of  long  bones, 
but  in  syphilitic  ones  are  found  in  their  shafts.  In  youth,  epithelioma 
occurs  in  the  form  of  warts  on  the  hands ; in  persons  touched  with 
syphilis,  in  the  genitals;  in  chimney-sweeps,  on  the  scrotum;  in 
smokers,  on  the  lips,  etc.  This  conjoined  influence  of  constitutional 
and  local  influences  indicates  the  complex  nature  of  the  causes  which 
produce  morbid  growths.  A study  of  these  causes  is  of  the  greatest 
moment  to  the  physician,  who  is  desirous  of  operating  upon  the  local 
disease  through  the  constitution,  or  the  contrary — as  previously  explain- 
ed in  the  sketch  of  the  function  of  nutrition. 


Deve'.o'pment  of  Morbid  Growths. — Morbid  growths,  once  formed, 
continue  to  grow  according  to  the  histological  laws  which  regulate  de- 
velopment in  the  textures  generally — that  is  to  say,  after  arriving  at  a 
certain  point,  they  attract  from  the  blood-vessels  in  the  neighborhood, 
or  from  such  new  ones  as  are  formed  within  themselves,  the  nutritive 
materials  whereby  they  augment  in  bulk.  In  voluntary  muscular  fibre 
this  appears  to  be  accomplished  by  the  fasciculi  multiplying  fissiparously. 
They  divide  as  represented  (Fig.  163),  and  hypertrophy  is  thus  occa- 
sioned by  multiplication  of  parts.  In  non-voluntary  contractile  fibre, 
also,  the  individual  fusiform  cells  multiply,  enlarge,  and  elongate,  a 
change  well  observed  in  the  pregnant  uterus,  in  which  organ  many  of 
the  small  non-contractile  spindle-shaped  fibres  enlarge,  become  con- 
tractile, and  then  undergo  the  fatty  degeneration,  break  down,  and 
ultimately  disappear  (Figs.  165  and  330).  In  the  same  manner  the 

Fig.  300.  Section  of  small  commencing  cancerous  nodule,  growing  from  the  mu- 
cous coat  of  the  stomach,  showing  molecular  exudation  between  the  epithelial  and 
muscular  coats,  a,  Epithelium  ; muscular  coat.  No  glands  were  visible.  260  di. 


DEVELOPMENT  OF  MORBID  GROWTHS. 


235 


elementary  parts  in  hypertrophies  of  other  textures,  augment  fissiparously 
or  endogenously  as  in  bone  and  cartilage.  That  this  may  be  the  result 
of  local  irritation  is  remarkably  well  shown  by  the  observation  of  Red- 
fern,  who,  having  made  an  incision  into  the  cartilage  of  the  patella  of  a 
dog,  found,  on  subsequent  examination,  that  the  cells  had  enlarged  in 
the  neighborhood  of  the  divided  tissue  nearest  the  osseous  vessels,  as 
seen  Fig.  136. 

Other  forms  of  morbid  growth,  especially  tumors,  are  very  variable 
as  to  rapidity  of  increase  ; but  the  manner  in  which  the  development  is 
accomplished  is  of  three  distinct  kinds.  1st,  The  elementary  textures 
are  produced  in  the  same  manner  as  they  are  in  adult  tissues.  They 
are  either  more  numerous  or  larger,  but  preserve  their  normal  relation 
and  mode  of  arrangement  (lipoma,  adenoma,  anigonoma).  2d,  A matter 
is  thrown  out  from  the  blood,  which  serves  as  a blastema  for  the  forma- 
tion of  cells,  which  may  be  detected  in  various  stages  of  development, 
undergoing  the  same  changes  that  similar  textures  are  seen  to  present  in 
the  embryo  (fibroma,  osteoma).  3d,  The  cells,  whether  pre-existing  or 
newly  formed,  assume  such  a property  of  self-multiplication  that  their 
normal  relation  and  mode  of  arrangement  is  destroyed  (epithelioma, 
enchondroma,  carcinoma).  These  three  modes  of  increase  may  occur 
singly  or  together.  Any  one  or  two  of  them  may  be  superadded  to  the 
third,  and  their  occurrence  at  different  times  and  in  various  proportions 


accounts  to  a great  extent  for  the  apparent  anomalies  exhibited  in  the 
progress  of  individual  growths. 

The  third  mode  of  development  just  alluded  to  deserves  special  con- 
sideration. It  consists  of  the  usual  kind  of  endogenous  multiplication  of 
cells,  with  this  difference,  that  sometimes  these  cells  previously  existed, 
whilst  at  others  they  have  been  newly  formed  in  an  exudation.  To 
explain  my  meaning,  I must  beg  the  reader  to  consult  two  figures — one  by 
Kolliker  (Fig.  301),  representing  cell  structures  in  the  softened  articular 

Fig.  301.  Cartilage  cells  from  a velvety  articular  cartilage  of  the  condyle  of  the 
femur  of  a man. — {Kolliker.)  350  diam. 


236 


PRINCIPLES  OP  MEDICINE. 


cartilage  of  man,  ami  tlie  other  by  Redfern  (Fig  302),  showing  similar 

formations  in  a cancerous  exudation  into  the  brain.  In  both  a similar 

^ /S'5>  mode  of  cell  development 




will  be  perceived,  yet  the 
one  takes  its  origin  in  pre- 
existing articular  cartilage 
cells,  whilst  the  other  must 
arise  in  the  new  cells  of  an 
exudation,  as  the  wliite  sub- 
stance of  the  brain  contains 
no  corpuscles  from  which 
thej'’  could  be  developed. 
In  tlie  cornea  and  epithe- 
lium similar  changes  occur, 
as  well  as  in  the  bones  and 
mesenteric  glands.  Yet 
these  lesions,  so  closely 
allied  in  their  essential 
nature,  have  in  tliese  dif- 
ferent textures  been  called 
bv  different  names,  and 


Fig.  302. 

have  been  widely  separated  pathologically.  In  the  non-vascular  cor- 
nea and  cartilage,  it  has  been  called  inflammation,  but  in  the  equally 
non-vascular  epithelium,  it  has  been  named  cancer.  Again,  in  the  vas- 
cular bones  and  glands,  a cancerous  exudation  has  received  various 
names,  such  as  medullary  or  osteo-sarcoma,  enlarged  glands,  etc. ; whilst 
in  the  brain  and  other  localities  it  has  been  called  encephaloma,  or  soft 
'cincer.  It  seems  to  me  that  in  all  these  cases  the  lesion  is  the  same, 
:.r,d  therefore  that  we  ought  in  accordance  with  their  nature  to  group 
them  together.  To  call  some  of  them  inflammation  and  others  cancer, 
supposing  the  first  to  be  innocent  and  the  last  malignant,  is,  I contend, 
incorrect  pathology.  True  theory  points  out  that  all  these  lesions  are 
equally  destructive,  in  consequence  of  increased  endogenous  cell  growth, 
and  practical  experience  has  long  determined  the  question  of  their  being 
alike  difficult  to  control. 

As  a general  rule,  the  greater  the  number  of  cells  any  growth  con- 
tains, the  more  rapidly  it  extends.  Hence  a tumor  is  subject  to  the 
laws  which  govern  the  development  and  multiplication  of  cells,  in  addi- 
tion to  those  connected  with  locality  and  the  general  powers  of  the  con- 
stitution. Thus,  room  for  expansion,  and  a greater  or  less  amount  of 
temperature  and  moisture,  exercise  undoubted  influence  over  morbid 
growths.  We  see  the  influence  of  room  for  expansion  in  the  cases  of 
adenoma  and  carcinoma.  In  adenoma  the  cells  are  confined  within 
l^ouches  or  ducts  (Figs.  21-^,  219).  They  become  crowded  on  each  other ; 
and  thus,  by  means  of  compression,  tend  to  atrophy  and  breaking  dowm, 
rather  than  to  self-multiplication.  This  is  assisted  if  the  distension  from 
v;ithin  so  irritates  the  fibrous  stroma  of  the  gland  that  it  becomes  hyper- 
trophied, and  occasions  a further  obstacle  to  expansion  around  the  seat 
of  cell  increase.  In  carcinoma,  we  observe  that  the  growth  takes  place 


Fig.  302.  Cells  from  a cancerous  tumor  of  the  brain. — {Redfern.)  260  diam. 


PROPAGATION  OF  MORBID  GROWTHS. 


237 


in  extent  and  rapidity,  proportionally  to  the  number  and  power  of  ex- 
pansion in  the  cells.  If  compressed  by  much  fibrous  or  hard  tissue  they 
multiply  slowly  ; but  if  an  ulceration  occurs,  say  in  the  skin,  then  they 
become  developed  rapidly,  and  constitute  the  so-called  soft  fungoid  ex- 
crescences. Heat  and  moisture,  as  they  are  essential  to  cell  growth 
throughout  the  animal  and  vegetable  worlds  (increased  temperature  with 
fluidity  favoring — cold  and  dryness,  checking  it  within  certain  limits), 
so  the  influence  of  these  physical  agents  may  be  observed  to  be  equally 
powerful  in  morbid  growths.  Kapid  augmentation  of  a tumor  is  gene- 
rally accompanied  by  increased  heat  and  softening  of  the  parts,  whilst 
colder  and  harder  swellings  develop  themselves  slowly. 

Propagaf.i'm  of  Morbid  Growilis. — It  has  seemed  to  most  patholo- 
gists that  whilst  some  morbid  growths  are  local,  and  if  removed  by  the 
surgeon  do  not  return,  others  are  constitutional  or  general,  and  if  cut 
away  exliibit  a great  tendency  to  come  back.  The  former  have  been 
called  innocent  or  benignant,  and  the  latter  malignant.  So  far  has  the 
notion  of  malignancy  in  certain  growths  been  carried,  that  surgeons  have 
refused  to  remove  them,  not  because  they  were  inaccessible,  or  so  con- 
nected with  parts  as  to  render  the  operation  directly  dangerous  to  life, 
but  simply  because  they  thought  the  disease  was  in  the  blood,  and  that 
cutting  away  the  local  swelling  would  either  be  useless,  or  give  increased 
activit}'^  to  the  lesion. 

Firmly  believing  that  many  lives  have  been  sacrificed  to  this  erro- 
neous principle  of  practice,  I endeavored  to  combat  it  in  my  work  on 
cancerous  and  cancroid  growths,  published  in  1849.  The  progress  of 
medical  science  since  then  has  fully  confirmed  the  truth  of  my  opinions 
on  that  subject.  Cases  are  now  on  record  which  prove  that  every  kind- 
of  morbid  growth  is  malignant,  even  in  the  worst  sense  of  those  who  uso 
that  term,  and  that  other  growths,  which  the  most  experienced  surgeons, 
as  well  as  histologists,  have  declared  to  present  the  typical  characters  of 
malignancy,  have  been  repeatedly  excised  with  the  greatest  success. 
The  establishment  of  these  facts  by  the  many  recorded  cases  which  may 
now  b'e  confidently  depended  on  as  having  been  carefully  observed,  and 
especially  those  of  M.  Velpeau,  prove  tke  impropriety  of  making  this 
distinction  between  morbid  growths. 

Thus  Fibroma^  consisting  of  absolutely  nothing  but  fibres,  in  all  its 
forms  has  frequently  returned  after  operation,  so  that  it  has  received  the 
name  of  recurrent  (Syme,  Paget),  and  it  has  also  invaded  every  part  of 
the  economy.  The  dermoid  variety  has  been  shown  by  M.  Paget,  not 
only  to  return  in  the  mamma  after  excision,  but  to  infiltrate  itself  in  the 
form  of  numerous  distinct  nodules  throughout  the  lung.*  A somewhat 
similar  case  is  given  by  Lawrence,!  in  an  old  man,  and  another  in  a girl 
aged  six  years.  Lebertj;  has  recorded  seven  cases  where  sarcoma  had 
spread  to  the  neighboring  glands  of  the  original  growth,  and  to  various 
internal  organs.  Professor  Smith  of  Dublin,^  in  a magnificently  illustrated 
memoir,  has  published  two  cases  in  which  neuroma  occurred  in  all  parts 

* Surgical  Pathology,  vol.  ii.  p.  151,  et  seq.  f On  Surgical  Cancer,  p.  73,  1st 
edit. ; p.  26,  2d  edit.  \ Traite  d’ Anatomie  Pathologique,  p.  195,  et  seq.  § A Treatise 
on  Neuroma,  Folio,  Dublin,  1849. 


238 


PRINCIPLES  OF  MEDICINE. 


of  the  body,  and  Virchow  has  given  a case  where  neuroma  returned  in 
the  arm  four  times,  and  was  four  times  excised.^  Lipoma  may  be  general 
in  the  form  of  excessive  obesity,  but  even  when  local  may  return  after 
extirpation.!  Murchison  has  given  three  cases  where  multiple  fatty 
tumors  were  hereditary. J Angionoma  may  be  so  constitutional,  that 
cases  have  been  published  in  which  aneurisms  were  present  in  almost 
every  artery  in  the  body.g  Nsevoid  tumors,  returning  after  operation 
in  different  parts  of  the  body,  have  been  described  by  Muller  and 
Walther;||  and  two  others,  in  which  similar  vascular  growths  were  dis- 
seminated among  various  textures,  are  given  by  Cruveilhier^  and 
Laurence.* **  As  regards  cystoma^  I have  frequently  been  struck  in 
opening  dead  bodies  with  the  frequency  and  universality  of  cystic  forma- 
tions in  some  of  them.  In  one  man  I found  innumerable  sebaceous 
cysts  scattered  over  the  whole  anterior  surface  of  the  thorax  ai  d abdo- 
men. The  constitutional  nature  of  cystoma^  moreover,  is  occasionally 
demonstrated  in  cases  of  bronchocelc  and  mollusca.  Adenoma  is  emi- 
nently constitutional,  the  glands  being  differently  affected  in  a variety 
of  general  disorders,  as  plague,  syphilis,  scrofula,  typhoid  fever,  etc. 
Velpeau  refers  to  several  cases  where  it  recurred  after  operation  in  the 
same  or  opposite  breast,!!  and  Aitken  has  recorded  two  well  observed 
instances  where,  subsequent  to  the  growth  having  recurred  in  the 
mamma,  it  appeared  in  the  lungs,  liver,  and  ovaries.JJ  Ep}theJioma 
not  only  spreads  to  the  neighboring  glands,  but  has  also  been  shown 
by  Mr.  Paget  to  infiltrate  the  lungs  and  heart,  after  operations  for  the 
removal  of  similar  growths  in  distant  organs. §§  Enchondi  oma  has  in- 
vaded numerous  parts,  and  among  others  in  the  same  case,  the  testicles 
and  lungs. II II  Osteoma^  composed  of  true  bone  (not  cancer  in  bone),  has, 
in  a case  by  Mr,  Swan,  after  affecting  the  femur,  appeared  secondarily  in 
the  pleura,  lungs,  omentum,  and  diaphragm. A similar  case  is  given 
by  Laurence.***  Muller!!!  has  also  referred  to  such  constitutional 
osseous  tumors  under  the  name  of  Osteoids.  Of  the  constit-utional 
characters  of  carcinoma^  I need  say  nothing. 

It  follows  that  every  kind  of  morbid  growth  may  be  malignant  in 
whatever  sense  that  term  be  employed,  whether  used  to  signify  a growth 
incurable,  recurring  after  the  operation  or  primary  lesion  ; or  growths 
infiltrating  neighboring  or  distant  tissues  or  organs,  or  as  continuing 
their  progress,  and  destroying  life  in  spite  of  all  the  resources  of  art. 

On  the  other  hand,  it  is  easy  to  prove  that  all  these  forms  of  growth 
may  either  disappear  spontaneously,  or  be  cured  successfully  by  opera- 
tion, so  that  the  individual  may  permanently  recover.  With  regard  to 

* Archiv  fiir  Patholog.  Anat.,  Band.  xii.  p.  114,  f Sedillot,  Recherches  sur  le 
Cancer,  1849,  obs.  xxix.  \ Edinburgh  Medical  Journal,  June  1857.  § Cruveilhier. 

Livraison,  28.  Scarpa.  Tab.  ix.  | Journal  der  Chir.  u.  Augenheilk,  B.  v.  p,  261, 
1828.  ^ Anatom.  Pathologique  Gen.,  tom.  iii.,  1856.  **  On  Surgical  Cancer,  p. 

22,  2d  edit,  ff  Maladies  du  Sein,  p.  404,  et  seq.,  1st  edit.  Xt  Medical  Times,  April 
11,  1857,  p.  359.  §§  Opus.  Cit.,  vol.  ii.  pp.  448,449,  ||  ||  Paget  in  Medico-Chir. 

Trans.,  vol,  xxxviii.  Eichte,  tJeber  das  Enchondrom,  p.  58.  Laurence,  2d  edit,  p 28. 
Richet.  Gazette  des  Hospitaux,  Nos.  71  and  95,  1855.  Lond.  Pathological 

Trans.-  vol.  vi.  p.  817.  ***  On  Surgical  Cancer,  2d  edit  , p.  18.  fff  Archiv.  fiir 

Anotomie  und  Physiologie,  1853,  t.  v.  pp.  396,  442. 


PROPAGATION  OF  MORBID  GROWTHS. 


239 


carcinoma  this  has  been  denied  by  some  and  is  doubted  by  many.  On 
this  subject  I wrote  in  1849  as  follows,  regarding  the  permanent  re- 
covery from  cancer  * “ Doubts  must  always  exist,  regarding  such  cases, 
as  long  as  no  authentic  record  is  preserved  of  the  minute  examination 
of  the  tumor  removed.  Every  experienced  surgeon  who  adopts  a favor- 
able or  unfavorable  view  of  this  question  can  point  to  crowds  of  cases 
in  support  of  his  opinion ; but  when  he  is  asked  whether  the  growth 
operated  upon  be  truly  cancer  or  not,  it  will  be  found  that  he  has  no 
positive  grounds  on  which  to  form  a conclusion.  He  considered  it  to  be 
cancer,  nothing  more.  In  the  present  state  of  our  knowledge,  then,  I 
believe  that  there  is  no  possibility  of  pronouncing  accurately  whether  an 
operation  will  be  successful  or  not.  It  appears  to  me  that  all  analogy 
opposes  the  doctrine  of  the  necessarily  fatal  nature  of  cancer,  or  of  any 
other  morbid  alteration  of  the  economy.  There  was  a time  wlien  phthisis 
pulmonalis  was  also  thought  to  be  necessarily  fatal,  and  when  recoveries 
from  it  led  practitioners  to  doubt  their  diagnosis  rather  than  the  truth  of 
a received  dogma.  Morbid  anatomy  has  exploded  that  error,  as  it  will 
doubtless  do  that  in  regard  to  cancer.”  * 

Since  then,  M.  Velpeau,  in  a work  published  in  1854,  has  proved  the 
correctness  of  these  statements,  and  has  shown  that  cases  which  not 
only  presented  all  the  characters  of  scirrhoma  and  encephaloma,  but 
which  were  proved  to  be  so  by  careful  histological  examination,  have 
been  successfully  extirpated  without  returning.  Some  of  these  cases  are 
truly  remarkable,  the  disease  having  advanced  apparently  to  its  last  stage 
and  involved  large  masses  of  neighboring  glands,  so  that  the  operation 
was  performed  under  the  most  unfavorable  circumstances.  In  these 
cases,  however,  the  persons  operated  on  have  lived  since  the  local  extir- 
pation of  the  disease  up  to  this  time,  that  is,  from  nine  to  twenty  years, 
in  perfect  health.f 

While  thus  it  is  contended  that  there  is  no  growth  which  may  not 
be  malignant,  and  none  which  may  not  be  innocent  in  the  sense  inferred, 
it  is  not  denied  that  some  growths  have  a greater  tendency  to  spread 
and  affect  the  system  than  other.s.  In  reference  to  treatment,  therefore, 
it  becomes  of  the  greatest  importance  to  determine  the  laws  which  ap- 
parently govern  the  propagation  and  multiplication  of  different  morbid 
growths,  or  the  circumstances  which  render — say  carcinoma  and  epithe- 
lioma— more  susceptible  of  being  communicated  to  neighboring  and 
internal  organs,  than  purely  fibrous  or  osseous  growths. 

There  is  o le  circum  stance  in  reference  l O the  removal  of  tumors 
which  is  frequently  overlooked  by  surgeons,  viz.,  that  certain  growths, 
abounding  in  cells,  have  a great  disposition  to  infiltrate  themselves  among 
muscles  and  neighboring  parts,  and  may  be  detected  there  by  the  micro- 
scope, although  invisible  to  the  naked  eye.  In  one  case  I found  numerous 
granules  and  commencing  cells  in  the  muscles  of  the  tongue  below  an 
epithelial  ulcer,  though  it  seemed  healthy  (Fig.  232) ; and  in  the  sterno- 
mastoid  muscle,  covering  a tumor  of  the  parotid  gland,  clumps  of  nuclei 

* Cancerous  and  Cancroid  Growths,  p.  233. 

f Velpeau,  Traite  des  Maladies  du  Sein,  etc.,  1854;  and  2d  edition,  1858,  in  the 
preface  to  which  are  enumerated,  p.  xxx,  no  less  than  23  cases  which  up  to  the  close 
of  that  year  remained  well.  See  also  note  at  the  conclusion  of  this  article. 


240 


PRINCIPLES  OF  MEDICINE. 


were  developed,  and  the  fasciculi  of  the  muscle  were  converted  into  fibres 

(Fig.  303).  In 
this  case  the 
muscle  looked 


pearance  of  be- 
ing infiltrated 
with  cancer. 

It  follows 

Fig  303.  that  in  many 

cases  where  the  surgeon  thinks  he  has  removed  a morbid  growth,  he  really 
leaves  multitudes  of  germs  behind  wdiich  continue  to  propagate  the  disease. 
Dr.  Handyside  removed  the  inferior  extremity  of  a boy  at  the  hip  joint,  in 
June  1843,  for  cancer  of  the  femur.  I carefully  examined  a small  portion 
of  one  of  the  upper  flaps,  which  was  subsequently  cut  away,  on  observing  a 
piece  of  the  tumor  attached  to  it,  and  found  all  the  muscles  fatty  and 
infiltrated  with  young  cancer  cells  (Fig.  304).  In  short,  all  the  muscles 
which  formed  both  flaps  were  already  cancerous,  and  I told  the  operator 
that  the  disease  would  probably  return  in  the  stump  The  incisions  healed 


favorably,  but  in  a few  months  cancerous  nodules  appeared  not  only  in 
the  cicatrix  but  in  other  places,  and  caused  death.'"  I have  also  seen 
the  same  mode  of  propagation  in  nerves  as  has  been  figured  in  muscles 


* Cancerous  and  Cancroid  Growths,  p.  103. 

Fi"  303.  Fil)rc  of  the  sterno-mastoid  muscle,  in  tlie  neighborhood  of  a cancerous 
growth,  partly  transfoi’mcd  into  fibres,  with  masses  of  young  cancer-cells.  This 
figure,  published  by  me  fifteen  years  ago,  exhibits  all  the  facts  subsequently  seen  by 
the  so-called  cell  pathologists.  I need  scarcely  point  out  to  the  experienced  observer 
how  an  imaginative  histologist,  when  copying  such  an  appearance,  might — by 
strengthening  the  outlines  of  those  fibres  which  surround  the  groups  of  nuclei — make 
the  whole  re.scml)lo  endogenous  cell  growth. 

Fig.  301.  Fasciculi  of  muscle,  forming  the  flap  in  an  amputation  of  the  thigh, 
already  infiltrated  with  young  cancer  colls,  a,  The  latter,  after  the  addition  of  acetic 
acid. 

Fig.  303.  Granules,  nuclei,  and  granule  cells,  infiltrated  among  the  tubes  of  the 
brachial  nerve,  near  a cancerous  growth.  250  diam. 


pale  and  atro- 
pliied,  but  ex- 
hibited no  an- 


PROPAGATION  OF  MORBID  GROWTHS. 


241 


(Fig.  232,  303).  I have  found  the  brachial  nerve  in  connection  with  a 
cancerous  tumor  of  the  humerus,  infiltrated  with  granular  masses  and 
granules,  some  of  these  latter  arranged  in  rows,  and  meeting  together, 
apparently  to  form  nuclei  of  new  cells,  as  in  Fig.  305.  Professor  Van 
der  Kolk  of  Utrecht  has  confirmed  these  observations,  and  also  traced 
incipient  cancer-cells  among  the  tubes  of  neighboring  nerves. 

Hence  one  of  the  chief  modes  of  propagation  oi  morbid  growths,  is 
that  the  cells  in  the  process  of  development  become  infiltrated  among 
neighboring  tissues.  But  how  do  tliey  accomplish  this?  Van  der 
Kolk  suggests  that  the  fluids  which  they  contain  mingle  with  the  juice 
of  the  parenchymatous  substance  around  them,  and  that  in  the  latter 
there  are  deposited  molecules  and  granules,  which,  having  received  from 
the  former  certain  tendencies  to  evolution,  are  ultimately  transformed 
into  similar  structures.  This  view  is  not  only  exceedingly  ingenious  but 
very  probable,  and  will  serve  to  explain  how  the  blood  and  distant 
organs  are  secondarily  affected.  The  notion  of  solid  germs  floating  in 
the  blood  has  no  facts  in  its  support,  but  the  idea  of  a fluid  secreted  by 
cells  being  absorbed  is  consonant  with  every  known  law  of  nutrition. 

The  molecules  in  the  fluid,  then,  of  a morbid  growth,  formed  during 
its  development,  as  the  result  of  cell  or  other  formation,  would  seem  to 
be  the  most  probable  material  producing  secondary  growths.  We  have 
seen  that  many  tumors  which  have  no  cells,  may  be  recurrent  and  attack 
tissues  secondarily.  Still  they  all  contain  a paronch3unatous  molecular 
juice,  and  as  a general  rule  those  that  are  most  soft  and  pulpy  are  most 
liable  to  return.  I have  recorded  two  singular  examples  of  cancroid 
growths  which  returned  and  proved  fatal.  In  one  of  these,  the  tumor 
was  removed  from  the  breast  by  Mr.  Page  of  Carlisle,  and  consisted  of  a 
pulpy  fibrous  substance,  in  various  stages  of  development,  and  of  granular 
cells.  Six  months  afterwards  a similar  growth  af  like  structure  formed 
in  both  thighs,  of  which  the  patient  died  (Figs.  306  to  308). 

In  another  case  the  leg  was  amputated  above  the  knee  by  Mr. 
Norman  of  Bath,  for  a fungoid  tumor,  below  the  gastrocnemius  muscle. 


Fig.  306.  Fig.  307.  Fig.  SOS. 

It  consisted  of  fusiform  corpuscles  in  different  stages  of  development, 
m.ingled  with  naked  nuclei,  a multitude  of  molecules  and  granules,  as 
represented  in  the  figure  (Fig.  309).  Two  years  later  a similar  tumor 
formed  in  the  right  chest,  which  compressed  the  lung,  and  caused  death. 
These,  together  with  the  cases  ot  sarcoma,  neuroma,  enchondroma. 


Fig.  306.  Structure  of  the  soft  part  of  the  tumor  removed  by  Mr.  Page  of  Carlisle. 
Figs.  307  and  308.  Structure  of  the  more  indurated  parts.  250  dlam. 


16 


242 


PEIXCIPLES  OF  MEDICINE. 


and  epithelioma,  referred  to,  show  that  constitutional  tendencies  do  exist 

for  the  reproduction  of  morbid  growths, 
! ' similar  to  those  which  have  previously 

been  formed.  A recurrence  of  all  dis- 
eases, and  especially  of  apoplexy,  epi- 
lepsy, rheumatism,  bronchitis,  etc.,  are 
equally  common,  and  appear  to  follow 
the  same  law.  But  the  idea  that,  be- 
cause they  do  so,  they  should  be  distin- 
guished by  the  name  of  “ malignant,’’ 
appears  to  me  unpathological.  We  may 
just  as  correctly  talk  of  a rheumatism 
being  innocent  or  malignant,  as  apply  those  terms  in  different  cases  to 
fibrous,  cartilaginous,  osseous,  or  other  kinds  of  morbid  growth,  for  no 
other  reason  than  because  sometimes  they  are  localised  in  a part,  and 
at  others  are  more  general.* 


3u9. 


Fig.  310. 


Decline  or  Degeneration  of  Morbid  Growths. — In  their  decline,  as  in 
their  development,  the  various  kinds  of  morbid  growths  follow  the  laws 
which  regulate  degeneration  of  texture.  Some,  as  lipoma  and  adenoma, 
have  been  known  to  be  gradually  absorbed  and  disappear.  Others 
undergo  the  albuminous,  fatty,  mineral,  or  pigmentary  transformations, 
to  be  subsequently  described.  To  enter  into  the  peculiarities  of  each 
morbid  growth  in  this  respect  would  lead  me  too  far.  They  will  be 
referred  to  generally  afterwards.  All  I need  say  here  is,  that  every  kind 
of  morbid  growth  may  degenerate  and  prove  abortive  in  one  way  or 
another.  Cancer  even  has  been  known  to  slough  out,  and  heal  by 
cicatrix,  besides  having  been  checked  in  its  development  and  rendered 
abortive  in  every  known  mode  of  retrograde  transformation.  (See 
Morbid  Degenerations  of  Texture). 


Geneiial  Theatment  of  Morbid  Growths. 

The  treatment  of  morbid  growths  may  be  divided  into  local  and 
constitutional.  The  local  treatment  comprehends — 1st,  Means  of  re- 
tardation and  resolution.  2d,  Means  of  extirpation. 

* The  facts  to  which  I have  alluded,  and  others  of  a like  kind  that  are  daily  occur- 
ring, have  induced  M.  Velpeau,  in  the  second  edition  of  his  work  on  diseases  of  the 
breast  (1868),  to  speak  as  follows — “ J’ai  dit  plus  haut  ciue,  sans  avoir  de  conviction 
absolue  sur  les  transformations  cancereuses,  j’etais  loin,  cependant,  d’etre  aussi  decide 
(pdautrefois  dans  le  sens  negatif  Les  faits,  cn  se  multipliant  dans  ma  pratieiue,  ont 
tini  par  ebranlcr  mes  croyances  et  meme  par  me  faire  pencher,  sous  ce  rapport,  vers 
la  doctrine  affirmative  defendue  avec  talent  en  dernier  lieu  per  M.  Bennett  d’Edim- 
bourg.”  He  adds,  much  to  his  honor,  “ Renoncer  ainsi  it  ses  anciennes  doctrines, 
juste  au  moment  ou  les  autres  savants,  ou  la.  jeunesse  active  et  laborieuse  s’en  em- 
l)arcnt  et  les  soutiennent  avee  ardcur,  pent  etre  peiiible  sans  doute,  mais  les  besoins 
dc  la  verite  doivent  passer  avant  tout ! ” 


Fig.  300.  Structure  of  a fungoid  growth  of  the  leg,  removed  by  Mr.  Norman  of 
Bath. 

Fig.  SIO.  The  same,  after  the  addition  of  acetic  acid. 


260  diam. 


GENERAL  TREATMENT  OF  MORBID  GROWTHS. 


243 


].  Means  of  Retardation  and  Resolution, — These  consist  in  applying 
all  those  means  which  are  opposed  to  development  of  tissue,  such  as 
topical  cold  and  graduated  pressure,  avoiding  moist  applications  and  local 
irritation.  Such  means,  as  they  are  opposed  to  those  circumstances 
which  are  known  to  favor  cell  growth  in  the  animal  and  vegetable 
worlds,  such  as  heat,  moisture,  stimulants,  and  room  for  expansion, 
might  be  expected  to  retard  the  progress  of  morbid  growths.  Dr.  James 
Arnot  has  in  consequence  found  much  benefit  from  the  application  of 
frigorinc  mixtures,  and  Dr.  Niel  Arnot  has  applied  graduated  pressure 
w th  occasional  good  effect.  Tlie  difficulty  of  such  treatment  consists  in 
the  frequent  impracticability  of  their  application,  as  they  can  only  be 
serviceable  when  the  growth  is  *situated  externally,  at»d  on  particular 
parts  of  the  body.  Huch  treatment  also  is  counteracted  by  the  fact,  that 
although  }mu  may  freeze  the  external  parts,  the  growth  is  continually 
supplied  with  warm  blood  from  within;  and  that  when  you  compress 
outside,  you  thereby  run  the  risk  of  causing  extension  towards  the 
interior.  Both  these  means,  however,  which  may  be  carried  on  con- 
jointly, are  eminently  deserving  further  trial.  As  moisture  favors,  so 
dryness  is  opposed  to  growth,  and  the  avoidance  of  local  irritations,  as 
they  are  a common  exciting  cause,  is  obviously  indicated. 

2.  Means  of  Extirpation. — These  are  excision  of  the  part,  and  the 
application  of  chemical  agents  which  destroy  texture. 

From  all  that  we  have  said  as  to  the  origin,  mode  of  development, 
and  propagation  of  morbid  growths,  it  would  appear  that  they  may  all 
destroy  life,  and  that  those  which  exhibit  the  most  rapid  powers  of 
spreading  may  supervene  on  the  more  indolent  ones.  Hence,  as  a 
general  rule,  so  soon  as  it  becomes  evident  that  means  of  retardation  and 
resolution  have  failed  to  arrest  their  progress,  an  operation  should  be  had 
recourse  to.  If  early  excision  were  more  practised,  many  of  the  Lament- 
able cases  which  occur  in  practice  would  not  arise.  Should  the 
cancerous  growth  even  be  advanced,  it  should  never  be  neglected  so  long 
as  the  diseased  parts  are  external  and  within  the  reach  of  the  knife. 
We  have  also  seen  that  surgeons,  in  removing  the  tumors,  have  left  un- 
touched tissues  infiltrated  with  cells  capable  of  causing  their  regeneration. 
Hence  the  neighboring  textures  should  be  carefully  scrutinised,  and  all 
those  portions  of  them  infiltrated  with  cancerous  germs  carefully  removed. 
For  this  purpose  the  microscope  ought  to  be  a necessary  instrument  in 
the  operating  theatre,  and  every  suspected  tissue  in  the  neighborhood 
examined  by  experienced  histologists,  before  the  lips  of  the  wound  are 
closed.  This  proceeding,  which  I recommended  in  1849,  has  not,  so 
far  as  I am  aware,  yet  been  practised  by  surgeons,  but  its  propriety  has 
since  then  been  supported  by  Van  der  Kolk,  and  it  will  yet,  I believe, 
become  generally  practised,  when  a knowledge  of  the  pathology  of 
morbid  growths  is  better  understood.  The  practice  of  M.  Girouard  of 
Chartres,  who  by  caustic  directed  towards  the  neighboring  tissues 
around  cancers,  has  sought  to  destroy  the  germs  whereby  they  spread, 
and  thus  prevent  return  of  the  growth,  is,  in  this  point  of  view,  highly 
encouraging.^ 

* Archiv.  Gen,  de  Med.,  tom.  xcv.  p.  Y39. 


244 


PRINCIPLES  OF  MEDICINE, 


The  application  of  chemical  means,  as  various  kinds  of  escharotics, 
to  destroy  local  growth,  has  been  extensively  tried,  but  without  as  yet 
having  enabled  practitioners  to  arrive  at  any  definite  results.  The  great 
obstacle  is  the  impossibility  of  attacking  the  entire  growth  ; and  if  this 
is  not  always  performed  by  excision,  still  less  frequently  is  it  accom- 
plished by  escharotics.  Of  late  years  an  opinion  has  prevailed  that  this 
mode  of  treatment  deserves  further  trial.^  M.  Velpeau  speaks  favorably 
of  sulphuric  acid  mixed  with  saffron ; and  Mr.  Syme  has  proposed  saw- 
dust as  a cheaper  material  than  saffron,  whilst  its  action  is  confined 
superficially  by  a wall  of  gntta  percha  made  to  adhere  to  the  skin.f  By 
such  an  escharotic  the  whole  morbid  growth,  it  is  said,  may  be  destroyed 
at  once.  The  immediate  pain  is  prevented  by  bringing  the  patient  under 
the  influence  of  chloroform,  the  slough  is  subsequently  poulticed  until 
it  separates,  and  then  the  granulating  surface  allowed  to  heal.  Great 
discussion  has  occurred  as  to  the  value  of  the  chloride  of  zinc,  applied 
by  vertical  scorings  or  slight  incisions,  so  that  it  shall  gradually  perco- 
late through  the  entire  growth.  This  mode  of  proceeding  takes  from 
three  to  seven  weeks, J but  is  effectual  in  removing  the  tumor,  as  all 
those  who  have  examined  the  preparations  in  the  Middlesex  Hospital, 
and  such  as  have  been  removed  by  the  same  method  of  alternate  incision 
and  application  of  caustic  by  Mr.  Moullin  of  London,  may  easily  satisfy 
themselves.^  M.  Maisonneuve  has  employed  Canquoin’s  paste,  composed 
of  the  chloride  of  zinc,  1 part;  wheat  flour,  3 parts ; mixed  up  with  a sufii- 
cient  quantity  of  water.  This  is  formed  into  arrow-shaped  heads,  dried 
and  thrust  into  or  around  the  tumor,  according  to  circumstances.  ||  Other 
chemical  agents  have  been  proposed,  but  the  experience  acquired  of  these 
methods,  and  especially  of  their  ultimate  good  effects,  is  as  yet  so  limited 
as  to  preclude  the  possibility  of  forming  a just  estimate  as  to  their  merits. 

Constitutional  Treatment. — We  are  altogether  unacquainted  with  any 
means  of  counteracting  the  tendency  which  predisposes  to  morbid  growths. 
But  considering  that  for  the  most  part  the  constitutional  change  is  con- 
nected with  excess  of  nutrition,  and  in  this  res])ect  is  altogether  opposed 
to  what  we  observe  in  cases  of  scrofula  and  tubercle,  we  may  infer  that 
lowering  the  nutritive  processes,  while  we  yet  allow  the  general  tissues 
to  be  supported,  should  be  the  rule  of  practice.  In  carcinoma,  and 
rapidly  formed  growths,  the  body  (unless  it  produce  emaciation  by  at- 
tacking the  chylopoietic  viscera)  is  for  the  most  part  fatty,  and  a diminu- 
tion of  this  element  in  the  food  should  be  aimed  at.  But  at  a later 
period,  when  exhaustion  makes  its  appearance,  nutrients  and  stimulants 
wull  be  required  to  prolong  life. 

Note. — It  is  impossible  to  over-estimate  the  services  which  have  been  rendered 
to  science  by  M.  Velpeau,  from  carefully  watching  the  results  of  those  operations  he 


* Langston  Pai’ker,  on  the  treatment  of  Cancerous  disease  by  Caustics,  1856. 
f Edinburgh  Medical  Journal,  November  1857-. 

\ Report  of  the  Surgical  Staff  of  the  Middlesex  Hospital,  etc.,  1857. 

§ I have  myself  been  able  to  do  this  through  the  kindness  of  Drs.  Van  der  Byl 
and  Handfield  Jones. 

II  Journal  of  Practical  Medicine  and  Surgery,  March  1858,  p.  485. 


MOKBID  DEGEXERATIONS  OF  TEXTURE. 


245 


has  performed,  where  the  tumor  extirpated  has  been  microscopically  examined.  At 
a time  when  some  surgeons  were  sneering  at  histological  research,  he  applied  to  MM. 
Lebert,  Follin,  and  Kobin,  and  obtained  careful  microscopical  examinations  of  the 
tuino  rs  he  reinoved.  The  result  now  is,  that  we  have  the  most  positive  proof  that 
cancerous  growths  may  be  successfully  removed  by  the  surgeon,  and  the  individual 
still  survive  in  perfect  health,  for  periods  varying  from  six  to  twenty  years.  Had  the 
microscopic  examinatio-i  not  been  made,  we  should  still  have  remained  in  doubt  as  to 
the  true  character  of  the  tumor.  But  the  following  extract  from  a letter  I received 
from  M.  Velpeau  last  October  can  leave  no  doubt  in  the  minds  of  the  most  sckeptical. 
The  references  are  to  the  pages  in  the  first  edition  of  his  work  on  the  Diseases  of  the 
Breast,  where  the  cases  will  be  found  detailed  at  length. 


54  Rue  de  Grenelle  St.  Germain, 
October  19^A,  1864. 

“ I can  now  inform  you  that  the  Demoiselle  D.  (p.  584),  operated  upon  nearly 
twenty  years  ago,  and  at  present  eighty  years  of  age,  remains  cured  and  in  excellent 
health.  It  is  the  same  wiih  Madame  D.  (p.  584),  operated  on  in  1847,  with  M™e.  Q-. 
(p.  594),  with  Mad™G.  L.  (p.  596),  operated  upon  twenty-eight  years  ago,  and  who  are 
still  living.  Mesdames  V.  (p.  684),  H.  (p.  686),  L’h.  (p.  608),  and  the  man  referred 
to,  p.  499,  still  live,  ani  have  had  no  return  of  the  disease.” — “To  my  former  list  I 
could  now  add  991  cases.  I would  especially  refer  to  that  of  Madame  de  la  Vie. . . ., 
who  was  operated  on  six  years  ago,  for  a lardaceous  encephaloid,  perfectly  charac- 
terized, occupying  the  left  breast.  This  lady,  tolerably  stout  and  otherwise  strong, 
now  possesses  the  most  excellent  health.  It  is  the  same  with  Madame  de  Mon. . . ., 
but  the  most  extraordinary  case  is  the  following: — A lady  B.,  who  has  been  operated 
on  nine  times  for  a fungoid  encephaloma  of  the  right  breast  (four  times  by  caustic, 
five  times  by  the  knife)  under  the  same  conditions  as  H.  (p.  686),  has  now  un- 

dergone a permanent  cure.  All  these  operations  were  practised  during  five  years. 
After  each  of  them  the  general  health  improved  for  some  months.  Then  the  growth 
re-appeared,  and  it  was  necessary  to  commence  once  more.  On  the  last  occasion,  it 
was  necessary  to  penetrate  to  the  ribs,  and  cauterize  the  surface.  The  wound  not- 
withstanding at  length  cicatrised,  and  the  former  large  excavation,  occupying  the 
whole  side  of  the  thorax  in  this  courageous  lady,  is  now  solidly  healed.  She  has  re- 
covered her  embonpoint,  and  suffers  in  no  way,  and  enjoys  a health  that  leaves  nothing 
to  be  desired.  Everything  went  through  the  same  course  as  occurred  in  the  case  of 
Madme.  H.  (p.  686).” 

“ Such  is  the  information  in  my  power  to  give  you,  begging  you  to  observe  that  in 
all  these  cases,  as  in  all  those  to  which  I give  the  name  of  cancer,  every  precaution, 
whether  clinical  or  anatomical,  was  employed,  and  the  diagnosis  estabhs'hed  by  direct 
observation,  careful  dissection,  and  microscopical  research.” 


It  results  from  these  facts  that  the  views  long  maintained  by  the 
author,  as  to  the  possibility  of  permanently  eradicating  cancer,  may  now 
be  considered  to  have  been  incontestibly  demonstrated. 


MORBID  DEGENERATIONS  OF  TEXTURE. 


In  the  same  manner  that  there  may  be  hypertrophy  or  increase,  so 
there  may  be,  although  from  exactly  opposite  causes,  atrophy  or  diminu- 
tion of  texture.  Atrophy  may  consist  in  simple  decrease  of  bulk,  the 
organ  or  tissue  otherwise  retaining  its  usual  structure  and  function. 
There  may  be  less  work  to  do,  and  less  force  consequently  required;  and 
for  the  same  reason  that  the  legs  of  a dancer  become  larger,  those  of  a 


246 


PKINCIPLES  Of  medicine. 


bed-ridden  individual  become  smaller.  So  also  as  there  may  be  increased 
bulk  with  alteration  of  texture,  so  there  may  be  diminished  size  with 
change  of  tissue.  These  latter  atrophies,  as  they  constitute  true  organic 
diseases,  especially  merit  our  attention;  and  they  may  be  arranged  in 
four  groups,  viz. — 1st,  Albuminous;  2d,  Fatty;  3d,  Pigmentary;  and 
4th,  Mineral  Degenerations. 

Albuminous  Degeneration. 

We  have  already  seen  how  essential  albumen  is  to  nutrition  : and 
that  to  be  made  assimilable  in  various  forms  to  the  tissues  of  the  body, 
it  must  be  subjected  to  certain  processes.  Under  other  circumstances  it 
may  be  effused,  or  collect  in  particular  parts  of  the  system,  constituting 
organic  diseases.  If  transuded  through  the  ves-els  in  a fluid  form,  that 
is,  dissolved  in  water,  as  we  find  it  in  the  serum  of  the  blood,  it  produces 
what  is  called  dropsy.  If  precipitated  from  its  solution  in  a solid  form, 
it  may  constitute  a variety  of  inorganizable  deposits  presenting  various 
kinds  of  ultimate  structure.  Lastly,  tissues  composed  of  various  proxi- 
mate principles  may  be  wholly  converted  into  an  albuminous  substance, 
and  thereby  have  their  vital  properties  impaired  or  lost.  We  shall  notice 
these  shortly  in  succession. 

Albumen  in  solution  is  frequently  effused  from  the  blood-vessels  as 
.serum,  constituting  dropsy.  It  is  distinguished  from  an  exudation  by 
containing  no  fibrin.  There  is  not,  therefore,  that  disposition  to  rapid 
coagulation  and  formation  of  an  organized  blastema,  although  there  is 
often  a precipitation  of  matter,  capable  of  assuming  various  forms.  We 
have  seen  that  an  exudation  depends  on  an  alteration  of  the  vital  force 


Fig.  311. 

which  governs  the  attraction  and  selection  of  nutritive  materials  from  the 
blood.  Serous  effusion  or  dropsy,  on  the  other  hand,  is  always  indicative 
of  mechanical  obstruction  to  the  return  of  blood  from  the  capillaries 

Fig.  311.  Structureless  membrane  formed  by  heating  the  clear  fluid  of  pemphigus. 
On  the  left  hand  the  membrane  is  folded  together. — ( Wedl),  800  diam. 


ALBUMINOUS  DEGENERATION. 


24'; 


tlirougli  the  veins.  Thus,  pressure  of  a tumor  on  the  large  venous, 
trunks,  disease  of  the  heart  and  liver  rendering  the  circulation  difficult, 
or  of  the  kidneys  and  skin  diminishing  the  secretion  or  exhalation  of 
fluid,  are  its  most  common  precursors.  In  Bright’s  disease  of  the  kid- 
ney, conjoined  with  various  changes  in  the  texture  of  the  organ,  seiuin 
containing  albumen  passes  off  in  the  urine. 

Membranous  Albumen. — Albumen  in  solution,  if  it  exists  in  tolerable 
quantity,  is  veiy  apt  to  be  precipitated  in  flakes  or  membranes.  x\t  the 
onset  of  vesicular  diseases,  as  pemphigus,  the 
fluid  effused  has  been  observed  on  being 
heated  to  contain  smooth  or  folded  laminae 
(Fig.  311).  The  same  laminae  may  be  pro- 
duced artificially  by  bringing  oil  or  chloro- 
form in  contact  with  serum.  Hence  they 
are  not  fibrinous  but  albuminous.  The  mere 
shaking  of  white  of  egg,  or  manipulating 
serum  in  various  ways,  will  often  cause  these 
laminae  to  form  and  constitute  shreds,  which 
resemble  fibres,  but  are  truly  membranous 
(Panum,  Melsens).  Sometimes  such  mem- 
branes, if  produced  slowly,  collect  round  a 
central  nucleus  and  ultimately  form  a concre- 
tion. The  same  has  been  observed  by  Wedl 
in  the  scrotum,  where  the  skin  has  been  con- 
verted into  a tough  substance  like  caoutchouc  (Fig  312).  The  concen- 
tric laminae  which  form  in  the  interior  of  aneurisms  present  a similar 
structure  and  are  probably  albuminous.  (See  Concretions.) 

Fih'oid  Albumen. — Many  tissues,  especially  fibrous  ones,  when  ex- 
posed to  a certain  amount  of  pressure,  become  unusually  dense.  This 
may  be  the  result  of  an  exudation,  which  undergoes  a peculiar  transfor- 
mation, the  whole  becoming  white  in  color,  hard  and  tough  to  the  feel, 
and  consists  of  dense  fine  fibrous  texture.  It  may  also  be  the  result 
of  a peculiar  transformation,  or  fibrillation  of  pre-existing  tissues,  inde- 
pendent of  exudation.  It  has  been  described  by  Dr.  Handheld  Jones 
under  the  name  of  fibroid  degeneration.  We  find  it  in  various  situa- 
tions— 1st,  in  the  areolar  texture  of  the  skin,  producing  peculiar  indu- 
rations, as  in  the  hide  bound  integument  of  infants.  2d,  On  serous 
membranes,  where  it  occasions  opaque  thickenings,  as  in  the  arachnoid, 
pleura,  peritoneum,  and  pericard:u>u.  The  white  spots  in  or  upon  the 
pericardium  covering  the  heart  are  of  this  character,  and  all  of  them 
have  their  probable  origin  in  a chronic  form  of  exudation,  which  is 
subsequently  transformed  into  a white  albuminous  mass  (Fig.  171). 
The  thickened  valves  of  the  heart,  and  especially  the  rough  indurated 
masses  occupying  their  free  margins,  are  also  examples  of  this  lesion. 
3d,  In  mucous  membranes  the  areolar  tissue  between  the  basement 
membrane  and  muscular  coat,  and  even  the  non- voluntary  muscular 
substance  itself,  is  very  liable  to  undergo  thickening  and  induratiorK 

Fig.  312.  Edges  of  albuminous  laminae,  in  a case  of  hydrocele,  where  the  skin 
was  destroyed,  a,  Edges  of  horizontal  laminae ; 6,  the  same  in  another  place,  with 
brownish-yellow  pigment  granules. — {Wedl.)  250  diam. 


a 


Fig.  31-2. 


243 


PKINCIPLES  OP  MEDICmE. 


Wo  Lave  scon  tlie  stomach  and  bladder  upwards  of  an  inch  thick  from 
this  cause  (Fig.  81o).  4th,  In  the  areolar  texture  of  parenchymatous 

organs,  as  in  the  liver,  kidneys,  lungs,  etc., 
it  constitutes  the  lesion  denominated  cirrho- 
sis, which  consists  of  dense  fibrous  deposits, 
aud  causes  atrophy  of  the  glandular  sub- 
stance. ^^See  Cirrhosis.)  Dr.  Handheld 
Jones  considers  the  white  fibrous  tumors  ef 
the  uterus  to  belong  to  the  same  class  of  mor- 
bid alteration,  which  they  no  doubt  do,  as  also 
similar  formations  in  the  placenta,  spleen, 
and  other  organs.  This  form  of  degeneration 
gradually  passes  into,  and  may  be  identical 
with  fibrous  growth,  as  the  result  of  exuda- 
tion. 5th,  The  remarkable  change  which  takes  place  in  cartilage  belongs 
to  this  head,  and  has  been  ably  described  by  Dedfern.  Under  the  in- 
fluence of  a stimulus,  vital  or  mechanical,  the  cells  enlarge  and  their  in- 
cluded nuclei  multiply,  and  the  previously  hyaline  inter-cellular  substance 
fibrillates  and  becomes  transf  jrnied  into  bundles  of  fibres  (Fig.  269,  270). 

CcUoid  Albumen. — Cell-walls  are  generally  of  an  albuminous 
character,  but  between  them  and  the  nucleus  there  exists  for  the  most 
part  a fluid,  so  that  interchanges  are  constantly 
going  on  between  the  three  essential  portions  of 
the  cell,  whereby  its  growth  is  kept  up,  and  in 
many  cases  development  carried  on.  It  fre- 
([uently  happens,  however,  that  even  in  formative 
1-uids,  albumen  is  thrown  down  in  globular  masses, 
hO  as  to  resemble  cells.  Thus,  1st,  In  pus,  soft 
cancer,  and  other  forms  of  niorbid  growth,  there 
1 ay  frequently  be  seen  diaphanous  bodies  floating 
: bout,  of  various  sizes,  of  extreme  delicacy,  and 
] V rfectly  globular  in  shape.  Very  commonly  they 
are  homogeneous  and  perfectly  transparent,  but 

sometimes  they  contain  ore  or  more 
bright  refractii'.g  granules,  and  at  others  a 
cavity  seems  to  have  formed  in  the  inte- 
rior, but  no  nucleus  (Fig.  315).  2d,  Fus 
corpuscles  (Fig.  68)  aud  collections  of 
blood  globules  may  frequently  be  seen  sur- 
' rounded  by  a similar  diaphanous  coating 

Fig.  .317.  more  or  less  thick.  In  lecent  haemor- 


rhagic apoplexies  in  man,  I have  seen  collections  of  blood  corpuscles,  sur- 

Fig.  813.  Dense  fibrous  structure,  with  naked  nuclei  from  thickened  and  indurated 
coats  of  the  stomach. 

Fig.  314.  The  same  after  the  addition  of  acetic  acid. 

Fig.  315.  Diaphanous  albuminous  bodies,  with  fatty  cancer  cells  from  the  dia- 
phragm. 

Fig.  316.  Groups  of  blood  corpuscles  from  an  apoplectic  extravasation  in  tfe 
human  brain,  surrounded  by  an  albuminous  layer. 

Fig.  317.  A similar  albuminous  layer,  round  groups  of  blood-cells  from  the  brain 
■^f  a pigeon.  260  diam. 


ALBUMINOUS  DEGENERATION. 


248 


Fig.  318. 


rounded  as  if  by  a cell-wall  (Fig.  31G,)  and  Dr.  J.  B.  Sanderson  lias  pro- 
duced them  artificially  in  pigeons,  by  pricking  the  brain  through  the 
cranium  with  needles,  and  caus- 
ing extravasation  of  blood.  A 
few  days  after  such  an  experi- 
ment, groups  of  oval  corpuscles 
may  be  found  surrounded  by  a layer  of  albumen,  often  presenting  a series 
of  concentric  rings*  (Fig.  317).  There  can  be  no  doubt  that  in  these 
cases  an  albuminous  precipitate  is  tornied  round  the  blood  corpuscles, 
which  are  beginning  to  break  down  and  decay.  3d,  Another  torm  ot 
celloid  albu  nen  may  be  seen  in  certain  mechanical  softenings  ot  the  brain 
and  spinal  cord,  where  the  nerve-tubes  break  up,  unite  at  their  edges, 
and  form  globules  bounded  by  double  lines.  I have  seen  them  pro- 
duced under  the  microscope  by  mechanical  pressure  between  glasses,  in 
the  manner  represented  in  the  figure  (Fig  ^318.) 

Molecular  Albumen. — Some  textures  assume  a peculiar  kind  of  in- 
duration, which  on  examination,  is  found  to  consist  of  molecular  amor- 
phous matter.  1st,  Induration  of  the  brain  consists  of  an  albuminous 
molecular  matter  deposited  among  the  tubes,  rendering  the  thinnest 
sections  opaque,  and  giving  to  the  texture  a peculiar  toughness.  This 
induration  is  common  around  chronic  abscesses  of  that  organ,  and  may 
have  originated  in  exudation,  which  has  been  transformed  into  the  sub- 
stance described.  2d,  Certain  peculiar  yellow  masses,  found  in  the  kid- 
ney and  spleen,  with  abrupt  margins  of  irregular  outline,  appear  to  me 
to  constitute  a degeneration  of  a similar  character.  3d,  Certain  forms 
of  tubercle  may  be  said  to  consist  of  the  same  amorphous,  finely  mole- 
cular albuminous  substance. 

Waxy  Degeneration. — A peculiar  change  in  the  pre-existing  texture 
of  various  organs,  known  under  this  appellation,  sometimes  called  brawny 
or  bacony,  as  in  the  case  of  the  liver  and  spleen,  appears  to  me  to  be  a 
form  of  albuminous  degeneration.  1st,  The  liver  when  thus  altered 
presents  to  the  naked  eye  a pale  fawn  color,  its  tissue  is  of  unusual 
density,  and  its  section  presents  a smooth  surface, 
with  semi-transparent  edges.  The  hepatic  cells 
under  the  microscope  are  seen  to  be  shrivelled, 
colorless,  and  of  peculiar  transparency,  with  the 
nucleus  ab.sent,  or  evidently  disappearing  (Fig. 

319).  2d,  In  this  degeneration  of  the  kidneys 

the  organ  presents  the  same  general  aspect ; and 
on  minute  examination,  the  glandular  cells  are 
found  similarly  affected  to  those  in  the  liver, 
and  the  Malpighian  bodies  not  unfrequently 
undergo  the  same  alteration.  (See  Diseases  of  the 
Kidney.)  3d,  In  the  spleen  the  same  characters  are  presented,  both  to 
the  naked  eye  and  under  the  microscope,  the  cells  of  the  parenchyma, 

* Monthly  Journal  of  Medical  Science,  September  and  December  1851. 


Fig.  318.  Substance  of  nerve-tube,  by  means  of  traction,  broken  across  and  form- 
ing two  globules,  with  double  outline. 

Fig.  319.  Cells  of  the  liver,  in  waxy  degeneration  of  that  organ. 


250  diam. 


250 


PEINCIPLES  OF  MEDICINE. 


as  well  as  those  in  the  Malpighian  bodies,  b Jng  compressed  together 
shrivelled,  and  presenting  a similar  pale,  translucent  appearance.  4th, 
In  the  intestinal  mucous  membrane  it  is  by  no  meaiis  unfrequent,  com- 
muiiicating  to  it  a peculiarly  blanched  and  thin  appearance.  Under  the 
microscope  the  villi,  vessels,  and  epithelial  cells  in  various  degrees,  may 
be  seen  to  have  undergone  this  peculiar  degeneration.  5th,  I have  seen 
the  same  transformation  in  the  placenta,  as  Vfell  as  in  simple  chronic, 
cancerous,  and  tubercular  exudations.  By  others  it  has  been  seen  in 
bone,  and  there  is  no  reason  why  it  may  not  affect  almost  every  organ 
and  tissue  of  the  body.  It  is  evidently,  as  an  albuminous,  as  widespread 
in  its  extent  as  the  fatty  degeneration. 

This  lesion  has  received  various  names,  having  been  denominated 
“ lardaceous  degeyieration  ” by  Abercrombie,  and  rightly  considered  allu- 
minom  in  its  nature  by  Hodgken,  Bright,  and  Bokitanski.  By  Budd, 
it  was  regarded  as  The  term  waxy  is  evidently 

the  best,  derived  from  its  resemblance  in  the  kidney  and  liver  to  bees- 
wax. Under  the  microscope  also  it  resembles  in  its  translucency  color- 
less wax  or  spermaceti. 

The  term  amyloid  degeneration,  recently  employed  to  designate  this 
lesion  by  Virchow  and  his  followers,  is  not  only  vicious  but  productive 
of  the  greatest  confusion.  This  term  means  resembling  starch,  and  has 
been  used  by  me  to  designate  rounded  soft  mineral  bodies,  frequently 
found  in  the  brain  and  in  cerebral  tumors  (Fig.  S92),  and  which  in 
structure  resemble  starch.  It  has  also  been  applied  by  Carter  to  starch- 
like  bodies  found  in  various  tissues;  and  more  recently  by  Bernard,  Pavy, 
and  others,  to  the  substance  obtained  from  the  liver,  and  which  is  readily 
transformed  into  sugar.  In  both  these  latter  cases,  there  is  a chemical 
relation  to  the  substance  of  starch,  as  seen  by  the  actions  of  re-agents. 
But  the  waxy  degeneration  has  no  relation  to  starch  whatever.  I have 
never  seen  it  transformed  blue  by  iodine,  either  with  or  without  sul- 
phuric acid,  but  only  into  a brownish  or  purple  red,  which  is  the  color 
of  iodine  itself.  The  truth  is,  I have  found  that  this  albuminoid  degen- 
eration has  the  property  of  fixing  certain  colors,  like  the  nuclei  of  the 
textures ; so  that  not  only  when  steeped  in  iodine  is  it  deeply  tinged  as 
compared  with  the  surrounding  textures,  but  the  same  thing  occurs  wdien 
it  is  exposed  to  the  action  of  carmine  and  indigo  in  solution. 

This  degeneration  was  first  carefully  examined  b}^  me,  microscopically, 
in  1845,  in  the  case  of  Margaret  Clark  (see  Phthisis),  when  the  peculiar 
translucency  and  degeneration  of  tie  hepatic  cells  was  observed  and  care- 
fully figured.  It  was  demonstrated  and  aescribed  at  that  time  and  since 
to  all  my  pathological  and  clinical  classes  in  Edinburgh.  In  April 
1853,  some  of  these  figures  w^ere  published,  in  No,  YIII.  of  the  first 
edition  of  this  work  (Fig.  319).  On  the  17th  of  December  1853,  I 
brought  the  subject  before  the  Physiological  Society  of  Edinburgh  in  a 
verbal  communication,  which  is  very  imperfectly  reported,  but  in  which 
the  announcement  was  made  that,  in  the  specimens  of  spleen,  liver,  and 
kidney  then  on  the  table,  I was  “ satisfied  from  numerous  observations, 
that  it  was  a primary  alteration  of  the  cells,  and  though  frequently 
associated  with  fatty  degeneration,  w^as  not  essentially  connected  wdih  it.”* 

* Monthly  Journal,  February  1854,  p.  186. 


ALBUillXOUS  DEGENERATION. 


251 


These  views  I have  ever  since  maintained  and  taught  in  this  school,  and 
never  failed  to  point  out  the  fundamental  error  of  Virchow  and  his  fol- 
lowers, who  associate  it  with  starch,  and  call  it  amyloid. 

The  clinical  history  of  the  waxy  degeneration  has  yet,  for  the  most 
part,  to  be  studied ; but  observations  I have  made  tend  to  convince  me 
that  it  may  often  be  diagnosed  in  the  living  body  with  certainty.  It  is 
the  frequent  cause  of  persistent  diarrhoea  in  leucocythemia  and  of  a peculiar 
form  of  albuminuria,  afterwards  to  be  noticed  (see  Diseases  of  the  Kidney). 

This  lesion  is  not  unfrecj^uently  associated  with  the  fatty  degenera- 
tion next  to  be  spoken  of,  especially  in  the  liver  and  kidney,  when  in  a 
cirrhosed  state.  (See  Fig.  of  Cirrhosed  Liver.)  It  wmald  appear  from 
analyses  of  the  liver,  mostly  made  by  Dr.  Drummond,  and  collected  by 
Dr.  AV.  Gairdner,^  that  the  human  liver,  when  affected  with  the  waxy 
degeneration,  contains  less  water,  considerably  less  fat,  and  a greater 
amount  of  solid  constituents  than  natural. 

Colloid  Degeneration. — AA^e  have  previously  seen  that  there  is  a 
peculiar  form  of  cancer  called  colloid,  in  which  glue-like  matter  is  asso- 


Fig.  820.  Fig.  321. 

dated  with  cancer  cells.  But  colloid  occurs  independently  of  cancer, 
constituting  the  sole  contents  of  certain  cysts  (see  Cystoma).  It  would 
appear  to  vary  in  chemical  composition,  as  I have  observed  that  speci- 
mens of  it  sometimes  coagulate  into  a solid  mass,  whilst  at  others  they 
are  unaffected  by  the  action  of  spirits.  If  not  identical,  it  is  at  least 
allied  to  the  albuminous  degeneration.  The  enlargement  of  the  thyroid 
gland  in  bronchocele,  and  the  contents  of  compound  ovarian  cysts,  are 
generally  owing  to  the  formation  of  colloid  matter  (Fig.  320).  Not 
unfrequently  colloid  masses  become  indurated,  and  assume  a radiating 
striated  appearance  (Fig.  321). 

* Monthly  Journal  of  Medical  Science,  Alay  1854. 

Fig  320.  Section  of  the  thyroid  body,  with  some  of  its  glandular  sacs,  distended 
with  colloid  matter. — {Kolliker.') 

Fig.  321.  Radiated  colloid  masses  from  a cyst  in  an  atrophied  kidney,  a.  Lines 
radiating  from  a central  point : 6,  radiated  mass  surrounded  with  a clear  border ; 
c,  radiated  mass  with  a central  granular  substance  and  radiated  border  c ; J,  the  same 
with  an  external  clear  border ; c,  a mass  with  two  granular  globules  in  the  centre. — 
( Wedl. ) 250  diam. 


252 


PKmCIPLES  OF  MEDICINE. 


General  Pathology  and  Treatment  of  the  Albuminous  Degeneration. 

It  lias  been  previously  pointed  out  that  albumen  is  essential  to  nutri- 
tion, and  that  it  forms  the  basis  of  the  blood  and  of  the  tissues.  The 
flesh  which  constitutes  the  food  of  carnivora,  and  the  albumen  which 
comprises  so  large  a portion  of  the  fodder  of  graminivora,  are  alike,  by 
the  solvent  action  of  the  digestive  juices,  reduced  to  a fluid  state.  In 
this  condition  it  passes  into  the  blood,  forming  the  walls  of  the  blood 
corpuscles,  besides  entering  largely  into  the  constitution  of  the  liquor 
sanguinis,  as  serum,  that  is,  albumen  dissolved  in  water.  During  the 
building-up  process,  it  undergoes  various  transformations,  among  which 
those  of  its  conversion  into  the  fibrin  of  flesh,  and  the  gelatine  of  bones, 
are  perhaps  the  most  important.  By  its  association  with  the  other  proxi- 
mate principles,  also,  it  enters  into  the  composition  of  every  texture  and 
organ  in  the  body,  and  again  joins  the  blood  as  albumen,  mixed  with  a 
minute  portion  of  effete  matter  as  fibrin.  There  can  be  no  doubt,  as 
we  shall  subsequently  see,  that  under  certain  circumstances  it  may  be 
changed  into  fat  also,  so  that  from  multitudinous  transformations  this 
important  element  is  susceptible  of  undergoing,  it  well  merits  the  term 
which,  in  its  pure  state,  Mulder  bestowed  upon  it,  namely,  that  of 
“ proteine.” 

As  albumen,  we  have  seen  how  it  may  produce  abnormal  conditions 
of  the  tissues,  in  various  forms.  The  essential  conditions  for  this  kind 
of  degeneration  appear  to  be — 1st,  Extreme  slowness  of  effusion  from 
the  blood-vessels,  as  in  cases  of  chronic  tubercle  and  fibroid  transforma- 
tion ; and  2dly,  Mechanical  obstruction  of  the  veins,  in  some  part  of  the 
circulation,  giving  rise  to  dropsy.  In  the  former  case,  it  is  favored  by 
excess  of  acidity  in  the  primae  viae,  which  by  its  power  of  dissolving  the 
albuminous  compounds,  must  assist  in  adding  this  element  to  the  blood 
in  undue  proportion.  Why,  on  the  other  hand,  muscles,  cartilage,  and 
the  exudations,  should  sometimes  pass  into  the  albuminous  fibroid  degen- 
eration, under  much  the  same  circumstances  that  at  others  they  become 
fatty,  is  a point  in  pathology  which  is  still  involved  in  obscurity. 

The  treatment  will  depend  on  the  cause,  nature,  and  seat  of  the 
degeneration,  but  these  in  the  living  body  are  so  obscure  and  deceptive 
as  frequently  to  afford  no  indication  for  remedies.  In  the  albuminous 
tubei-cular  exudations,  correcting  excess  of  acidity  in  the  stomach  and 
bowels  tends  to  check  its  excess,  whilst  the  administration  of  animal  oils 
favors  its  transformation  into  the  nutritive  molecular  basis  of  the  chyle. 
Wherever  mechanical  causes,  or  interruptions  of  the  venous  circulation, 
give  rise  to  dropsy,  recovery  will  depend  on  the  means  at  our  disposal 
for  their  removal. 


F ATTY  Degeneration. 

I have  previously  described  fatty  growths  (see  Lipoma),  wLich,  by 
encroaching  on  neighboring  tissues,  and  especially  muscles,  cause  their 
atrophy.  1 have  also  shown  how  fatty  matter  accumulated  within  c}'sts, 
undergoes  various  transformations,  both  histological  and  chemical,  at  one 
time  presenting  a granular  form,  and  at  another  a crystalline  one,  com- 


FATTY  DEGENERATION. 


253 


posed  of  cholesterine  or  margarine  (see  Cystoma).  It  is  now  ascertained 
that  there  is  no  kind  of  tissue,  whetlier  healthy  or  morbid,  that  may  not 
undergo  a fatty  degeneration.  Such  alteration  frequently  causes  one 
of  the  most  formidable  organic  diseases  which  the  physician  is  called 
upon  to  treat. 

Deposition  of  Fatty  Molecules  and  Granules. — Fat  is  as  necessary 
a constituent  of  the  food  and  of  the  tissues  as  albumen,  and  its  universal 
presence  in  the  organs,  texture,  and  fluids  of  the  body,  renders  it  easily 
capable  of  precipitation  and  of  accumulation,  if  in  excess.  The  moment 
the  smallest  particle  of  oil  is  formed,  and  comes  in  contact  with  an  albu- 
minous fluid,  a membranous  precipitation  of  the  latter  takes  place  around 
it,  which  tends  to  keep  the  various  fatty  molecules  distinct  and  separate 
from  each  other.  No  doubt,  under  the  action  of  heat,  trituration,  press- 
ure, or  the  action  of  acids,  which  dissolves  the  albuminous  envelope,  the 
molecules  are  sometimes  fused  together,  and  con-stitute  smaller  or  larger 
globules.  The  great  predominance  of  the  molecular  form  of  fatty  depo- 
sition, however,  is  evident  in  all  morbid  alterations  of  texture.  In  this 
state  we  find  it  constituting  the  substance  of  the  atrophied  suprarenal 
an  1 thymus  glands  in  the  adult  ; the  exudation 
in  chronic  softening  of  the  brain,  and  other 
parenchymatous  organs  ; accumulated  within 
cysts,  the  result  of  transformation  of  their  con- 
tents; in  the  centre  of  colloid  masses;  in  chronic 
exudations,  and  extravasations  of  blood,  present- 
ing a milky,  yellow,  or  fawn-colored  hue ; or  in  the  blood,  urine,  and 
other  fluids,  giving  them  a chylous  character.  Indeed,  the  presence  of 
fatty  molecules  may  be  said  to  be  almost  constant  in  morbid  products; 
and,  when  collected  together  in  masses,  they  constitute  organic  lesions 
of  the  greatest  gravity. 

Fatty  D generation  of  Cells. — It  was  shown  by  Keinhardt,  that  all 
kinds  of  cell  formation,  under  certain  circumstances,  undergo  the  fatty 
degeneration.  The  manner  in  which  this  is  accomplished  is  in  all  cases 
the  same.  A few  fatty  molecules  first  form  between  the  nucleus  and 
cell-wall.  These  increase  in  number,  and  some  of  them  apparently  are 
fused  together  to  produce  larger  ones.  This  process  goes  on  until  at 
length  the  whole  contents  of  the  cell  consist  of  fatty  molecules  and 

b c (1  e f a h i k 


Fig  322. 


Fig.  323. 

granules.  The  nucleus  is  now  no  longer  visible,  and  in  many  cases 
wastes  away,  as  if  from  pressure.  Occasionally,  this  fatty  deposition  of 

Fig.  322.  Fatty  molecules  in  groups,  from  the  opalescent  or  white  opaque  centres 
of  large  colloid  masses  in  the  ovary. 

Fig.  323.  Granular  corpuscles  and  masses  from  cerebral  softening,  a.  Nucleated 
cell  with  a few  granules ; 6,  granules  within  the  cell,  partly  obscuring  the  nucleus  ; 
e,  granules  over  the  nucleus ; d,  granules  within  the  cell,  no  nucleus  visible ; c,  cell 
nearly  filled  with  granules ; /,  cell  completely  filled  with  granules  ; g,  cell  contracted 
in  its  middle ; A,  granular  mass,  the  cell-wall  having  dissolved ; i and  A,  granular 
masses  peeled  off  from  the  vessels. 


254 


PRINCIPLES  OF  MEDICINE. 


molecules  tal^es  place  within  the  nucleus  in  the  first  instance  (Fig.  323.) 
In  either  case  the  cell-wall,  distended  by  the  accumulation  of  fatty 
particles,  at  length  gives  wa}’^,  and  the  included  oil  granules  either 
abed  e separate,  or  for  a time  adhere  together 

in  granular  masses.  Sometimes  these 
bodies  are  easily  ruptured  by  external 
violeoce ; at  others  they  are  more  re- 
sistant, and  the  oily  matter  is  forced 
through  the  cell-wall,  and  collects  outside,  whilst  the  cell  itself  is  more 
or  less  collapsed  (Fig.  324,  e).  In  this  way  collections  of  fatty  granules 
and  grannie  cells  take  place  in  the  ducts  of  all  glands  which  are  lined 
by  epithelium  ; in  the  air  vesicles  of  the  lung  and  in  the  bronchi;  in  the 
cells  of  the  liver,  causing  fatty  degeneration  of  that  organ ; in  the  shut 
sacs  of  vascular  glands,  as  the  spleen,  and  in  all  cell  formations  from 
exudation,  especially  those  of  pus  and  cancer. 

In  stall-fed  animals,  a moderate  accumulation  of  fatty  granules  in 
the  interior  of  the  hepatic  cells  is  a normal  condition ; and  the  amount 
of  fat  in  various  tissues,  which  separates  health  from  disease,  is,  under  a 
variety  of  circumstances,  impossible  to  determine  with  exactitude. 

Fatty  Degeneration  of  Muscle. — There  can  be  no  doubt  that  the 
fibro-albuminous  substance  constituting  flesh  is  capable  of  undergoing  a 
transformation  into  fat.  Of  the  exact  chemical  nature  of  that  trans-- 
formation  we  have  yet  to  be  informed  ; but  it  may  not  only  be  observed 
ill  the  dead  body,  but  may  be  produced  artificially,  by  exposing  muscle 
to  a running  stream  of  water,  whereby  it  is  changed  into  adipocere.  In 


Fig.  325. 


Fig.  826.  Fig.  327. 

voluntary  muscle,  we  observe  that  the  degeneration  commences  with 
diminished  distinctness  of  the  transverse  striae,  especially  at  the  circum- 
ference of  the  fasciculus.  As  this  extends  inwards,  minute  molecules 
of  fat  occupy  the  position  of  the  striae,  and  at  length  obliterate  them  ; 
gradually  these  coalesce,  globules  of  various  sizes  are  formed  wdthin  the 


Fig.  324.  Granular  corpuscles  acted  upon  by  pressure,  a.  Some  of  the  oily 
granules  made  to  coalesce ; 6,  oil  forced  through  the  cell-wall ; c,  the  same  with 
collapse  of  the  cell-wall ; J,  rupture  of  the  cell-wall ; e,  dislocation  of  the  nucleus. 

Fig.  326.  Early  stage  of  fatty  degeneration  of  voluntary  muscle.  «,  The  muscle 
breaking  across ; h,  the  fibrillae,  easily  separated.  In  both  specimens  the  tissue  is 
soft  although  the  transverse  stria'  are  still  visible. — {Wedl) 

Fig.  326.  Advanced  stage  of  fatty  degeneration  in  the  muscular  fasciculi  of  the 
heart.  The  transverse  striie  have  disappeared,  and  the  fasciculi  are  wholly  composed 
of  oil  granules  and  globules  more  or  less  aggregated  together.— ( Wedl.) 

Fig.  327.  Another  example  of  advanced  fatty  degeneration  of  voluntary  muscle, 
the  fasciculi  presenting  various  degrees  of  the  alteration.  250  dtam. 


FATTY  DEGENERATION. 


255 


sarcolerama,  and  the  normal  structure  of  voluntary  muscle  disappears. 
Durino-  the  early  changes  the  fasciculus  becomes  soft,  exhibits  a ten- 
dency to  crack  crossways,  and  ultimately  is  so  pulpy  as  to  be  capable  of 
being  squeezed  easily  into  an  amorphous  mass,  from  which  large  oil  drops 
exude.  To  the  naked  eye,  the  muscular  substance  becomes  paler,  and 
more  fawn-colored,  and  at  length  yellow,  and  its  normal  density  is  greatly 
diminished.  These  changes  are  easily  observed  in  the  heart,  in  which 
organ  they  have  been  made  the  subject  of  special  research  by  Onnerod, 
Paget,  Quain,  and  others.  The  histological  and  clinical  researches  of 
Dr.  R.  Quain*  on  this  subject  ai-e  of  the  greatest  importance. 

All  the  voluntary  muscles,  however,  are  susceptible  of  undergoing  a 
similar  lesion,  and  it  not  unfrequently  occurs  in  those  of  the  lower  ex- 
tremity after  long  continued  paralysis,  disease  of  the  hip-joint,  or  other 
lesions  which  necessitate  immobility  of  the  parts.  In  this  case,  and 
occasionally  in  the  heart  itself,  in  addition  to  the  transformation  of  the 
muscular  fasciculi  above  described,  adipose  tissue  accumulates  between 
them,  and  by  compressing  their  sub'tance  adds  to  the  rapidity  and  com- 
pleteness of  the  transformation.  In  such  cases  the  muscles  are  of  a pale 


Fig.  328.  Fig.  829. 


yellow  color,  yielding  on  section  large  quantities  of  oil,  while  they  pre- 
serve their  usual  form  and  fibrous  look.  I have  seen  all  the  muscles  of 
the  lower  extremities  so  affected.  Occasionally,  while  some  muscles 
exhibit  this  transformation  in  its  most  advanced  stage,  others  close  be- 
side them  present  their  normal  red  color,  so  that  the  limb  on  dissection 
resembles  the  alternate  red  and  fatty  streaks  of  bacon.  In  this  case  the 
degenerated  muscle  has  the  whole  of  its  fasciculi  transformed  into 
adipose  cells,  with  nuclei,  as  seen  in  Fig.  329. 

* Med.  Chir.  Trans.,  vol.  xxii. 

Fig.  828.  Fatty  degeneration  of  the  psoas  magnus  muscle  of  a lad,  who  died  with 
morbus  coxarius.  a,  Muscular  fasciculi  in  which  no  traces  of  transverse  striae  are  per- 
ceivable. The  longitudinal  striae  are  still  not  quite  obliterated,  although  mingled  with 
numerous  fatty  granules.  6,  Muscular  fasciculi,  wholly  composed  of  minute  molecules 
and  granules,  with  no  traces  of  either  transverse  or  longitudinal  striae,  c,  Fat  cells 
of  various  sizes  running  between  and  encroaching  upon  the  fasciculi. 

Fig.  329.  Other  fasciculi  from  another  portion  of  the  same  muscle,  after  the  addi- 
tion of  ether.  The  adipose  cells  have  been  made  round  and  somewhat  flaccid ; the 
nucleus  consists  of  a congeries  of  brownish  granules.  250  diam. 


256 


PRINCIPLES  OF  MEDICINE. 


In  involuntary  muscles  fatty  degeneration  may  also  be  observed, 
although  it  is  by  no  means  so  common  as  in  voluntary  ones.  In  this 

case  oily  molecules  are  deposited  in 
the  elongated  fusiform  cells  com- 
posing the  texture,  and  by  their 
pressure  on  the  nucleus  cause  its 
disappearance.  Whether  the  dis- 
tended pregnant  uterus  shrinks  to 
its  normal  proportions  after  deliv- 
ery wholly  in  consequence  of  such 
a degeneration  (Heschl)  is  a point  not  yet  determined.  But  there  can 
be  no  doubt  that  many  of  the  greatly  enlarged  fusiform  cells  of  the  organ 
(Fig.  165)  do  become  more  or  less  crowded  with  fatty  granules  (Fig.  380). 

Fatty  Degeneration  of  Blood  vessels.  — T\iq  larger  blood-vessels,  espe- 


Flg.  333. 


cially  the  arteries,  are  very  commonly  the  seat  of  a fatty  degeneration, 
generally  called  atheroma.  It  presents  the  appearance  of  a whitish  or 
yellowish  cheesy,  but  sometimes  indurated  and  brittle  substance,  depos- 
ited between  the  coats  of  the  vessel,  and  often  protruding  on  its  inner 
surface.  This  deposit  consists  of  numerous  fatty  granules,  mingled  wdth 
crystals  of  cholesterine  (Gulliver),  to  which,  when  hard  and  brittle,  are 
added  calcareous  amorphous  salts  (Figs.  331  to  333). 

The  smaller  vessels  and  capillaries  are  frequently  seen  to  be  covered 

Fig.  330.  Enlarged  fusiform  cells  of  the  pregnant  uterus,  after  delivery,  filled  with 
fatty  granules.  250  diam. 

Fig.  331.  Atheroma  of  a blood-vessel.  Natura  size. 

Fig.  332,  Fatty  granules,  oil  di  ops  and  granule  cells,  with  crystals  of  cholesterine 
from  broken  down  atheroma  of  an  artery. 

Fig.  333.  Transverse  section  through  the  coats  of  the  popliteal  aidery  of  an  aged 
woman,  who  had  gangrene  of  the  feet,  a,  Inner  coat;  b,  longitudinal  fibres  ; c,  circu- 
culai  fibres  ; r/,  fimbriated  and  elastic  coats  loaded  with  fatty  granules  ; c,  external 
areolar  tissue. — {Wedl.)  200  diam. 


FATTY  DEGENEEATIOX. 


257 


with  patches  of  fatty  granules,  which  vary  in  number  from  two  or  three, 
to  large  masses  of  them,  which  infiltrate  the  ne’ghboring  tissue.  The 
various  appearances  of  these  were  carefully  described  and  figured  by  me 
in  1842,"^  and  attributed  to  exudations  thrown  from  the  vessel.  In 
1849  Mr.  Paget  f also  described  the  same  facts,  and  attributed  them  to 
fatty  degeneration  of  the  vessels  themselves.  Now,  without  denying  the 
occasional  fatty  transformation  of  the  walls  of  minute  vessels,  and  the 
accumulation  of  fatty  molecules  within  the  nuclei,  it  may  l eadily  be  seen 
that  for  the  most  part  the  fatty  granules  are  outside  the  vessels.  Indeed, 
the  extreme  tenuity  of  the  capillary  wall  does  not  permit  of  their  forma- 
tion in  its  substance,  as  it  is  much  thinner  than  the  granules  them- 
selves. Besides,  it  may  frequently  be  observed  that  the  largo  amount 
of  fatty  granules  outside  the  vessels  is  enormously  disproportioned  to  the 
bulk  of  the  latter,  and  altogether  inexplicable  by  supposing  them  to  be 
formed  in  and  given  ofiFby  the  vascular  walls  themselves,  which  for  that 
purpose  must  assume  a secretive  function.  I have  also  seen  and  figured 
cell-formations  in  every  stage  in  the  granular  fatty  matter,  cm  stituting 
softening  of  the  brain.  (See  Fig.  150.)  Of  these  Mr.  I'agct  wiote  in 


1853,1 — “ Produced  as  they  are  in  parts  of  the  brain  and  cord  in  which 
no  cell  structures  naturally  exist  (for  they  may  be  as  abundant  in  the 
white  substance  as  in  the  grey),  we  have  yet,  I believe,  to  trace  the 
source  and  method  of  their  formation.”  This  admission  appears  to  me 
altogether  hostile  to  the  idea  of  their  originating  in  a degeneration  of 
the  vessels,  whilst  their  formation  in  an  exudation,  as  I have  previously 
described  (p.  167),  is  consonant  with  every  known  fac4-.  The  true 


* Edin.  Mod.  and  Surg.  Journal,  vols.  Iviii.  and  lix. 
f Medical  Gazette, 
f Surgical  Pathology,  vol.  i.  p.  146. 

Fig.  334.  Cerebral  vessels  of  an  aged  individual  who  died  of  apoplexy,  a,  Ulti- 
mate capillaries;  A,. larger  vessel ; c,  small  artery,  with  fatty  granules  scattered  over 
its  surface. — ( Wedl.) 

Fig.  335.  Vessels  from  softening  of  the  corpus  striatum,  coated  with  granules  and 
granular  masses. — ( Wedl.) 


258 


PRINCIPLES  OF  MEDICINE. 


softening  of  the  brain  from  deficiency  of  nutrition  frequently  exhibits 
structural  changes  altogether  difierent,  as  I shall  subsequently  demon- 
strate. (See  Ui'cases  of  the  Nervous  System — Softening.) 

Fatty  Degeneration  of  the  Placenta. — Tlie  lesion  which  has  received 
tins  name  from  Dr.  Barnes  and  others,  was  figured  by  me  in  1844,* 
and  likened  to  that 
which  occurs  in  cer- 
tain softenings  of  the 
brain.  I still  hold 
the  same  opinion  in 
regard  to  it,  and  con- 
sider the  fatty  mole- 
cules and  granule 
cells  not  to  be  formed 
'by  a transformation 
'of  the  placental  tis- 
sue itself,  but  of  the 
exudation  or  extra- 
vasation of  blood 
which  is  poured  out  F 

from  its  vessels.  The  yellowish  or  fawn-colored  deposits  may  be  in- 
filtrated throughout  the  tissue  of  the  placenta  over  a greater  or  less 
space,  or  they,  may  occur  in  isolated  spots  forming  nodules.  They  are 
generally  somewhat  indurated,  and  give  rise  to  the  idea  that  they 


Fig.  338. 


Fig.  339. 


are  coagulated  fibrin.  I have  frequently  examined  them  and  traced  all 
* Treatise  on  Inflammation.  Plate — Fig.  10. 


Fig.  336.  Villi  from  the  placenta  of  a six  months’  fcet-us.  a and  6,  The  vessels 
coated  with  molecular  fatty  matter ; c,  exudation  from  the  vessel,  nearly  occupying 
the  whole  substance  of  the  villus  ; d,  chronic  exudation  outside  the  vessel  converted 
into  brown  ])igmcnt. — ( Wedl.) 

Fig.  337.  Fatty  granules  coating  the  blood-vessels,  within  the  placental  villi. — 
{Cowan.) 

Fig.  338.  Groups  of  fatty  granules  scattered  through  the  substance  of  a placental 
villus. — {Cowan.) 

Fig.  339.  Fatty  granules  both  coating  the  vessels,  and  scattered  through  the  villus 
substance. — ( Cowan. ) 


FATTY  DEGENERATION. 


259 


the  changes  intermediate  between  a coagulated  exudation  or  extravasa- 
tion of  blood,  and  the  ultimate  conversion  of  the  foreign  matter  into  a 
mass  of  molecules  filling  up  the  intervascular  spaces.  Similar  observa- 
tions have  been  more  recently  made  by  Drs  Handheld  Jones  * and 
Cowan. f 111  many  cases  the  fatty  material  may  be  eeen  forming  a layer 
SO}  arate  from  the  vessel  and  inside  the  limitary  membrane  of  the  villus. 
In  most  cases,  also,  the  texture  of  the  placenta  is  pale  from  compression, 
or  shrunken,  but  still  intact,  and  the  vessels,  though  coated  externally 
with  oil  granules,  are  themselves  quite  healthy.  Occasionally,  in  atro- 
phied placenta,  a quantity  of  browmish  pigment  is  deposited  between  the 
vascular  wall  and  limitary  membrane  or  the  villus,  which  is  probably 
owing  to  a modification  of  the  fatty  matter  or  of  the  coloring  material 
of  the  blood  (Fig.  352,  a).  (See  Pigmentary  Degeneration.) 

Fatty  Degeneration  of  Cartilage. — The  cells  of  cartilage  are  liable 
to  undergo  the  same  fatty  degeneration  as  is  observable  in  other  cells. 
Tlie  molecules  at  first  formed, 
how'ever,  are  exceedingly 
minute,  thus  communicating 
a brownish  opaque  aspect  to 
the  interior  of  the  cell  (Fig 
340).  Subsequently  they 
coalesce  and  form  larger  gra 
nules,  which  again  unite  to 
produce  drops  of  oil  of  con- 
siderable size.  During  this  Fig.  340. 

change  the  nucleus  disappears,  and  sometimes  the  hyaline  intercellular 
substance  presents  a multitude  of  brownish  points,  which  communicate 
to  it  a marked  opacity  (Fig.  351).  At  others  it  undergoes  the  fibroid 
transformation  formerly  described  (Fig.  137,  and  Figs.  269,  270). 

Fatty  Degeneration  of  Done. — Wedl  has  described  the  cancelli  of 
bone  in  syphilitic  caries  as  being  dilated  and  filled  with  fat,  owing  to 
the  exudation  poured  into  them  having  undergone  the  fatty  degeneration 
(Fig.  341),  and  in  most  cases  of  ulcerated  bone  a large  fciniation  of  oily 
molecules  and  loose  globules  of  oil  may  frequently  be  observed.  Virchow 
has  detected  similar  molecules  in  the  lacunae  and  canaliculi.  The  molities 
ossium,  or  malacosteon  of  adults,  is  also  a form  of  fatty  degeneration  of 
bones  (Paget),  in  which  the  cancelli  are  loaded  with  large  oil  drops,  often 
tinted  red.  Combined  with  these,  there  is  a formation  of  numerous 
cells,  which  vary  in  size  from  the  5 00^^^  of  an  inch  in 

diameter,  and  contain  a round  nucleus,  also  varying  much  in  size,  and 
occasionally  showing  various  stages  of  division  and  of  endogenous  deve- 
lopment (Fig.  344).  This,  like  so  many  other  of  the  so-called  fatty 
degenerations  of  texture,  is  probably  owing  to  an  exudation  from  the 
blood-vessels,  mingled  with  more  or  less  extravasation  of  the  colored 
corpuscles,  in  which  we  find  new  cells  developed,  combined  wdth  fatty 
transformations  of  the  albuminous  and  fibrinous  materials.  In  this 
* British  and  Foreign  Med.  Chir.  Rev.,  voi.  ii.  p.  354. 
f Edin.  Med.  and  Surgical  Journal,  April  1854. 


Fig.  340.  Cells  in  fatty  tracheal  cartilage.  They  are  filled  with  fatty  brown  mole- 
cules, and  the  secondary  cells  contain  oil  globules. — ( Wedl.)  250  d'lam. 


260 


PRINCIPLES  OF  MEDICINE. 


Fiy.  341, 


Fig,  343, 


Fig.  344. 


regarded  as  arrested  development  of  bone  with  increased  growth  of  car- 
tilage cells  (Kolliker) 

FatUj  Degeneration  of  other  Textures.  — It  would  occupy  too  much 
space  for  us  to  describe  or  even  particularise  every  tissue  that  is  now 
known  to  undergo  a fatty  degeneration.  All  the  glands  may  undergo 
this  change.  Nervous  texture  may  soften,  break  up,  its  fatty  material 
be  liberated,  and  accumulate  in  oil  drops  of  greater  or  less  size.  In 
emphysema,  the  pulmonary  texture  is  sometimes  fatty.  (Rainey.)  The 
cornea  (Canton)  and  the  lens  (Dalrymple,  Lebert)  also  may  be  similarly 
affected,  forming  soft  cataract.  Indeed,  under  various  circumstances,  it 
may  be  said  that  there  is  no  organ  or  texture  of  the  body,  which  in  some 
form  or  other  may  not  undergo  this  degeneration. 

Fattg  Degeneration  of  the  Exudations. — We  have  already  seen  that 
what  has  often  been  called  fatty  transformation  of  tissue,  is,  in  fact,  fatty 
transformation  of  the  constituents  of  the  blood,  which  have  been  exuded 
or  extravasated.  Simple  exudation  is  constantly  undergoing  fatty  de- 
generation. I have  seen  the  false  membrane  of  pleurisy  converted  into 
a creamy  substance,  composed  of  innumerable  fatty  molecules,  granular 
masses,  and  granule  cells.  Pus  cells  may  frequently  be  observed 
to  contain  fatty  granules,  and  to  present  all  the  intermediate  stages 
of  conversion  into  the  granule  cell,  and  the  same  may  be  observed  in  the 
pus  and  fibre  cells  of  granulating  sores.  In  Cancerous  exudation.,  the 
fatty  degeneration  is  so  common,  as  to  have  attracted  peculiar  attention, 
under  the  name  of  “ Reticulum.”  This  occurs  in  two  forms.  In  one 
it  is  seen  on  a fresh  cut  surface,  scattered  throughout  the  growth  to  a 

Fig.  341,  Horizontal  section  of  the  occipital  bone  in  a case  of  syphilis,  a,  Dense 
external  table,  the  internal  composed  of  dilated  caucelli  filled  with  fat,  seen  by  re- 
flected light. — ( Wcdl.)  3 diam. 

Fig.  342.  Thin  section  of  the  same  bone  showing  one  of  the  cancelli  enlarged  and 
filled  with  fat  globules,  surrounded  by  empty  lacunae. — (IIW/.) 

Fig.  343.  Thin  section  of  the  outer  table  of  the  same  bone. — ( Wcdl.) 

Fig.  344.  New  cells  I'ormcd  in  inalacosteon.  a,  From  the  marrow  of  the  femur ; 
b,  others  with  developing  nuclei ; c,  fiom  a rib  in  anoth.cr  case,  in  which  some  organs 


were  cancerous. — {Wcdl.) 


250  diam. 


FATTY  DEGENERATION. 


261 


greater  or  less  extent,  as  a network,  more  thick  and  abundant,  however 
in  some  places  than  in  others.  In  the  other  it  exists  in  masses  of 
a bright  yellow  or  orange  color ; sometimes  closely  resembling  tubercle 
for  wnicii  it  has  often  been  mistaken.  In  the  first  form,  granule  cells’ 
loose  oil  granules  mure  or  less  mingled  with  decayed  and  broken-down 
canc.r-ceiis,  are  cuimnon.  ^ In  the  second,  irregular  bodies,  resembling 
tubeicie  corpuscles,  resulting  from  alteration  in  the  form  of  the  nucleus 
after  the  ceil-wall  has  been  broken  down,  are  numerous  (Fig.  848).  In 
son:  3 retrograde  cancers  I have  seen  large  portions  of  the  growth 

Fig.  347. 


Fig.  345.  Fig.  346.  Fig.  348. 

entirely  composed  of  such  corpuscles,  and  not  unfrequently  these, 
as  well  as  cancer-cells  in  all  stages  of  decay,  are  associated  with  crystals 
of  cholesterine  or  margarine  (Figs.  345,  346).  Tubercular  exudation 
may  always  be  observed  to  contain  a greater  or  less  number  of  fatty 
granules  embedded  in  it,  as  well  as  contained  in  the  tubercle  corpuscles. 
AVhat  is  called  the  softening  of  tubercle  is  owing  to  an  increase  of  these, 
by  the  gradual  transformation  of  the  albuminous  part  of  the  exudation 
into  fatty  molecules,  whereby  the  whole  is  rendered  soft  and  pulpy. 
(See  Fig  158.) 

Fatty  Degeneration  of  Morbid  Growths. — All  these  are  susceptible  of 
becoming  fatty,  and  consequently  soft  and  pultaceous ; the  transforma- 
tion is  accomplished  in  a manner  exactly  similar  to  what  we  have 
described  as  occurring  in  the  tissues  of  which  they  are  composed,  or  of 
the  exudations  which  are  conjoined  with  them. 


General  Pathology  and  Treatment  of  Fatty  Degeneration. 

The  causes  of  fatty  degeneration  .vre  to  be  sought  in  all  those  cir- 
cumstances which  weaken  the  vital  action  of  a part,  but  do  not  interfere 
materially  with  the  assimilation  of  hydro-earburets.  The  disease,  how- 
ever, is  not  purely  local,  as  it  may  frequently  be  observed  that  the  kid- 
neys, liver,  heart,  and  other  textures,  are  prone  to  undergo  the  fatty 
change  in  the  same  person.  Hence  everything  that  increases  fatty 

Fig.  345.  Ketrograde  cancer-cells,  granules  and  granular  masses,  with  crystals  of 
cholesterine,  from  the  reticulum  of  cancer  of  a lymphatic  gland. 

Fig.  346.  Fatty  and  broken  down  cancer-cells,  with  crystals  of  margarine,  from 
the  reticulum  of  cancer  of  the  liver. 

Fig.  347.  Fatty  granular  matter  from  the  softened  reticulum  of  a cancer  of  the 
breast. 

Fig.  348.  Liberated  and  altered  nuclei,  with  fatty  molecules,  from  the  reticulum 
of  a cancer  of  the  testicle.  250  diam. 


262 


PRINCIPLES  OF  MEDICINE. 


matter  in  the  blood,  such  as  its  introduction  bj  means  of  assimilation, 
or  its  not  passing  off  in  consequence  of  diminished  excretion,  tends  to  its 
deposition.  Thus  indulgence  in  rich  food,  and  alcoholic  liquors 
abounding  in  carbon,  especially  if  there  be  little  exercise,  occasions  it. 
Whether  the  fatty  matter  be  deposited  directly  from  tne  blood,  or 
whether  it  he  the  subsequent  result  of  a chemical  transformation  of 
tissue  or  exudation,  has  excited  discussion.  Dr.  Qiiain  supports  the 
latter  view,  and  has  performed  experiments,  whereby  it  would  seem  that 
healthy  muscular  fibrin  may  be  rendered  fatty  artificially,  by  digesting 
it  for  a fortnight  in  water.  I have  repeatedly  seen  muscles  and  bones 
converted  into  adipocere,  during  the  maceration  in  water  necessary  to 
clean  the  latter,  and  have  frequently  examined  the  former  during  the 
process,  so  as  to  satisfy  myself  that  the  fibrinous  material  of  fiesh  under- 
goes a chemical  transformation  into  fat.  I believe  with  Dr.  Quain  that 
the  same  thing  occurs  in  the  living  body,  not  only  when  dead  tissues 
are  enclosed  i.i  it,  as  in  the  experiments  of  Wagner,  but  slowly  in  living 
texture,  until  its  vigor  is  at  length  so  impaired  that  it  is  incapable  of 
performing  its  function.  This  view  in  no  way  excludes  the  probability 
of  the  fact  that  in  certain  cases  fatty  matter  may  transude  through  the 
vessels  in  a fluid  state,  and  collect  outside,  or  be  infiltrated  to  a certain 
extent  among  neighboring  textures  in  a molecular  form.  Further,  we 
have  seen  that  fat  may  occur  within  cells  as  a secretion,  and  by  its 
accumulation  cause  not  only  atrophy  of  the  nucleus,  but  also  obstruction 
of  tubes  and  an  endless  variety  of  organic  and  functional  derangement 
ill  the  eccnomy,  according  to  the  extent  and  seat  of  the  degeneration. 

The  treatment  of  this  lesion  is  a field  of  inquiry  which  as  yet  has 
scarcely  been  entered  upon.  In  most  cases,  indeed,  its  diagnosis  in  the 
living  subject  is  very  uncertain.  But  the  cultivation  of  histology,  by 
gradually  enlightening  us  concerning  those  degenerations  which  are 
essentially  fatty,  and  enabling  physicians  to  recognise  them  as  the  cause 
of  symptoms  with  which  he  has  been  long  familiar,  will  assuredly  at  no 
distant  day  lead  to  more  correct  principles  of  practice.  Already  we 
begin  to  see  indications  of  this  in  our  notions  regarding  Bright’s  disease, 
and  in  the  results  of  organic  chemistry  applied  to  clinical  medicine.  At 
present  it  would  be  premature  to  speculate  on  this  subject,  and  what 
little  there  is  to  be  said  will  be  found  under  the  head  of  special  diseases. 
(See  Obesity.) 

Pigmentary  Degeneration. 

The  formation  of  pigment  in  plants  and  animals  is  essentially  con- 
nected with  that  of  fat,  most  colors  either  being  different  kinds  af  tinted 
oil,  or  secreted  in  cells  at  the  expense  of  carbonaceous  products,  which 
are  readily  transformed  into  fatty  compounds.  In  morbid  conditions  we 
find  several  of  the  textures  of  different  tints,  but  more  especially  red, 
yellow,  brown,  green,  or  black,  from  chemical  alteration  in  the  coloring- 
matter  of  blood  or  bile.  Sometimes  the  change  of  color  is  the  result  of 
peculiar  secretions  ; at  others,  of  the  deposition  of  carbon. 

Red  Figments. — All  red  coloration  in  the  human  body  is  owing  to 
the  presence  of  blood,  the  coloring  principle  of  which  has  been  called 
hematine.  When  observed  in  an  isolated  blood  corpuscle,  in  which  it 


PIGMEJNTAKY  PEGEJS  PKATIOX. 


2G3 


is  secreted,  the  real  color  is  seen  by  transmitted  light  to  be  yellow, 
although,  as  occurs  with  a strong  infusion  or  tincture  of  saffron,  it  looks 
red  to  the  naked  eye  when  concentrated.  Unless,  how- 
ever, it  were  known  that  the  real  color  of  the  blood  is 
yellow,  it  would  be  impossible  to  understand  the  pre- 
sence of  this  latter  tint  around  ecchymotic  spots,  and 
in  other  situations.  Virchow  first  described  in  extra- 
vasations of  blood  prismatic  crystals,  with  rhomboidal 
bases,  often  approaching  a needle  shape,  of  a yellowish 
or  deep  ruby  color,  which  he  denominated  hemaioi- 
dine.  They  are  most  frequently  found  in  the  sangui- 
neous extravasations  of  the  brain,  in  the  corpora  lutea 


of  the  ovaries,  and  in  chronic  haemorrhages  of  the 
liver,  of  hydatid  cysts,  and  of  other  textures,  but 
rarely  in  pulmonary  or  cancerous  extravasations.  In 
size,  they  vary  from  the  gfj’ooth  to  the  ^^oth  of  an  J 

inch  in  their  long  diameter  (Fig,  349).  They  are  ^ 

transparent,  and  strongly  refractive,  insoluble  in 
alcohol,  ether,  dilute-mineral  acids  and  alkalies.  Con- 
centrated  mineral  acids  cause  them  to  assume  the  ” 

shades  of  green,  blue,  rose-tint,  and  finally  a dirty  yel-  Fig.  349. 

low. 


Yellow  Pigment. — The  real  color  of  the  blood  corpuscles  is  vellow, 
and  so  is  the  liquor  sanguinis  in  which  they  are  dissolved,  and  conse- 
quently all  recent  exudations  of  lymph  as  well  as  most  kinds  of  pus  and 
tubercle.  Blood,  after  being  extravasated,  is  broken  down  and  absorbed  ; 
and  as  the  coloring  matter  becomes  less  intense,  it  generally  assumes 
a yellowish  tint,  as  around  ecchymotic  spots  and  old  extravasations. 
Hence,  also,  the  color  of  the  corpora  lutea,  and  the  yellow  soften ii  gs 
of  the  brain,  as  well  as  the  deep  orange  tint  occasionally  observed  as 
the  result  of  haemorrhages.  The  adipose  texture,  and  morbid  accumu- 
lations of  fatty  matter,  assume  a yellow  tint,  as  when  muscle  undergoes 
the  fatty  degeneration,  and  the  reticulum  previously  described  forms  in 
cancer. 

There  is,  however,  another  source  of  this  color  in  the  bile,  as  it  con- 
tains a deep  yellow  pigment,  which,  when  absorbed  into  the  blood,  tinges 
all  the  textures,  and  passes  off  in  large  quantities  by  the  skin  and  kid- 
neys. The  urine  when  impregnated  with  it  in  considerable  quantity,  lias 
the  color  of  porter  to  the  naked  eye.  When  bile,  diluted  with  water,  is 
treated  with  nitric  acid,  a marked  series  of  changes  in  color  ensue.  A 
little  acid  renders  it  green,  a larger  quantity  blue,  purple,  violet,  and 
lastly,  a dull  red  or  brown  yellow.  These  changes  are  supposed  to  be 
owing  to  the  existence  of  three  coloring  matters  in  the  bile—  one  brown, 
the  cholepurrhin  ; another  yellow,  the  hilifulvin — both  discovered  by 
Berzelius;  a third  the  hiliphoeln  of  Simon.  Whether  these  pigments 
are  derived  from,  or  converted  into  hematine,  has  not  yet  been  ascertain- 
ed, though  Virchow  suspects  that  they  are  the  same,  from  the  similar 
changes  produced  in  crystals  of  hematoidine  by  the  action  of  acids. 

Brown  Pigments. — During  the  decomposition  of  extravasated  blood, 


Fig.  349.  Crystals  of  hematoidine.  a,  Large  oblique  rhombic  prisms  ; at  -p, 
oblique  six-sided  prism  ; 6,  smaller  forms. — {Wedl.)  250  diam. 


264 


PRINCIPLES  OF  MEDICINE. 


it  has  often  been  observed  that  the  tints  it  sometimes  presents  are  of  a 

reddish,  and  sometimes  of  a bistre 
brown.  Bile^  also,  when  in  mass,  and 
inspissated,  often  assumes  this  color. 
Different  ganglia  scattered  through 
the  nervous  system  owe  their  color  to 
the  formation  of  brown  pigment  mole- 
cules, which  are  deposited  in  the 
nerve-cells.  The  skin  in  some  races, 
is  naturally  brown  or  swarthy ; the 
areolae  round  the  nipples  assume  this 
tint  during  pregnanc}^ ; exposure  to 
the  sun  induces  this  coloration  of  the 
skin,  and  causes  freckles,  and  often 
large  brown  patches  to  appear  on  it  in 
the  fairest  women , many  warts  and 
naevi  are  also  of  this  color.  In  all 
these  cases  the  color  arises  from  the 
deposition  of  a brown  molecular  pig- 
epidermis,  and  sometimes,  as  in  warty 
najvi,  from  accumulation  of  dark  pigment  in  minute  sacs  (Fig.  350). 

Not  unfrequently  brown  pigment  may  be  observed  collected  within 
cartilage  cells,  when  that  texture  is  diseased  iu  the  nei«-hborhood  of 


Fig  350, 

ment,  in  the  deeper  cells  of  the 


Flg.351.  ^ ^ ^ Fig.  352. 

necrosed  bone,  or  in  death  of  cartilage  itself  (Fig.  351).  Occasionally, 
also,  it  is  found  covering  placental  villi,  or  situated  between  the  vessel 
and  limitary  membrane  of  the  tuft,  evidently  the  result  of  changes  oc- 
curring in  extravasated  blood  (Fig.  352). 

Dr.  Addison  has  de.scribed  a form  of  anmmia,  in  which  the  skin 


Fig,  350,  Wartlike  brown  n(evus  maternus  of  the  female  mamma,  a,  Epidermic 
cells,  with  their  nuclei  concealed  by  a dark  brown  pigment ; h.  ttie  nuclei  surrounded 
with  similar  pigment;  c,  cells  witliout  pigment;  </,  reddish-brown  pigment,  in  the 
substance  of  an  hypertrophied  papilla ; c,  nuclei  in  fibrous  texture  ; f,  vascular  loon. 

— (ir«/^.) 

Fig.  351.  Atrophied  bronchial  cartilage,  with  deposition  of  brown  pigment,  a, 
Cells  containing  brown  granular  pigments ; 6,  cells  containing  large  fat  globules ; c, 
secondary  cells  with  fatty  granules.  The  inter-cellular  substance  is  loaded  with  and 
obscured  by  brown  pigment  granules. — ( Wtdl.) 

Fig  352.  Placental  villi,  containing  brown  pigment  from  an  aborted  foetus,  18 
inches  long,  a,  Villus,  at  its  termination  loaded  with  brown  pigment ; 6,  one  only 
partially  so  filled  at  its  summit,  but  with  molecular  pigment  scattered  through  its  sub- 
sta-.ic  j. — ( \7cdl.)  250  dia7n. 


PIGMEJSTAKV  J>E(iKN  EK A I'lON. 


265 


assumes  a peculiar  coloration,  in  connection  with  a diseased  condition 
of  the  supra-renal  capsules.  It  presents  “ a dingy  or  smoky  appearance, 
or  various  tints  or  shades  of  deep  amber  or  chestnut  color  ; and  in  ore 
instance  the  skin  was  so  universally  and  so  deeply  darkened,  that,  but 
for  the  features,  the  patient  might  have  been  mistaken  for  a mulatto.”  * 
Eleven  cases  have  been  published  by  Dr.  Addison,  and  several  more 
subsequently  by  Mr.  Hutchison,  Dr.  Wilks,  and  others,!  where,  co-inci- 
dent with  this  bronzing  of  the  skin,  the  supra-renal  capsules  were  indu- 
rated, cancerous,  or  otherwise  diseased.  The  presumed  connection  be- 
tween the  functions  of  these  glands,  and  the  secretion  of  pigment  in  the 
integuments,  has  excited  the  attention  of  physiologists  and  pathologists. 
The  experiments  of  the  former  and  observations  of  the  latter  have  not 
shown  that  there  is  any  true  relation  between  disease  of  these  glands 
and  the  amount  of  pigment  in  the  skin.  Dr.  Harley, | more  especially, 
has  demonstrated  that  their  excision  in  white  and  piebald  rats,  causes 
no  alteration  in  the  health  or  external  appearance  of  the  animals.  Nu- 
merous cases  also  are  now  on  record  of  bronzed  skin  without  alteration  in 
the  supra-renal  capsules,  and  of  extensive  lesion  of  these  glands  without 
bronzed  skin. 

Green  Pigment. — The  cause  of  green  pigment  has  not  yet  been 
determined.  We  have  seen  that  nitric  acid  produces  a grass  green  color 
when  added  to  bile,  and  it  is  possible  that  the  addition  of  some  acid 
matter  to  heinatine  in  certain  states  of  combination  may  produce  a 
similar  result.  Abscesses  of  the  brain  not  unfrequently  contain  pus  of 
a decided  green  color,  and  vomited  matters  occasionally  present  the 
same  hue.  The  fmces  in  young  children  are  sometimes  of  a spinach 
green,  which  is  supposed  to  result  from  an  altered  condition  of  bile,  or 
from  the  pre^jence  of  blood.  The  contents  of  cysts  frcc|uent]y  contain 
fluid  of  different  shades  of  green.  In  mortification  and  putrefaction 
after  death,  the  integuments  frequently  assume  a greenish  hue.  Lastly, 
morbid  growths,  especially  in  the  bones  of  the  cranium,  have  been  de- 
scribed and  figured  of  a decidedly  green  color  {Chloi  traob)  by  Balfour,^ 
King,  II  and  Lebert.!" 

Black  Pigment. — Black  pigment  is  b}''  far  the  most  cemmon  degen- 
eration met  with,  and  is  found  in  various  situations.  Thus  ecchymotic 
extravasations  generally  assume  a dark  purple  or  black  color.  Vomit- 
ings of  blood  in  yellow  fever  and  gastric  cancer  are  frequently  dark 
brown  or  black ; so  also  are  the  faeces  after  blood  has  been  mixed  with 
them  [Melcena].,  or  taking  ferruginous  medicines;  certain  softenings  of 
the  stomach  itself,  of  the  intestinal  glands,  and  of  the  entire  mucous 
membrane  in  cases  of  dysentery;  the  contents  of  ovarian  cysts  and  other 
encysted  tumors;  intestinal  and  ovarian  cicatrices;  the  sordes  on  the 
teeth  and  gums  in  cases  of  fever  ; and  mortified  or  dead  parts.  When 
morbid  growths  are  black  they  have  received  the  name  of  Melanoma^ 

* On  the  constitutional  and  local  effects  of  disease  of  the  supra-renal  capsules. 
1855. 

f Medical  Times  and  Gazette.  Guy’s  Hospital  Reports,  1862. 

t Brit,  and  P’or.  Med.  Chir.  Review,  vol.  xxi.  1858. 

§ Edin.  Med.  and  Surg.  Journal,  vol.  xliii.  p.  319. 

II  Monthly  Journal  of  Medical  Science,  Aug.  1853. 

^ Anatomic  Pathologique,  Planche  xlv. 


266 


PRINCIPLES  OF  MEDICINE. 


and  the  black  coloration  of  the  collier’s  lung  and  bronchial  glands  ha?> 
been  called  False  Melanosis  or  Black  Phthisis 
Nothing  is  more  common  than  to  see  chroiiio 

6 


353). 

Black  patches  have  occasionally  been  produced 
on  the  skin,  apparently  from  the  secretion  of  pig- 
mentary matter  on  the  surface,  which  is  capable  of  being  washed  off,  A 
case  of  this  kind  is  recorded  by  Mr.  Teevan,*  in  the  person  of  a young 
girl,  aged  15,  the  upper  part  of  whose  face  was  covered  with  a black 
discoloration.  The  coloring  matter  was  analysed  by  Dr.  Bees,  who 
found  in  it  carbon,  associated  under  the  microscope  with  short  hairs, 
epithelial  scales,  and  granules  and  globules  of  fat. 

Portions  of  necrosed  bone  are  often  of  a black  color,  a change  which 
according  to  Wedl  commences  at  the  external  portion  of  the  systems  of 
bone  corpuscles,  disposed  round  the  Haversian  canals.  The  blackening 
is  probably  owing  to  a chemical  change  of  the  osseous  texture,  similar  to 
what  occurs  in  caries  of  teeth  from  the  action  of  acid  saliva.  It  is  not 


tubercle  surrounded  by  black  pigmentary  deposit. 
Scattered  tubercles  on  the  peritoneum  are  often 
surrounded  by  a black  ring,  which,  when  magni- 
fied, present  the  appearance  represented  (Fig. 


Fig.  354. 

dependent  on  an  exudation,  which  in  sections  of  a bone  so  affected  is 
nowhere  visible  (Fig.  354). 

Black  pigment  may  exist  in  the  form  of  minute  granules  (Fig.  355), 
* London  Medico-Chir.  Transactions,  vol.  xxviii. 

Fig.^  353.  Ring  of  black  pigment  masses  {a)  and  molecules  {h)  round  a tubercle  of 
the  peritoneum.  The  black  tint  disappeared  after  some  days’  immersion  in  alcohol. 

250  diam. 

Fig.  354.  Transverse  section  of  a necrosed  tibia.  «,  Medullary  canals  divided 
transversely ; 6,  pigment,  formed  at  the  junetions  of  the  concentric  bone  systems : c. 
radiating  bone  canaliculi. — {Wedl.)  90  diam. 

Fig.  355.  Black  pigment  molecules  from  the  lung. 

Fig.  35G.  Black  pigment  irregular  masses  semi-crystalline,  from  an  intestinal  ag- 
gregate gland. 

Fig  357.  Polygonal  cells  loaded  with  pigment,  from  the  surface  of  the  pericardium. 
Fig.  358.  Cells  loaded  with  pigment,  having  clear  nuclei,  from  a melanotic  tumor 
of  the  horse.  250  diam. 


PIGMENTARY  DEGENERATION. 


2G7 


or  of  irregular  masses  scattered  tliroughout  a texture  (Fig.  356).  Some- . 
times  the  former  are  fouud  within  cells  which  may  be  round,  flattened, 
many-sided,  or  have  irregular  prolongations  (Figs.  357,  359).  This 
occurs  in  the  choroid  membrane  of  the  eye  ; in  the  skin  of  men  and 
animals  during  health ; in  the  melanotic  growths  so  common  in  grey 
horses  (Fig.  358),  in  the  epithelial  cells  of  the  collier’s  lung,  and  in 
certain  forms  of  cancer  (Figs.  359,  360).  In  alt  these  cuses  the  nucleus 
is  sometimes  clear  and  colorless,  and  at  other  times  ob-cured  by  the 
black  pigment.  Black  pigment  may  also  occur  in  the  cry^  talline  form, 
associated  with  hematoidine,  in  old  sanguineous  extravasations.  It  has 
then  been  called  Melanin. 

It  may  be  easily  shown  that  the  black  pigment  granules,  cells,  and 
crystals,  found  in  morbid  products,  althougb  they  may  closely  resemble 
each  other  to  the  naked  eye,  and  even  under  the  mici  oscope,  are  difi’erent 
in  their  chemical  compositions.  Thus  one  kind  of  black  pigment  loses 
color  on  the  addition  of  nitro-muriatic  acid  or  chlorine  wat(;r,  whilst 
another  resists  not  only  these  agents,  but  even  the  action  of  the  blow- 


pipe. It  follows  that  the  latter  consists  of  carbon,  as  in  Fig.  360, 
while  the  former  is  a peculiar  secretion  formed  within  cells,  or  a trans- 
formation of  the  coloring  matter  of  the  blood,  as  in  Fig.  359. 

Blue^  purple,  and  other  pigments. — Blue  pigment  has  been  described 
as  occasionally  occurring  in  urine.  This  was  first  ascertained  by  Prout 
to  be  due  to  blue  indigo,  and  it  appears  probable  from  the  researches  of 
Schunk  and  others,  that  all  the  blue  and  purple  colorations  which  have 
been  seen  in  urine,  are  due  to  the  decomposition  of  Indican  (a  normal 
constituent  of  this  excretion)  and  the  formation  of  blue  and  red  indigo. 
The  addition  of  strong  sulphuric  acid  to  an  equal  quantity  of  urine,  at 
once  produces  these  colorations. — (Carter.) 

General  Pathology  and  Treatment  of  Pigmentary  Degeneration. 

The  formation  and  modifications  of  pigment,  as  observed  in  plants 
and  animals,  is  a subject  which  has  been  little  studied,  and  opens  up  a 

Fig.  3.59.  Cells  in  a melanotic  cancer  of  the  cheek,  the  black  pigment  in  which 
disappeared  on  the  addition  of  hydrochloric  acid. 

i ig.  360.  Cells  in  the  black  sputum  of  the  collier,  the  pigment  in  which  is  persis- 
tent under  the  action  of  every  known  chemical  agent.  250  diam. 


268 


PRINCIPLES  OF  MEDICINE, 


wide  field  of  inquiry  for  tlie  chemical  histologist.  In  endeavoring  to 
ascertain  the  causes  which  give  rise  to  change  of  color  in  the  textures, 
we  must  attend  to  the  following  circumstances : 

Is^,  Coloring  matter  bears  a certain  relation  to  the  non-nitrogenous 
and  oily  constituents  both  of  plants  and  animals.  Thus  vegetable  oils 
and  resins  are  seen  to  form  in  plants  where  starch  or  chlorophyle  is  col- 
lected ; the  latter  substances  disappearing  in  the  cells,  as  the  quantity  of 
oil  increases  in  them.  In  animals  we  almost  always  find  pigment  asso- 
ciated with  fat.  The  brilliant  colors  of  the  invertebrata  are  so  many 
colored  fats,  and  the  pink  fat  of  the  salmon,  and  green  fat  of  the  turtle, 
indicate  the  same  relation  in  animals  higher  in  the  scale.  The  epider- 
mic appendages,  which  are  generally  colored,  are  always  covered  with 
fat,  secreted  by  a special  apparatus — the  sebaceous  glands.  The  blood 
corpuscles  are  intimately  associated  with  the  chyle,  which  is  an  oily 
emulsion,  and  the  bile  is  rich  in  fat.  In  diseased  conditions  of  the  liver, 
the  hepatic  cells  often  contain  oil  to  the  exclusion  of  the  yellow  pigment. 

2(i,  It  would  appear  that  light,  heat,  and  exposure  to  atmospheric 
air,  are  connected  with  the  production  of  pigme  it.  The  young  leaves 
of  plants  are  much  lighter  in  color  than  those  which  are  older,  and  the 
h lir  of  young  animals  is  not  so  dark  as  that  of  the  adult.  In  autumn 
the  leaves  fade,  and  become  brown,  reddish,  or  yellow,  and  in  man  we 
observe  that  the  pigment  of  the  hair  ceases  to  be  formed  in  advanced 
age,  which  at  length  becomes  white.  Young  fruit  is  green,  and  as  it 
ripens,  the  part  exposed  to  the  sun  is  most  colored.  Exposure  of 
the  skiu  of  man,  as  is  well  known,  renders  it  darker,  and  the  fairest 
sldnned  individuals  (whose  integuments  are  well  loaded  with  fat) 
are  those  who  are  most  subject  to  freckles.  Then  it  must  be  remem- 
bered, that  while  light  evolves  color  in  living,  it  destroys  pigment  in 
dead  textures. 

New  the  decomposition  of  the  atmosphere  is  carried  on  in  vegetables 
by  the  leaves,  under  the  stimulus  of  light,  and  in  animals  by  the  lungs 
and  skin.  In  plants  the  leaves  fix  the  carbon  and  give  off  the  oxygen  ; 
in  animals  the  lungs  receive  oxygen,  while  carbon  is  separated  in  the 
form  of  carbonic  acid  by  the  same  organs,  and  oxygen  in  combination 
with  water,  in  the  form  of  exhalation,  is  given  off  both  by  the  lungs  and 
skin.  That  the  skin  is  connected  with  respiration  is  proved  by  the  fact, 
that  if  its  functions  are  interrupted,  pulmonary  diseases  and  even  asphyx- 
ia are  the  common  results.  Carbon  is  also  separated  in  the  form  of  oily 
matter  largely  by  the  skin  and  by  the  liver,  an  org \n  also  connected 
with  respiration  Hence  why  Europeans  in  tropical  climates,  by  breath- 
ing a rare  atmosphere,  eating  much,  and  taking  little  exercise,  are  liable 
to  hepatic  diseases.  Thus  the  lungs,  skin,  and  liver,  are  intimately  as- 
sociated, in  the  function  of  excreting  carbon,  and  it  is  curious  that  these 
arc  the  three  organs  in  which  pigment  is  formed. 

3i?,  There  seems  to  be  a certain  connection  between  the  materials  in- 
troduced into  the  structure  of  the  plant  or  animal  by  means  of  the  soil 
and  of  food.  Some  plants  are  rich  in  acids,  others  in  alkalies,  or  vari- 
ous salts  originally  derived  from  the  soil,  and  we  have  seen  that  these 
re-agents  operate  on  coloring  matter.  Although  this  subject  has  been 
very  slightly  investigated,  we  can  still  perceive  how,  by  the  evolu- 


MINERAL  DEGENERATION. 


269 


tion  of  chemical  products,  acting  on  different  pigments,  the  various 
shades  of  color  may  be  occasioned,  which  we  observe  in  most  plants 
and  some  animals  at  certain  seasons.  Thus  green  chlorophyle  may  be 
changed  in  one  place  into  a yellow  resin,  and  in  another,  by  the  for- 
mation of  ulmic  or  other  acids,  be  transformed  reddish  or  brown.  In 
animals  the  influence  of  nutrition  is  traced  with  more  difficulty,  but 
even  here  we  may  discern  that  at  certain  seasons  (such  as  that  of  breed- 
ing) new  products  are  evolved,  which,  by  operating  on  the  blood  or  the 
vital  properties  of  cells,  may  eliminate  more  or  less  color.  Accord- 
ing to  Heusinger,  carbonaceous  food  used  in  excess  tends  to  the  pro- 
duction of  pigment,  and  hence  he  explains  how  the  Greenlanders, 
notwithstanding  the  cold,  are  dark  colored,  from  their  constant  con- 
sumption of  fat. 

For  the  pathology  of  carbonaceous  deposit  in  the  lungs  of  the  collier, 
I must  refer  to  the  special  diseases  of  the  respiratory  system.  (See  Car- 
bonaceous Lungs.) 

The  treatment  of  pigmentary  degenerations  is  most  uncertain,  but  if 
the  preceding  observations  are  in  any  way  well  founded,  it  must  be  clear 
that  the  management  of  this  lesion  must  be  directed  to  removing  the 
physiological  conditions  on  which  it  depends. 

Mineral  Degeneration. 

By  this  term  is  understood  the  infiltration  or  deposition  of  mineral 
matter  into  a texture,  in  such  a way  that  it  is  no  longer  capable  of  per- 
forming its  functions.  We  have  already  seen  that  sometimes  this  takes 
place  in  such  a regular  manner  as  to  form  bone,  which  replaces  the  pre- 
existing texture,  as  in  muscle,  membrane,  or  certain  exudations  and 
tumors.  But  at  others  it  enters  into  the  constitution  of  a texture  dis- 
solved in  fluid,  and  is  thus  deposited  in  or  throughout  its  substance, 
changing  its  physical  and  destroying  its  vital  characters.  In  this  way 
we  separate  mineral  degenerations  from  concretions,  which  are  accidental 
collections  in  hollow  viscera,  although  undoubtedly  they  insensibly  pass 
into  one  another.  There  is  scarcely  perhaps  any  tissue,  whether  elemen- 
tary or  compound,  that  may  not  undergo  the  mineral  degeneration.  But 
it  is  frequently  observed  in  the  coats  of  blood-vessels  more  or  less  asso- 
ciated with  atheroma;  in  exudations;  in  certain  morbid  growths — rarely 
in  nervous  texture. 

Mineral  Degeneration  of  Blood- Vessds. — Nothing  is  more  common 
than  to  find  the  large  arteries  brittle  from  the  deposit  of  mineral  matter 
in  their  coats,  often  associated  with  fatty  degeneration  or  atheroma; 
sometimes  the  one  lesion  and  sometimes  the  other  having  the  predomi- 
nance. Plates  and  patches  of  mineral  matter  may  in  this  way  often 
be  observed,  which  on  stripping  off  the  internal  membrane  (Fig.  362,  a) 
may  be  seen  embedded  in  the  middle  coat  h.  These  never  present  the 
structure  of  bone,  but  either  an  amorphous  conglomeration  of  mineral 
matter,  or  an  amalgamation  of  round  globules,  similar  to  those  which 
Czermak  has  described  as  sometimes  occurring  in  dentine  (Fig.  362,  cf 
Occasionally,  though  more  rarely,  the  smaller  vessels  undergo  a similar 
degeneration.  In  this  case  mineral  matter  is  deposited  in  their  coats, 


270 


PRINCIPLES  OF  MEDICINE. 


which  when  widely  scattered  also  presents  a globular  form,  closely  re- 
sembling drops  of  oil, 
for  which  they  are  apt 
to  be  mistaken,  unless 
mineral  acids  are  added, 
when  they  dissolve  with 
effervescence.  Fig.  361 
represents  this  degene- 
ration in  the  small  ves- 
sels of  the  brain  as  de- 
scribed by  Dr.  Bristowe 
and  Mr.  Bainey.* 

Mineral  Degenera- 
tion of  Nervous  Texture. 
Deposition  of  mineral 
matter  in  the  tubes  or 
ganglionic  cells  of  ner- 
vous substance  is  a rare 
occurrence  in  man,  although  more  common  in  sheep  and  other  of  the 
inferior  animals.  Foerster,  however  has  recorded  the  case  of  a boy  who 


Fig.  362. 


had  paralysis  of  the  lower  extremities,  and  in  whose  spinal  cord  after 
death,  the  nerve-cells  and  tubes  were  found  encrusted  with  mineral  de- 
posits, as  seen  in  Fig.  363.  In  this  case,  also,  the  cretaceous  closely 
* London  Pathological  Transactions,  vol.  iv.  p.  118. 

Fig.  361.  Incrustation  of  the  small  vessels  of  the  brain,  with  carbonate  and 
phosphate  of  lime,  in  the  form  of  globules,  some  masses  of  which  are  separated, 
whilst  others  are  aggregated  together  outside  the  vascular  wall. — [Bristowe  and 
Rainey.) 

Fig.  362.  Structure  of  mineral  degeneration  of  the  walls  of  an  aneurism,  a.  The 
internal  membrane  with  groups  of  fatty  granules ; 6,  horizontal  section  of  the  creta- 
ceous middle  coats,  presenting  irregular  spaces,  of  various  dimensions,  filled  with 
carbonate  of  lime ; c,  globular  masses  of  mineral  matter,  in  the  lighter  portions  of 
the  section  b. — ( Wedl.)  250  diam. 


MINERAL  DEGENERATION. 


271 


resembled  fatty  matter;  but  on  the  addition  of  hydrochloric  acid, 
the  grauules  were  dissolved  ’ 

with  effervescence,’*' 

In  other  Textures  min- 
eral matter  may  be  depos- 
ited occasionally  in  their 
interstices,  but  if,  as  in 
muscular  tissue,  it  does  not 
assume  the  form  of  a bony 
growth  to  which  we  have 
previously  alluded  (p. 

229),  it  IS  usually  the  re- 
sult of  an  exudation.  The 
fibrous  membranes  of  the 
brain  not  unfreqiiently  in 
this  way  contain  calcareous 

laminated  depositions.  In  certain  parts  of  the  pia  mater,  and  the  choro'd 
plexus  especially,  we  often  find  mineral  bodies  of  a round  or  oval  form  re- 
sembling starch  corpuscles.  (See  Amyloid  Concretions,  Figs.  392  to  395.) 

Mineral  D- generation  of  the  Exudations. — All  the  forms  of  exuda- 
tion after  their  soft  parts  are  absorbed  may  occasionally  leave  behind 
them  a greater  or  less  quantity  of  mineral  matter.  Thus,  on  serous 
membranes,  in  areolar  textures,  in  the  sinuses  leading  from  chronic 
abscesses  and  so  on,  masses  of  earthy  matter  are  met  with,  formed  of 
amorphous  mineral  substances,  composed  of  phosphate  and  carbonate  of 
lime.  These  are  evidently  the  result  of  a simple  exudation,  the  animal 
matter  of  which  has  been  absorbed,  whilst  the  mineral  constituents  in 
excess  are  aggregated  together,  and  form  laminge  on  membranes,  or 
nodules  in  parenchymatous  organs.  I have  seen  the  gall-bladder  in  this 


Fi?.  365.  Fig.  366. 

way  converted  into  a calcareous  shell,  and  the  pericardium  into  an  un- 
yielding mineral  box,  inclosing  the  heart.  The  cardiac  valves  are  also 
especially  liable  to  these  mineral  incrustations.  A cancerous  ex'udation 
in  the  same  manner  undergoes  the  calcareous  transformation.  The  mes- 
enteric glands  may  not  unfreqiiently  be  observed  to  be  partly  cancerous 
* Mikroskopischen  Pathologischen  Anatomie,  Taf  xv. 


Fig.  363.  Mineral  degeneration  of  the  nerve-cells  and  tubes  of  the  spinal  cord. — 
{FoernUr^ 

Fig.  364.  Mineral  masses  in  a degenerated  cancerous  tumor  of  the  omentum. 

Fig.  365.  The  same,  in  a degenerated  cancerous  mass  in  the  liver. 

Fig.  366.  Cancer-cells  infiltrated  with  cretaceous  molecules,  in  a mesenteric  gland. 

250  diam. 


272 


PEIA^CIPLES  OF  MEDICINE. 


and  partly  cretaceous.  On  one  occasion  I examined  a large  cancerous 
growth  of  the  omentum  and  peritoneum,  which  was  so  loaded  with  phos- 
phatic  salts,  that  slices  of  it  when  dried  lost  little  of  their  bulk.  The 
juice  squeezed  from  this  tumor,  besides  masses  of  mineral  matter,  was 
seen  to  contain  cancer-cells  in  various  stages  of  disintegration,  naked 
nuclei,  fusiform  cells,  and  a multitude  of  molecules,  some  fatty  aod  some 
mineral  (Fig.  3G4).  On  another  occasion  I found  the  cancer-cells  em- 
bedded in  and  infiltrated  throughout  with  minute  cretaceous  molecules 
(Fig.  3CG).  In  cancer,  as  in  atheroma  of  arteries,  the  mineral  is  often 
associated  with  the  fatty  degeneration.  A Tubercular  Exudation  passes 
more  readily  into  cretaceous  and  calcareous  transformation  than  either 
the  simple  or  cancerous  forms.  Indeed  it  may  be  said  that  the  natural 
mode  of  arresting  the  advance  of  tubercle  is  by  converting  it  into  mineral 


Fig  367.  Fig  368. 

matter.  I possess  specimens  of  miliary  as  well  as  of  infiltrated  tubercle, 
arrested  in  all  stages  of  their  progress,  by  cretaceous  tran.^formation,  in 
which  case,  on  microscopic  examination,  it  is  seen  to  consist  of  mineral 
masses  associated  with  a few  tubercle  corpuscles,  debris  of  the  tissue  in 
which  it  occurs,  and  occasionally  a few  crystals  of  cholesterine  (Fig.  3G7). 

Alineral  Degeneration  of  3Iorbid  Growths. — Mineral  deposition  may 
occur  in  all  kinds  of  morbid  growths,  but  is  most  common  in  fibroma 
and  cystoma.  In  enchondroma  the  tendency  is  to  form  bone.  The 
white  fibrous  tumors  of  the  uterus,  we  have  previously  seen,  may 
undergo  the  osseous  transformation  (Fig.  282) ; but  this  is  an  occurrence 
of  extreme  rarity.  Far  more  commonly  the  centres  of  such  growths  are 
composed  of  amorphous  mineral  depositions  (Fig.  3G8),  which  frequently 
increase,  and  invade  their  whole  substance,  causing  arrest  of  their  progress. 
I have  often  found  embedded  in  the  uterine  walls,  mineral  masses,  varying 
in  size  from  a hen’s  egg  to  that  of  a cocoa-nut,  formed  in  this  manner. 
Fine  preparations,  showing  the  same  fact,  may  be  seen  in  the  Edinburgh 
University  Museum. 


CONCRETIONS. 

Ry  concretions  are  understood  non-organized  and  non-vascular  pro- 
ductions, formed  by  the  mechanical  aggregation  of  various  kinds  of 
matter,  generally  in  the  ducts  or  cavities  of  the  hollow  viscera.  It  has 

Fig.  367.  TMineral  masses  in  a cretaceous  tubercle  of  the  lung. 

Fig.  36  ■!.  Section  of  an  amorphous  mineral  mass  forming  a calcareous  nucleus  of 
a uterine  fibrous  tumor. — [Wcdl.)  250  diam. 


COI^CEETIONS. 


273 


already  been  pointed  out,  that  although  they  pass  gradually  into  the  class  of 
degenerations,  several  of  which  closely  resemble  concretions,  still  they  are 
distinguished  from  them  by  their  never  having  been  organized,  or  formed 
out  of  an  organic  structure.  They  possess  a remarkable  disposition,  how- 
ever, to  collect  round  a central  nucleus, 
which  may  be  organic  or  non-organic,  aud 
often  present  as  the  result  of  pure  accident. 

Hence  they  geuerally  exhibit  a tendency  to 
assume  the  globular  or  oval  shape. 

AlhuminousConcretions. — It  has  already 
been  explained  that  albumen  may  be  precipi- 
tated from  its  solutions  in  the  form  of  mem- 
brane (p.  246.)  This  is  sometimes  so  effected 
as  to  produce  concretions,  of  which  I have 
long  possessed  a remarkable  specimen,  found  Fig.  369. 

loose  in  the  cavity  of  the  abdomen.  Mr.  Shaw  has  described  a similar 
specimen,  about  one-half  the  size  of  mine,  containing  a nucleus  of  fat — 
also  formed  in  the  peritoneal  cavity.*  It  was  excised  from  a hernial  sac, 
and  consisted  of  aggregated  layers  of  albuminous  substance,  as  seen  in 
Figs.  369,  370,  371.  The  concentric  layers  of  aneurismal  coagula,  and 
some  so-called  fibrinous  depositions  on  the  valves  of  the  heart,  which 


Fig.  370.  Fig.  371. 

subsequently  become  white  and  indurated,  are  of  a similar  character. 
The  section  of  the  nucleus  in  my  specimen  (Fig.  372)  is  represented 
magnified  fifty  diameters.  Fig.  373,  showing  the  adipose  cells  of  the 
structure,  loaded  round  the  circumference  with  mineral  matter.  In  all 
other  respects  it  resembled  Mr.  Shaw’s  specimen. 

Fatty  Concretions. — These  constitute  gall-stones,  which  for  the  most 
part  are  formed  of  laminae  of  cholesterine,  associated  with  inspissated 
bile.  They  are  found  in  the  gall  ducts  or  bladder,  and  vary  in  color, 
size,  form,  and  number.  They  may  be  perfectly  white,  and  then  they 
consist  almost  wholly  of  pure  cholesterine.  Sometimes  they  are  brown, 


* London  Pathological  Trans.,  vol.  vi.,  p.  205. 


Fig.  369.  Longitudinal  section  of  the  albuminous  concretion,  referred  to,  and  its 
encysted  nucleus  of  fat. — {Shaw.) — Natural  size. 

Fig.  370.  Portion  of  one  of  the  concentric  lamellae,  of  the  same  concretion. 

Fig.  371.  Transverse  section  of  the  edges  of  the  concentric  lamellae.— (>S'/<aw).) — 250  di. 
18 


274 


PEINCIPLES  OF  MEDICINE. 


and  at  others  jet  black,  approaching  carbon  in  chemical  cainposition. 
There  may  be  only  one  large  gall  stone,  nearly  filling  the  gall-bladder. 

When  there  is  only  one,  it  is  oval 
in  form,  but  when  there  are  several 
stones  present,  they  take  a many- 
sided  form,  in  consequence  of  pres- 
sure on  each  other.  In  one  case,  as 
many  as  2000  minute  biliary  con- 
cretions were  counted  in  the  gall- 
bladder. The  black  gall-stones  are 
often  rough,  round,  and  spiculated. 
On  section  they  generally  present  a 
nucleus  which  is  composed  of  in- 
spissated bile  and  mucus,  surround- 
ed by  concentric  rings.  Occasional- 
ly, the  centre  of  the  stone  is  hollow, 
and  the  substance  lining  the  cavity 
crystalline.  The  tough  white  masses 
occasionally  found  in  cystic  tumors 
{cholesteatoma)  are  also  fatty  concretions.  Sometimes  also  "fatty  masses 
have  been  passed  by  stool,  and  more  especially  when  the  pancreas  has 
been  diseased. 


a 


b 


r y.  o /t. 

Pigmentari/  Concretions. — These  are  most  common  in  the  lungs  and 
bronchial  glands  of  colliers,  from  which  I have  often  dug  out  masses 
varying  in  size  from  a millet  seed  to  that  of  a pea,  with  shiny  smooth 
fractured  surfaces,  composed  of  pure  carbon.  Occasionally  1 have  seen 
a bronchial  gland  converted  into  a cyst,  filled  with  a thick  black  fluid. 


Fig.  372.  Section  of  the  nucleus  of  an  albuminous  concretion. — Natural  Rize. 

Fig.  373.  Section  of  the  nucleus  of  an  albuminous  concretion,  showing  the  cir- 
cumference loaded  with  mineral  matter,  and  the  cell-structure  of  the  interior.  50  d‘u 
Fig.  374.  Various  forms  of  biliary  concretions.  «,  White  biliary  concretions, 
composed  chiefly  of  cholesterine.  6,  Irregular  biliary  concretions  of  inspissated  bile, 
c,  Black  biliary  concretions,  chiefly  carbonaceous,  c?,  Yellow  biliary  concretions, 
with  spicula  formed  in  the  ducts  of  the  liver,  c.  Section  of  a dark-brown  biliary 
calculus,  so  indurated  as  to  be  capable  of  receiving  a polish,  showing  the  concentric 
arrangement  of  its  substance.  /,  Section  of  a large  white  biliary  concretion,  showing 
the  radiated  as  well  as  concent.’ic  arrang3inent. — Natural  size. 


CONCRETIONS. 


275 


like  inspissated  paint,  principally  composed  of  carbonaceous  matter, 
which  would  doubtless  in  time  also  have  formed  an  indurated  con- 
cretion. 

Mineral  Concre'ions. — This  is  by  far  the  most  common  form  of  con- 
cretion found  in  the  body,  and  usually  results  from  the  deposition  of 
■various  salts  from  their  solutions,  often  round  a nucleus  of  foreign 
matter,  so  as  to  form  solid  masses,  varying  in  size,  form,  and  general 
arrangement  of  parts.  Not  unfrequently  the  nucleus  may  be  a portion 
of  coagulated  blood  or  inspissated  mucus,  so  that  mineral  concretions  are 
sometimes  found  in  the  veins  { phleholites)  and  in  all  mucous  passages, 
such  as  the  salivary,  bronchial,  pancreatic,  hepatic,  renal,  etc.  Frag- 
ments of  degenerated  mineral  texture  may  also  be  pushed  out  from  the 
walls  of  such  passages  and  constitute  a nucleus,  which  collects  mineral 
matter  around  it.  In  almost  all  such  cases,  the  mineral  is  composed  of 
phosphate,  with  varying  proportions  of  carbonate  of  lime,  and  the  form 
of  the  concretion  will  be  influenced  by  the  size  and  shape  of  the 
cavity  in  which  it  is  found.  An  excellent  example  of  this  may  be 
seen  by  examining  the  grains  of  sand  in  the  pineal  gland,  which  will 
be  found  to  consist  of  botryoidal  masses  varying  in  size,  but  consti- 
tuting mineral  moulds  of  the  glandular  shut  sacs  in  which  they  were 
produced. 

Urinary  Concretions. — Mineral  concretions,  however,  are  by  far  most 
common  in  the  urinary  apparatus,  and  may 
be  formed  in  the  tubules  or  pelvis  of  the 
kidney,  in  the  ureter,  or  in  the  urinary  blad- 
der. In  the  tubules  of  the  kidney  they 
usually  assume  the  character  of  amorphous 
deposits,  filling  up  and  distending  the  tube, 
and  presenting  radiating  white  lines  in  the 
secreting  cones.  They  may  be  composed  of 
phosphate  of  lime  or  urate  of  ammonia  (Fig. 
d75).  Occasionally  masses  of  a putty-like 
substance  are  formed  in  the  substance  of  the 
kidney  by  the  accumulation  of  such  deposits, 
which  in  time  would  have  consolidated  into 
calculi.  More  rarely  the  entire  kidney  is 
so  infiltrated  with  mineral  matter,  that  its 
functions  are  destroyed.  I possess  a speci- 
men of  this  kind,  where  the  organ  might  be 
supposed  to  be  petrified,  and  others  exist  in  the  Edinburgh  University 
Museum. 

When  calculi  form  in  the  pelvis  of  the  kidney,  they  assume  the 
form  of  the  cavity,  which  varies,  however,  in  different  cases,  being  con- 
tracted in  some  and  dilated  in  others.  The  accompanying  figure  of 
a renal  calculus  exhibits  regular  protuberances,  jutting  out  between  the 
urinary  cones  from  a mass  formed  in  the  pelvic  cavity  (Fig.  381).  Kenal 
calculi  generally  give  rise  to  constant  irritation  and  surrounding  suppu- 


Fi?.  375. 


Fig.  375.  Yertical  section  of  the  kidney,  a,  Some  of  the  tubules  filled  with  urate 
of  ammonia,  and  presenting  irregular  black  streaks,  with  lateral  branches  and  twigs. 
60  diam.  h.  The  molecules  of  urate  of  ammonia  aggregated  together  in  masses. — 
[Wedl).  ^ 250  dmm. 


276 


PRINCIPLES  OF  MEDICINE. 


ration,  constituting  what  Eayer  has  called  calculous  pyelitis.  Their 

chemical  constitution  is 
usually  uric  acid,  or 
phosphate  of  lime, 
alone,  or  united  in  va- 
rious proportions. 

The  most  frequent 
seat  of  urinary  calculi 
is  in  the  bladder, 
whence,  from  the  cir- 

„ cum  stance  of  their  giv- 

Fig.  376.  Fig.  377-  • • r ° i? 

ing  occasion  for  one  of 

the  most  important  operations  in  surgery,  they  have  been  made  the  subject 


Fig.  378.  Fig.  379. 

of  careful  study.  Here  they  vary  in  size,  general  appearance,  and  chemical 


Fig.  380. 

constitution.  In  size  they  range  from  that  of  a millet-seed  or  smaller  grains 

Fig.  376.  External  view  of  a remarkable  renal  calculus,  with  projections  on  all 
sides  of  it  but  one,  impacted  in  the  pelvis  of  the  kidnev. 

Fig.  377.  Section  of  the  same  calculus,  with  nucleus  of  uric  acid  and  oxalate  of 
lime. 

Fig.  378.  Calculus  with  lithic  acid  nucleus,  surrounded  by  oxalate  of  lime,  and 
covered  externally  with  laminae  of  lithic  acid. — \Syme). 

Fig.  379.  Triangular  formed  calculus  of  lithic  acid  deposited  round  a phosphatic 
nucleus  at  one  corner. — {Siime). 

Fig.  380.  Oval  calculus  of  lithic  acid,  having  a lithic  acid  nucleus,  surrounded  by 
oxalate  of  lime  — (Lisfon). 

Fig.  381.  Oval  calculus  of  uric  acid. — {Liston). 


Keel  size. 


CONCRETIONS. 


277 


(known  under  the  name  of  gravel),  wliicli  may  pass  along  the  urethra,  to 
that  of  a body  weighing  several  ounces,  and  occupying  nearly  the  whole 
bladder.  In  form  they  may  be  round,  oval,  flattened,  irregular  or  nodu- 


Fig.  382.  Fig.  384. 

lated,  and  in  chemical  constitution  may  consist  of  phosphate  of  lime, 
triple  phosphate  of  ammonia  and  magnesia,  uric  acid,  oxalate  of  lime,  or 
zanthic  oxide.  Not  unfrequently  in  one  calculus  may  be  observed  de- 
posits of  varying  chemical  compositions,  round  a central  nucleus,  indi- 
cating the  salts  predominant  in  the  urine  during  the  period  of  its  forma- 
tion (Figs.  378  to  384). 

One  of  the  most  remarkable  circumstances  connected  with  vesical 
calculi  is,  that  the  nucleus  may  be  composed,  not  only  of  various  kinds 
of  salts  or  of  fragments  of  other  calculi,  but  even  of  foreign  substances 
which  have  been  introduced  from  without.  Thus,  various  rounded  bodies 
thrust  down  the  urethra,  may  form  the 
centres  of  these  concretions.  Fig.  385 
represents  a piece  of  slate  pencil  as  the 
nucleus  of  i phosphatic  concretion.  Mr. 

Syme  removed  it  by  the  operation  of 
lithotomy,  and  the  man  confessed  he 
had  introduced  the  foreign  body  him- 
self, which  had  slipped  from  his  fingers, 
and  entered  the  bladder  two  years  pre- 
viously. One  of  the  most  extraordinary  cases  of  this  kind  is  that  record- 
ed by  the  late  Dr.  R.  Mackenzie,  in  which  a man  in  a state  of  intoxica- 
tion was,  during  a quarrel,  knocked  down  by  his  comrades,  who  cruelly 
thrust  several  horse-beans  into  his  urethra.  Six  months  subsequently  he 
was  operated  upon  for  stone,  and  five  calculi  removed,  each  of  which  on 
being  cut  open  was  found  to  contain  a bean,  surrounded  by  a shell  of 

Fi",  382.  The  triple  phosphate  surroundins  a mulberry  concretion  of  oxalate  of 
lime. — {Liston). 

Fig.  383.  Nodulated  mulberry  calculus  composed  of  oxalate  of  lime. — {R.MacTcenzie). 

Fig.  384.  Phosphatic  calculus  formed  round  a fragment  of  uric  acid  calculus,  pre- 
viously broken  up  by  lithotrity. — {Syme). 

Fig.  385.  Phosphatic  calculus  formed  round  a piece  of  slate-pencil,  which  had 
been  introduced  into  the  bladder  through  the  urethra. — {Syme). — Real  size. 


278 


PRINCIPLES  OF  MEDICINE. 


triple  phosphate^  (Fig.  386).  Dr.  Dunsmure  has  also  related  a case  of 
lithotomy,  where  the  nucleus  of  the  stone  originated  in  the  man’s  falling 
with  violence  across  the  gunwale  of  a boat  in  such  a way  as  to  lacerate 
the  perineum,  and  force  a portion  of  his  woollen  trousers  into  the  blad- 


Fig.  386. 

der.  I examined  the  nucleus  of  the  calculus  after  removal,  and  found 
the  fibrous  substance  it  was  composed  of  to  consist  of  wool.f 

Prostatic  Concretions, — The  adult  prostate  gland  almost  invariably 

will  be  found  to  contain  a number 
of  calculi,  which  increase  in  num- 
ber with  the  age  of  the  individual, 
and  are  often  very  numerous  when 
the  gland  is  enlarged.  They  are 
of  a yellowish  color,  vary  in  size 
from  -gloth  to  the  of  an 

inch  in  diameter,  and  are  charac- 
terised by  their  concentric  laminag, 
surrounding  a single  or  double 
nucleus,  which  also  varies  greatly 
in  size.  Dilute  mineral  acids 
cause  the  calcareous  matter  to  be 
dissolved,  leaving,  however,  the 
structural  appearance  unaffected, 
and  rendering  them  occasionally 
soft  and  compressible.  In  this  re- 
spect they  resemble  the  amyloid 
bodies  which  occur  in  the  arach- 
noid, and  like  them  they  may  possibly  be  colloid  masses,  throughout 
* Monthly  Journal  of  Medical  Science,  January  1852. 
f Monthly  Journal  of  Medical  Science,  January  1852. 

Fig.  386.  Sections  and  external  appearance  of  the  calculi  in  Mr.  Mackenzie’s  case, 
formed  round  horse-beans,  introduced  into  the  bladder  in  the  manner  described.— 
{R.  Mackenzie). — Real  size. 

Fig.  387.  Prostatic  calculi,  exhibiting  the  concentric  laminae,  and  nuclei  of  these 
bodies. — ( Wedl).  250  diam. 


CONCr.ETIOXS. 


270 


wliicli  mineral  matter  is  imbibed  in  a fluid  state,  so  as  gradually  to 
convert  tliem  into  calculi. 

Hairy  Concretions. — Balls  composed  of  hair  are  not  unfrequentiy 
found  in  the  stomach  and  alimentary  canal  of  the  inferior  animals,  es- 
pecially such  as  are  in  the  habit  of  licking  their  hairy  coats.  Bare 


F g.  388. 

cases  have  been  recorded  where  similar  masses  have  been  found  in  the 
stomach  of  the  human  subject.  One  of  tliese  has  been  published  by 
Dr.  Ritchie  of  Grlasgow.^  It  was  that  of  a factory  girl,  aged  21,  who 
had  contracted  the  habit  of  pulling  hair  from  her  head,  while  employed 
at  work,  and  swallowing  it.  She  had  ileus,  followed  by  symptoms  of 
rupture  of  the  intestine.  On  dissection,  the  mass  here  figured,  forming 
a mould  of  the  stomach,  composed  of  moist  female  hair,  was  discovered, 

* Monthly  Journal  of  Medical  Science,  July  1849. 

Fig.  388.  Mass  of  hair  found  in  the  human  stomach,  as  described  above.  Tnfe- 
riorily  it  was  encrusted  with  a layer  of  altered  food,  a fragment  of  which  has  been 
removed  towards  the  left,  showing  the  hair  beneath. — [Ritchie). — Three-fourths  the 
real  size. 


280 


PRINCIPLES  OF  MEDICINE. 


Fig  390. 

amount  of  pressure  or  impaction  to  w hich 
they  have  been  subjected.  In  color  they 
are  of  a yellowish  brown,  but  are  much 
lighter  if  infiltrated  with  earthy  salts  to  any 
Fig.  389.  unusual  extent.  They  easily  crumble  down 

under  firm  pressure,  and  present  a short  fibrous  texture,  like  the  felt  of  a 
hat.  On  section  with  a sharp  instrument,  they  present  on  the  cut  surface 
a series  of  concentric  lines,  which  are  often  of  a lighter  color  and  harder 


and  two  smaller  ones  were  found  in  the  intestines  (Fig.  888).  Similar 
cases  with  hairy  concretions  are  recorded  by  Pollock*  and  May.f 

Vegetable  Fibrous  Concretions. — rThese  are  only  found  in  the  ali- 
mentary canal,  and  in  man  are  most  common  in  the  intestines.  The 
largest  collection  of  them  extant — made  by  the  second  Monro — is  in 
the  Edinburgh  University  Museum.  An  admirable  dissertation  re- 
garding them  was  published  by  his  son,  Monro  tertius.J  Wollaston 
first  demonstrated  that  they  were  principally  composed  of  the  fibrous 
matter  of  the  oat  seed,  a fact  confirmed  by  the  careful  researches 
and  published  figures  of  Dr.  Douglas  Maclagan.  § These  concretions 

vary  in  size  from  a pea  to  that  of  an 
orange.  They  are  round  or  oval  in  shape 
if  isolated,  but  are  frequently  compressed 
or  flattened  at  the  sides,  and  occasionally 
of  very  irregular  shapes,  according  to  the 


* Pathological  Transactions  of  London,  1851-.52. 

+ Association  Journal,  No.  156,  1856.  . 

:};  Morbid  Anatomy  of  the  Human  Gullet,  Stomach,  and  Intestines,  Edmbuign, 

1811. 

§ Monthly  Journal  of  Medical  Science,  Sept.  6,  1841. 

Fio-.  389.  Section  of  a remarkably-shaped  intestinal  concretion,  a.  Nucleus  of 
cxtra^isated  blood ; &,  6,  6,  concentric  lamin®.  It  weighed  14^  ounces,  measured  7 
inches  in  length,  and  was  evacuated  by  the  rectum. — Hims  and  Mosander.  nalj  me 

V€€tt  • 

Fig.  390.  Section  of  an  intestinal  concretion,  with  a plum  stone  for  its  nuckus,  in 
the  Monro  collection  of  the  Edinburgh  University  Museum.— size. 


CONCKETIONS. 


281 


consistence  than  the  general  substance  of  the  concretion.  In  the  centre 
may  frequently  be  observed  a nucleus  composed  of  some  foreign  body, 
such  as  a plum  or  cherry  stone,  a piece  of  bone,  etc.  Chemically,  they 
consist  principally  of  fibrous  vegetable  matter,  and  phosphate  of  lime, 
mino-lino-  with  small  proportions  of  water,  soluble  vegetable  matter,  fat, 
fsecS,  and  alittle  silica  derived  from  the  structure  of  the  oat — (Maclagan). 

On  examining  a small  fragment  of  these  concretions  under  a power 
of  200  diameters  linear,  they  are  seen  to  be  made  of  an  aggregation 
and  mingling  together  of  vegetable  fibres,  principally  derived  from  the 
caryopsis  of  the  oat,  mingle!  in  recent  specimens  with  numerous  irre- 
gular crystals  and  amorphous 
precipitate  of  the  phosphate  of 
lime.  The  fibres  vary  greatly  in 
length  and  diameter,  but  in  form 
are  pointed  at  one  extremity, 
truncated  at ' the  other,  with  a 
central  canal,  which  gradually 
diminishes  towards  the  pointed 
extremity.  The  accompanying 
figure  represents  a fragment  taken 
391.  from  the  concretion  represented 

Fig.  300,  from  the  Monro  collection,  in  which,  besides  the  vegetable  fibres 
alluded  to,  masses  of  molecular  mineral  matter  maybe  observed,  soluble 
in  dilute  nitric  acid,  of  which  the  white  concentric  lines  were  principally 
composed  (Fig.  391). 

As  reixards  the  niainer  in  which  these  concretions  are  formed,  it  is 

O . ' • 

to  be  observed,  tint  the  fibres  of  the  caryopsis  of  the  oat  possess,  in  a 
remarkable  degree,  the  property  of  felting,  which,  as  pointed  out  by  Dr. 
Carmichael  of  Huckie,^  is  prevented  by  oil,  and  favored  by  the  use  of 
dry  substances,  as  fuller’s  earth.  Both  these  substances  are  used  largely 
in  wool  manufactories,  the  one  for  carding  and  the  other  iov  felting.  I 
am  indebted  to  that  gentleman  for  some  specimens  of  concretions,  formed 
of  oat  dust  (that  is,  the  hairy  covering  of  the  oat),  simply  by  the  rota- 
tory or  oscillatory  motion  of  the  wire-cloth  sieve  of  a mill.  From 
thence  may  always  be  collected  soft  concretions  of  various  sizes,  formed 
round  pieces  of  thread,  or  other  foreign  bodies.  The  same  thing  appears 
to  result  in  the  animal  body,  from  the  peristaltic  action  of  the  intestines, 
when  the  fibrous  dust  is  imperfectly  separated  from  the  meal,  as  was 
formerly  the  case  in  the  oatmeal  used  largely  as  food  for  man  in  Scot- 
land. Since  the  employ’ inent  of  winnowing  machines,  and  greater  con- 
sumption of  meat  and  oleaginous  substances,  the  formation  of  these 
concretions  ha-!  become  very  lare.  In  horses,  however,  they  are  still 
common,  and  it  is  remarkable  that  in  remote  districts,  where  meal  is 
still  imperfectly  prepared,  cases  still  occasionally  occur,  such  as  the  one 
recorded  by  Dr.  Turner  of  Keith, f of  a man  who,  in  1841,  passed  four- 
teen, and  in  1845-46,  other  eighteen  of  these  concretions. 


* Monthly  .Journal  of  Medical  Science,  June  1848. 
f Monthly  Journal  of  Medical  Science,  Sept.  1841  and  January  1848. 


Fig.  391.  Hairs  from  the  caryopsis  of  the  oat,  felted  together,  and  mingled  with 
granular  masses  of  the  phosphate  and  carbonate  of  lime.  250  diam. 


282 


PRINCIPLES  OF  MEDICINE. 


Amyloid  and  Amylaceous  Concretions. — ValentiD,*  Lebert,f  G]uf>e.‘| 
and  others,  have  figured  rounded  mineral  bodies  with  concentric  circles 
frequently  present  in  the  brain’s  substance,  and  more  or  less  soluble  in 
mineral  acids.  In  April  1847,  § I presented  a portion  of  a tumor  to 
the  Pathological  Society  of  London,  which  was  attached  to  the  tento- 
rium, and  crowded  with  similar  bodies.  They  were  evidently  mineral 
concretions,  formed,  however,  on  an  organic  base,  varying  in  size  from 
Fig.  392.  Fig,  393.  394^ 


a b c d e Fig.  395. 

the  yJ^jj^th  to  the  o diameter.  Their  fracture  was 

exactly  like  that  of  starch  corpuscles,  but  they  were  not  rendci-ed  blue 
on  the  addition  of  iodine.  Nitric  acid  dissolved  the  mineral  matter, 
and  showed  them  to  be  composed  of  concentric  fibres,  surrounding  a 
nucleus,  with  distinct  nuclei  (Fig.  395).  They  were  embedded  in  a 
fibro-nucleated  structure,  which  formed  a sheath  round  each  concretion. 
Since  then,  I have  frequently  seen  similar  bodies  in  the  arachnoid  mem- 
brane and  substance  of  the  brain,  and  they  have  also  been  observed  by 
Drs.  Qnain,  Cleland,|j  and  many  others.  These  are  amyloid 

Virchow^f  was  the  first  to  point  out  that  several  similar-looking 
bodies  in  the  brain  assumed  a pale  blue  tint  on  the  addition  of  iodine,  and 
subsequently  became  violet-color  on  being  treated  with  sulphuric  acid. 
He  considered  them  to  be  cellulose,  a principle  which  he  also  had  shown 

* Handworterbuch  der  Physiologie,  Taf.  1,  Fig.  2. 

f Physiologie  Pathologique,  PI.  xi.  Fig.  10. 

I Pathologische  Anatomie,  Liv.  16,  Taf.  2. 

§ Proceedings  of  Pathological  Society  of  London,  1846-47,  p.  17. 

II  Glasgow  Medical  Journal,  July  1863. 

^ Archives,  Band.  vi.  s.  125.  1854. 

Fig.  392.  Mineral  amyloid  bodies  embedded  in  a seemingly  amorphous  matter. 

Fig.  393.  The  same,  after  dilution  with  water,  now  seen  to  be  invested  with  a 
fibrous  sheath  and  surrounded  by  fusiform  cells  and  naked  nuclei. 

Fig.  394.  The  same  after  the  additon  of  acetic  acid. 

Fig.  395.  The  same,  after  the  addition  of  nitric  acid,  a.  One  of  these  bodies  with 
a thick  investing  capsule ; 6,  e,  and  c?,  others  showing  the  various  ways  in  which 
they  crack  on  pressure ; e,  cylindrical  form  produced  by  rolling  them  between 
glasses.  250  diam. 


CONCRETIONS. 


283 


to  exist  in  other  pathological  formations.  Mr.  Busk*  demonstrated  that 
these  bodies  were  optically  as  well  as  chemically  identical  with  starch, 
and  that  they  were  true  corpora  amylacea.  They  have  been  found  in 
various  tissues  and  fluids  by  subsequent  observers,  and  have  been  made 
the  special  subject  of  research  by  Dr.  Carter,!  who  has  demonstrated 


Fig.  396.  Fig.  397. 

their  existence  in  almost  every  tissue  and  fluid  of  the  human  body,  and 
in  every  kind  of  morbid  product.  They  are  of  two  varieties,  the  one 
(described  by  Mr.  Busk)  re.sembling  wheat  starch,  the  other  and  rarer 
kind  corresponding  in  every  particular  with  that  derived  from  the  potato. 

It  follows,  that  there  exist  concretions,  some  of  which  resemble,  while 
others  really  are  starch  corpuscles.  The  former  are  amyloid,  and  the 
latter  amylaceous  concretions.  Both  these  bodies,  without  the  action  of 
re-agents,  are  not  only  liable  to  be  confounded  with  each  other,  but  with 
colloid  and  fat  masses.  It  is  questionable,  indeed,  whetiier  the  amyloid 
concretions  are  not  colloid  bodies,  which  have  subsequently  become  im- 
pregnated with  mineral  matter,  or  whether  they  are  not  starch  corpuscles 
that  have  undergone  a mineral  degeneration.  But  the  relation  of  these 
two  kinds  of  concretions  to  one  another,  to  fat  and  colloid  masses,  are 
points  which  have  not  yet  been  investigated.  All  speculation  on  this 
subject,  however,  is  at  present  highly  hypothetical,  and  it  is  only  from 
the  progress  of  organic  chemistry  that  we  can  hope  t-o  derive  a satisfac- 
tory explanation  of  those  transformations  which  go  on  in  the  blood  and 
tissues,  so  that  we  may  determine  the  laws  regulating  the  production  of 
the  amylaceous  and  amyloid  concretions.  (See  Waxy  Degeneration.) 

* Quarterly  Journal  of  Microscop.  Science,  vol.  ii.  p.  106.  1854. 

I Edinburgh  Medical  Journal,  August  1855,  and  Graduation  Thesis,  1856. 


Fig.  396.  Small  corpora  amylacea^  in  the  auditory  nerve  of  a deaf  individual,  with 
several  granule  cells. — {Foerster.) 

Fig.  397.  Variously-shaped  and  sized  corpora  amylacea^  from  the  human  pancreas, 
a,  Nucleated;  6,  c,  d,  variously-shaped;  e,  seen  edgeways. — {Carter,)  250  diam. 


SECTION  III. 


GENERAL  THERAPEUTICS. 

In  the  two  previous  sections  I have  endeavored,  to  give  a condensed 
account  of  the  present  state  of  the  art  of  diagnosis,  and  of  the  pathology 
of  organic  diseases.  A practical  knowledge  of  the  one,  and  a better 
appreciation  of  the  other,  have  been  very  widely  diffused  during  the 
last  twenty  years.  In  consequence,  a change,  almost  amounting  to  a 
complete  revolution  in  our  treatment  of  disease,  has  taken  place  within 
that  short  period.  It  is  true  that  this  change  is  not  yet  reflected  in  our 
systematic  works,  although  clinically  it  is  everywhere  recognized.  When 
■we  compare  the  actual  practice  of  medicine  with  what  it  is  and  with 
what  it  is  represented  to  be,  even  in  modern  books  on  the  theory  and 
practice  of  physic,  the  discrepancy  must  strike  even  the  least  observant. 
The  time,  therefore,  has  now  arrived  for  calling  the  attention  of  the  pro- 
fession, and  more  especially  of  its  youthful  members,  to  the  causes  which 
have  produced  so  important  a result,  and  for  pointing  out  some  of  those 
principles  on  which  an  improved  medical  art  for  the  future  must  neces- 
sarily be  based. 

In  endeavoring  to  estimate  the  means  at  our  disposal  for  the  cure 
or  relief  of  disease,  there  are  several  circumstances  which  demand  our 
attention,  such  as  the  influence  which  the  mind  exerts  over  the  body  ; the 
natural  progress  of  disease  ; the  knowledge  derived  from  an  improved 
diagnosis  and  an  advanced  pathology.  It  is  chiefly  from  an  inattention 
to  these  points,  and  an  illogical  disregard  of  their  effects  upon  our  general 
views  as  to  treatment,  that  much  of  the  contradiction  and  uncertainty 
which  prevail  as  to  the  effects  of  remedies  in  the  present  day  are  to  be 
attributed.  The  more  capable  we  are,  therefore,  of  appreciating  the  in- 
fluence these  circum.stances  exert  upon  the  patient  and  upon  ourselves, 
the  better  position  we  shall  occupy  in  our  attempts  to  emancipate  our- 
selves from  the  mere  authority  of  the  past,  and  to  assist  in  establishing 
a true  therapeutics  for  the  future.  These  points,  therefore,  require  our 
attention  before  we  enter  upon  a consideration  of  the  existing  knowledge 
of  the  treatment  of  maladies. 


THE  INFLUENCE  WHICH  THE  MIND  EXERTS  OVER 
THE  BODY. 

Although  such  influence  has  long  been  recognized,  it  has  been  proved 
in  recent  times  to  be  far  greater  than  was  formerly  supposed.  Thus, 


INFLUENCE  OF  THE  MIND  ON  THE  BODY. 


285 


althougli  it  is  universally  known  that  mental  emotions  exercise  a stimu- 
lating or  depressing  effect  on  all  the  bodily  functions,  and  that  various 
feelings,  desires,  a.id  appetites  increase  or  diminish  the  sooretion  of  dif- 
ferent giands,  it  has  been  reserved  for  modern  times  to  domonsbrate  that 
ill  certain  persons  mind,  sensation,  and  volition  can  be  thoroughly  con- 
trolled by  the  suggestive  ideas  of  another  individual.  If,  for  example, 
twenty  persons  chosen  at  random  from  the  population,  are  directed  to 
gaze  steadily  at  any  object  for  about  ten  minutes,  a peculiar  condition  of 
the  cerebral  functions  will  be  produced  in  one  or  more  of  them  (especially 
if  they  be  young) ; and  under  this  condition  those  affected  may  be  made 
to  act  in  accordance  with  any  train  of  ideas  which  may  be  suggested  to 
them,  their  motion  and  sensation  being  influenced  in  a variety  of  ways."^ 
It  seems  as  if  their  mental  faculties  became  fatigued,  in  consequence  of 
which  they  lose  the  power  of  controlling  any  idea  that  becomes  predominant. 

The  peculiar  mental  condition  thus  produced  manifests  itself  while 
the  individual  is  gazing  upon  the  object,  in  the  first  instance,  by  a misti- 
ness of  vision,  succeeded  in  some  by  a feeling  of  lassitude  and  desire  to 
sleep,  in  others  only  by  stiffness  of  the  eyelids,  and  in  a third  class  by 
deep-drawn  sighs,  hurried  respiration,  heaving  of  the  chest,  or  other  signs 
of  general  excitement.  If  now  such  persons  are  repeatedly  told,  in  a con- 
fident manner,  that  they  cannot  open  their  eyes,  it  will  be  found  that  they 
cannot  do  so,  especially  if  the  operator  directs  particular  attention  to  the 
eyelids  by  touching  or  pointing  to  them.  But  on  receiving  permission, 
or  on  being  commanded  to  open  them,  they  will  do  so  at  once. 

In  the  same  manner,  an  individual  so  affected  may  be  made  to  make 
every  conceivable  kind  of  motion  against  his  will,  or,  on  the  other  hand, 
such  movements  as  he  may  wish  to  make  can  be  impeded,  arrested,  or 
perverted.  Thus  I have  seen  a person  unable  to  speak,  from  inability 
to  open  the  jaws ; not  able  to  bend  an  arm  or  a leg ; fixed  to  a chair,  or 
prevented  from  sitting  down ; unable  to  approach  a particular  object,  or 
irresistibly  impelled  towards  it ; unable  to  cross  a real  or  imaginary  line 
on  the  floor ; the  arm  suspended  an.d  fixed  in  the  act  of  drinking,  or  the 
body  arrested  in  the  act  of  dancing ; the  individual  made  to  walk,  dance, 
or  run,  as  directed  ; to  imitate  riding  on  horseback,  when  seated  on  a 
chair  ; or  to  stagger  about  the  room  in  a supposed  state  of  intoxication, 
etc.  Many  of  the  lower  animals  also  appear  to  be  susceptible  of  being 
impressed  by  what  strongly  arrests  their  attention,  in  such  a way  that 
they  are  rendered  incapable  of  voluntary  motion,  or  irresistibly  impelled 
towards  the  object.  Hence  the  long  glittering  bodies  of  serpents,  or  the 
glaring  eyes  of  other  fascinate  birds  or  small  quadrupeds,  and 

render  them  an  easy  prey  to  their  enemies.  Hares  and  all  sorts  of 
animals,  also,  are  often  run  over  by  railway  trains.  Similar  effects  are 

* The  mode  of  producing  this  condition  may  be  varied,  but  it  is  in  all  cases  essen- 
tially the  same.  Thus  Mesmer  caused  individuals  to  sit  in  a kind  of  trough,  and 
they  were  dii’ected  to  look  at  a wire  placed  in  their  hand.  The  Fakirs  of  India  throw 
themselves  into  a trance  by  looking  at  the  extremity  of  their  own  noses.  Mr.  Braid 
of  Manchester  held  an  object  a little  above  the  eyes,  so  as  to  cause  fatigue  sooner. 
Dr.  Darling  causes  them  to  look  at  a small  coin  placed  in  the  palms  of  their  hands, 
whilst  others  fix  the  attention  of  persons  on  themselves,  on  the  tips  of  their  fingers 
extended  towards  their  eyes,  and  make  motions  or  so-called  passes  which  arrest  the 
attention. 


286 


GENERAL  THERAPEUTICS. 


produced  in  individuals  wlio  look  from  heiglits  and  precipices,  and  ex- 
perience an  uncontrollable  desire  to  leap  down,  although  they  know  it 
will  be  to  certain  destruction. 

In  like  manner,  during  this  condition  all  the  sensations  may  be  in- 
creased, perverted  or  destroyed,  through  the  medium  of  suggestive  ideas 
communicated  to  the  mind.  By  fixing  attention  on  any  part  of  the  skin 
it  may  be  made  to  feel  hot  or  cold,  tingling  and  painful^  or  benumbed 
and  destitute  of  sensibility,  according  to  the  ideas  communicated.  Sight 
may  be  lost  or  rendered  painful,  spectral  images  may  be  presented  to  the 
vision,  or  various  objects  made  to  resemble  others  to  w'hich  they  bear  no 
analogy.  Smell  also  may  be  perverted,  and  any  kind  of  odor  given  to 
inodorous  substances.  A rose,  in  the  hand  of  such  an  individual,  may 
have  the  smell  of  an  onion,  and  plain  water  the  fragrance  of  eau  de 
Cologne.  Various  noises,  in  like  manner,  may  be  heard;  hearing  is 
frequently  very  acute,  at  other  times  it  is  apparently  abolished.  Lastly, 
the  taste  may  be  affected,  and  plain  water  made  to  present  to  such  a 
person  the  sweetness  of  honey,  the  bitterness  of  wormwood,  or  the  acidity 
of  vinegar. 

Then,  as  regards  the  mental  faculties,  memory  may  be  lost,  whilst 
judgment  and  comparison  for  the  time  being  cannot  be  exercised.  The 
imaginative  faculties,  on  the  other  hand,  may  be  very  vivid,  so  that  the 
individual  readily  assumes  the  manners  of  other  persons  in  various  walks 
of  life — goes  through  the  operations  of  different  mechanical  trades,  con- 
ceiving himself  to  be  an  artisan — endeavors  to  escape  from  imaginary 
dangers  or  tries  to  repel  them — and  acts  as  he  himself  or  others  might 
be  naturally  supposed  to  do  under  any  given  circumstances  or  conditions. 
Thus  he  may  be  made  to  fight,  to  swim,  to  run,  to  stagg«^r  as  if  intoxi- 
cated, and  so  on.  Even  the  sex  may  in  this  manner  be  mentally  changed, 
and  a lady  may  assume  the  manner,  tone  of  voice,  and  language  of  her 
husband.  Such  persons  also  may  readily  be  conducted  in  imagination 
to  various  distant  countries  or  cities,  when  they  will  act  and  talk  as  if 
they  were  really  there ; or  they  may  be  led  through  a very  complicated 
series  of  actions,  such  as  a quarrel  termit  ating  in  a duel ; a fishing  or 
shooting  excursion  in  which  they  catch  numerous  fish;  or  bag  a quantity 
of  game,  etc.  etc. 

In  the  same  way  sleep  may  be  most  readily  induced,  and  become  so 
sound  that  all  ordinary  stimuli  will  not  awake  the  sleepers ; sensation 
even  being  occasionally  annihilated  for  the  time.  Yet  it  often  happens, 
that  at  the  command  of  him  who  has  communicated  the  suggestive  ideas, 
they  immediately  awake  from  a condition  of  sopor  out  of  which  local 
painful  applications  failed  to  arouse  them.  Susceptible  persons  may 
be  even  commanded  to  sleep  at  a particular  hour  on  a certain  day,  and 
awake  at  a particular  time,  and  this  they  will  do  under  the  idea  that  at 
the  hour  named  some  peculiar  influence  is  exerted  on  them.  This  con- 
dition is  analogous  to  that  of  somnambulism,  trance,  or  ecstacy,  and 
presents  all  the  intermediate  gradations  between  these  states  and  ordinary 
dreaming  and  reverie. 

What  is  very  curious  in  connection  with  many  of  these  nervous 
aberrations  is,  that  a person  may  be  perfectly  conscious  during  the  whole 
time  of  what  he  is  doing,  and  even  of  the  absurdity  of  his  actions.  He 


INFLUENCE  OF  THE  MIND  ON  THE  BODY. 


287 


may  know  that  the  water  he  drinks  is  not  milk  or  syrup,  and  yet  he 
declares  it  to  have  the  taste  of  those  liquids.  Frequently,  when  his 
movements  are  influenced,  he  evidently  resists,  but  seems  to  be  controlled 
by  a will  stronger  than  his  own.  He  even  laughs  at  his  own  ridiculous 
actions,  but  acknowledges  his  helplessness.  The  efforts  at  resistance  only 
induce  fatigue,  and  tend  to  render  him  more  certainly  the  victim  of  the 
influence  by  which  he  is  governed.  This  condition  is  certainly  closely 
allied  to  the  incipient  stage  of  monomania.  It  should  also  be  noticed 
that,  although  young  and  nervous  persons  are  undoubtedly  those  who 
are  most  commonly  affected,  such  is  by  no  means  always  the  ease,  as 
many  individuals  apparently  in  good  health  and  robust,  have  been  made 
to  exhibit  all  the  phenomena  described. 

Such  are  only  some  of  the  phenomena  which  may  be  produced  in 
those  affected  with  the  peculiar  nervous  condition  which  I am  describing. 
They  admit  of  infinite  modifications,  but  the  symptoms  are  all  r;-ferable 
to  increase,  diminution,  or  perversion  of  intelligence,  sensation,  or  volun- 
tary motion,  variously  combined,  according  to  the  endless  train  of  sug- 
gestive ideas  that  may  be  communicated  to  the  individual. 

Similar  phenomena  have  occurred  in  all  ages,  produced  in  certain 
persons  by  predominant  ideas,  and  variously  modified  according  to  the 
education,  politics,  or  religion  of  the  period.  Thus  the  effects  produced 
on  many  votaries  during  their  initiation  into  the  ancient  mysteries ; the 
ecstasies  of  the  Pythian  and  other  priestesses ; the  influence  of  religious 
enthusiasm,  of  the  evil  eye,  and  of  the  divining  rod;  the  dancing  epi- 
demics of  St.  A'^itus,  or  of  Tarantism,  in  the  middle  ages;  the  hallucina- 
tions of  the  Convulsionaries  at  the  tomb  of  St.  Medard,  in  Paris,  etc. 
etc.,  are  of  a like  character.*  Numerous  perversions  of  the  nervous 
functions,  identical  in  their  nature  with  those  described,  consisting  of 
sensory  illusions,  muscular  convulsions  or  rigidity,  and  peculiar  trains  of 
thought  influencing  acts  and  conversation,  may  also  be  found  in  the  his- 
tories of  witchcraft  or  demonology,  in  the  legends  of  the  saints,  the  journal 
of  Mr.  Wesley,  and  in  the  accounts  given  by  travellers  of  the  religious 
camp-meetings  in  the  woods  of  America.  The  same  occur  among  our 
modern  revivalists,  and  may  be  seen  among  the  mesmeric,  table-turning, 
and  spirit-rapping  communities  of  the  present  day.  They  are  perhaps 
more  common  now  than  previously,  and  excite  even  more  astonishment 
among  the  ignorant,  the  only  difference  being  that  the  same  phenomena 
which  in  a dark  age  were  attributed  to  divination  or  incantation  now 
assume  the  garb  of  science,  and  are  ascribed  to  Magnetism  or  Electricity. 

I consider  it  unnecessary  to  enter  into  any  lengthened  argument  to 
refute  the  numerous  hypotheses  which  ascribe  these  effects  to  external 
influences.  I know  of  no  series  of  well-ascertained  fa,cts  capable  of  sup- 
porting such  a doctrine.  I have  made  numerous  experiments  with 
the  aid  of  those  who  believe  in  Animal  Magnetism,  all  of  which  have 
only  convinced  me  that  no  such  principle  exists,  and  that  all  the  pheno- 
mena really  occasioned  depend  on  suggestive  ideas  communicated  to 
the  person  affected.  But  while  these  theories  scarcely  merit  atTention, 
the  facts  themselves  are  highly  important,  and  demand  the  careful  con- 
sideration of  the  physiologist  and  medical  practitioner.  Let  us,  then, 
* Hecker’s  Epidemics  of  the  Middle  Ages. 


288 


GENERAL  THERAPEUTICS. 


examine  into  wliat  can  reasonably  be  advanced  in  explanation  of  these 
nervous  phenomena. 

We  have  seen  that  sensation  may  be  defined  to  be  the  consciousness 
of  an  im,pression.  and  we  know  that  the  mind  strongly  intent  upon  an 
object  is  unconscio.us  of  those  impressions  which  are  going  on  around — 
so  that  no  sensation  results  from  these.  Every  physiologist  is  aware 
that  the  body  of  a decapitated  animal  may  be  thrown  into  violent  con- 
vulsions, and  cases  have  occurred  even  in  man  of  the  limbs  having  been 
thrown  about,  as  if  in  the  greatest  agony,  although  in  reality  no  pain 
whatever  has  been  experienced.  All-absorbing  mental  ideas  prevent 
sensation  of  local  impressions  unconnected  with  them  ; hence  wounds 
are  not  felt  in  battle,  blows  and  falls  are  unheeded  during  the  excite- 
ment of  intoxication  or  of  nitrous  oxide  gas,  and  Indian  warriors  and 
religious  enthusiasts,  intent  on  particular  trains  of  thought,  have  not 
suffered  from  any  of  the  supposed  torments  which  were  inflicted  on  their 
bodies.  These  facts,  then,  offer  a sufficient  explanation  to  the  physiolo 
gist  of  the  occasional  insensibility  of  somnambulists,  or  others  laboring 
under  some  predominant  idea. 

Whilst,  however,  an  individual  may  be  unconscious  of  impressions 
unconnected  with  his  particular  train  of  ideas,  ( verything  in  relation  to 
these  is  often  perceived  with  extraordinary  readiness.  The  abolition  of 
sensation  with  regard  to  general  impressions  seems  to  be  counterbalanced 
by  an  excpiisite  sensitiveness  relative  to  the  one  impression  either 
actually  made  or  suggested.  Dr.  Holland  has  very  ably  j.ointed  out  the 
effects  of  mental  attention  on  the  bodily  organs,  showing  that  there  are 
few  persons  who  do  not  experience  irritation  or  some  imagii.aiy  feeling 
ill  parts  to  which  their  attention  is  much  directed.*  If  at  right,  owing 
to  some  unusual  position,  we  feel  a beating  at  the  heart  or  at  the  temples 
we  easily  imagine  there  is  something  alarming  ; the  inspirations  are 
altered,  if  we  think  about  them ; if  we  suppose  the  mouth  is  dry,  we 
immediately  swallow  the  saliva  and  render  it  so  ; if  we  tai  cy  we  have  a 
cough,  we  cough  immediately,  and  clear  the  air  passages  ; and  if  we  sup- 
pose any  source  of  irritation  exists  on  the  skin,  we  involuntary  apply 
our  hand  to  and  rub  the  part.  Nothing  is  more  common  for  medical 
students,  when  first  studying  individual  diseases,  than  to  imagine  them- 
selves to  be  the  victims  of  each  in  succession.  Then,  in  certain  condi- 
tions of  the  system,  it  is  well  known  that  actual  pain  n ay  be  produced 
ill  a part  by  fixing  our  attention  upon  it.  Hypochondriacs  are  martyrs 
to  these  erroneous  impressions.  Supposed  pains  in  the  limbs  or  stomach 
prevent  their  walking  or  eating,  and  their  health  suffers  from  want  of 
exercise  or  want  of  food.  Sir  Benjamin  Brodie  has  given  some  singular 
cases  where  so-called  nervous  pains  of  this  description  have  actually  led 
to  tenderness  and  swelling  of  the  integuments  covering  the  part.  It 
may  easily  be  understood  how  facts  of  this  kind  may  be  made  to  assume 
the  appearance  of  prophecy,  and  how  informing  a valetudinarian  that  he 
will  certainly  have  a rheumatic  or  neuralgic  pain  on  any  given  day,  is 
likely  to  produce  it. 

As  illustrative  of  the  strong  influence  of  predominant  ideas  even  in 
healthy  persons,  I may  mention  the  following  circumstances  : — The  late 
* Medical  Notes  and  Reflections,  chap.  6. 


INFLUENCE  OF  THE  MIND  ON  THE  BODY. 


289 


Mr.  Mcfarlan,  druggist,  North  Bridge,  Edinburgh,  informed  me  that  on 
one  occasion  a butcher  was  brought  into  his  shop,  from  the  market-place 
opposite,  laboring  under  a terrible  accident.  The  man,  on  trying  to 
hook  up  a heavy  piece  of  meat  above  his  head,  slipped,  and  the  sharp 
hook  penetrated  his  arm,  so  that  he  himself  was  suspended.  On  being 
examined,  he  was  pale,  almost  pulseless,  and  expressed  himself  as  suffer- 
ing acute  agony.  The  arm  could  not  be  moved  without  causing 
excessive  pain,  and  in  cutting  off  the  sleeve  he  frequently  cried  out,  yet 
when  the  arm  was  exposed  it  was  found  to  be  quite  uninjured,  the 
hook  having  traversed  only  the  sleeve  of  his  coat.  The  Bev.  Mr. 
Stevenson  of  St.  George’s  Church,  Edinburgh,  told  me,  that  some  time 
ago  suspicions  were  entertained  in  his  former  parish  of  a woman,  who 
was  supposed  to  have  poisoned  her  newly-born  infant.  The  coffin  was 
exhumed,  and  the  procurator-fiscal,  who  attended  with  the  medical  men 
to  examine  the  body,  declared  that  he  already  perceived  the  odor  of 
decomposition,  which  made  him  feel  faint,  and  in  consequence  he  with- 
drew. But,  on  opening  the  coffin,  it  was  found  to  be  empty,  and  it  was 
afterwards  ascertained  that  no  child  had  been  born,  and  consequently  no 
murder  committed.  Numerous  instances  might  be  given  of  individuals 
engaged  in  duels,  or  on  other  occasions,  who  have  supposed  themselves 
to  be  wounded,  and  have  fallen  down  as  if  dead,  without  having  received 
the  slightest  injury. 

Then,  as  regards  irregular  movements  in  connection  with  predomi- 
nant ideas,  the  phenomena  of  hysteria  and  chorea  will  at  once  suggest 
themselves  to  you.  In  the  latter  disease,  peculiar  movements  are 
always  occasioned  by  the  exercise  of  volition,  or  by  certain  impulses 
which  cannot  be  controlled.  In  hydrophobia  there  is  a remarkable 
susceptibility  to  the  most  minute  circumstances,  which  give  rise  in  any 
way  to  the  idea  of  drink,  and  invariably  excite  the  most  fearful  spasms. 
Numerous  singular  instances  of  occasional  and  partial  perversion  of  the 
voluntary  movements  might  be  quoted,  either  arising  spontaneously,  or 
acquired  by  habit,  or  produced  in  animals  by  injuring  certain  parts  of 
the  nervous  system,  or  by  giving  particular  drugs ; but  I shall  content 
myself  with  relating  two  cases,  formerly  under  the  care  of  Dr.  Christisou, 
which  he  was  so  good  as  to  communicate  to  me.  The  first  was  that  of 
a gentleman,  who  frequently  could  not  carry  out  what  he  willed  to 
perform.  Often  on  endeavoring  to  undress,  he  was  two  hours  before 
he  could  get  off  his  coat,  all  his  other  mental  faculties  being  perfect. 
On  one  occasion,  having  ordered  a glass  of  water,  it  was  presented  to 
him  on  a tray,  but  he  could  not  take  it,  though  anxious  to  do  so,  and 
he  kept  the  servant  standing  before  him  for  half  an  hour,  when  the 
obstruction  was  overcome.  In  the  other  case  the  peculiarity  was 
limited.  If,  when  walking  in  the  street,  he  came  to  a gap  in  the  line  of 
houses,  his  will  suddenly  became  inoperative,  and  he  could  not  proceed. 
An  un-built  open  space  in  the  street  was  sure  to  stop  him.  Crossing  a 
street  was  also  very  difficult,  and  in  going  in  or  out  of  a door  he  was 
always  arrested  for  some  minutes.  Both  these  gentlemen  graphically 
described  their  feelings  to  be  “ as  if  another  person  had  taken  possession, 
of  their  will.”  These  and  similar  perversions  of  motion,  whether  of 
excess  or  diminution,  however  produced,  cannot  always  be  governed  by 
19 


290 


GENERAL  THERAPEUTICS. 


predommant  ideas,  but  that  they  frequently  are  so  is  proved  by  a mul- 
titude of  facts.  The  old  story  of  Boerhaave  is  as  apposite  as  any  other, 
who  is  said  lo  have  immediately  cured  several  girls  at  school  of  chorea, 
by  threatening,  in  a loud  voice,  that  the  next  who  was  attacked  should 
have  the  actual  cautery  applied. 

The  power  of  imitation,  which  must  operate  through  the  mind  of  the 
individual,  is  known  b}’  medical  men  to  be  very  strong,  however  inex- 
plicable. Immoderate  laughter  is  very  catching ; few  can  resist  even  a 
well-imitated  yawn,  and  on  board  ship  nothing  more  certainly  brings  on 
sea-sickness  than  seeing  others  ill.  Habits,  modes  of  expression,  dialect, 
carriage  of  the  body,  and  peculiar  movements,  are  also  readily  acquired 
from  those  around  us.  On  visiting  the  Bosjesmen,  who  were  exhibited 
here  some  years  ago,  the  effect  of  their  dance  on  the  audience  was  strik- 
ing. Beginning  slow,  to  the  rhythmical  beatings  of  their  clubs,  the  noise 
became  gradually  louder,  more  and  more  exciting,  every  step  and  ges- 
ture keeping  exact  time.  I myself,  and  some  friends  with  me,  at  length 
felt  a peculiar  jar  all  through  our  systems,  our  own  feet  involun- 
tarily kept  time  with  the  dancers,  and  from  the  feelings  then  experi- 
enced, we  could  at  all  events  comprehend  the  nature  of  those  impulses, 
which  have  caused  multitudes  to  join  in  the  dance  of  St.  Vitus  or  of 
Tarantism. 

In  all  these,  and  various  other  cases  which  might  be  cited,  it  must 
be  evident  that  the  effect  is  produced  by  operating  on  the  mind  of  the 
individual,  and  through  that  on  his  bodily  powers.  In  short,  pre- 
dominant ideaSj  whether  criginating  spontaneously  or  suggested  by  the 
words  and  actions  of  others,  seem  to  be  the  exciting  cause  in  individuals 
affected  with  a peculiar  condition  of  the  cerebral  functions.  As  regards 
the  nature  of  this  condition,  it  seems  analogous  to  that  of  sleep  or  dream- 
ing, in  which  certain  faculties  of  the  mind  are  active,  and  may  be  even 
stimulated  into  excessive  action,  whilst  others  are  suspended.  Hence  it 
has  been  called  Hypnotism  by  Mr.  Braid.*  All  the  phenomena  pro- 
duced are  strictly  analogous  to  what  medical  men  are  acquainted  with  in 
various  morbid  states;  and  it  must  now  be  considered  as  well  established, 
that  in  certain  conditions  of  the  nervous  system  they  may  be  induced  at 
will.  This  conclusion,  however,  is  something  new,  for  it  has  but  recently 
been  admitted  in  physiology  or  pathology,  that  a condition  of  the  cere- 
bral functions  may  be  occasioned  in  apparently  healthy  persons,  during 
which  suggestive  ideas  are  capable  of  producing  those  phenomena  we 
have  described,  and  which  render  them,  for  the  time,  as  irresponsible  as 
monomaniacs.  Yet  such  is  really  the  fact,  which,  once  admitted  into 
physiology,  must  have  an  important  influence  on  the  theory  and  practice 
of  medicine.  This  condition  may  probably  be  accounted  for  physiolog- 
ically in  the  following  manner  : — 

We  have  previously  seen  that  the  cerebral  lobes  contain  white  fibres, 
which  run  in  three  directions.  1st,  Those  which  pass  from  below  up- 
wards, and  connect  the  hemispherical  ganglion  with  the  spinal  cord. 
2d,  Those  which  pass  transversely,  forming  the  commissures,  and  which 
unite  the  two  hemispheres.  And  3d,  Those  which  run  from  before 
backwards,  uniting  the  anterior  with  the  posterior  lobes  on  each  side 

* Neurypnology,  or  the  Rationale  of  Nervous  Sleep.  1843. 


INFLUENCE  OF  THE  MIND  ON  THE  BODY. 


291 


(p.  139);  these  fibres  being  also  probably  subservient  to  that  combina- 
tion of  the  mental  faculties  which  characterises  thought  (p.  140).  Now 
all  metaphysicians  and  physiologists  are  agreed  that  the  mind  is  com- 
posed of  various  faculties,  and  that  different  portions  of  the  nervous 
mass  are  necessary  for  their  manifestation.  True,  it  is  by  no  means 
determined  of  how  many  faculties  the  mind  is  made  up,  and  still  less  is 
it  known  which  parts  of  the  brain  are  necessary  for  the  manifestation  of 
each  individual  faculty.  But  let  the  first  proposition  be  granted,  then 
there  is  no  difficulty  in  supposing  that  one  or  more  of  these  may  be 
paralysed  or  suspended,  whilst  others  are  entire,  any  more  than  there  is 
in  knowing  that  sensation  may  be  lost  whilst  motion  remains  intact, 
although  the  nerve  fibres  of  both  run  side  by  side.  I presume,  then, 
that  certain  mental  faculties  are,  as  the  result  of  exhausted  attention, 
temporarily  paralysed  or  suspended,  whilst  others  are  rendered  active  in 
consequence  of  being  stimulated  by  suggestive  ideas ; that  the  psychical 
stimuli  of  the  former  make  no  impressions  on  the  cerebral  conducting 
fibres,  while  those  of  the  latter  are  increased  in  intensity  ; that  the 
proper  balance  of  the  mind  is  thereby  disturbed,  and  thus  the  individual 
for  the  time  being  acts  and  talks  as  if  the  predominant  idea  was  a reality. 
The  condition  is  analogous  so  far  with  ordinary  somnambulism,  certain 
forms  of  hypochondriasis  and  monomania,  but  admits  of  infinite  changes 
according  to  the  nature  of  the  idea  suggested. 

According  to  this  theory,  therefore,  we  suppose  that  a psychical 
stimulus  is  generated,  which,  uncontrolled  by  the  other  mental  opera- 
tions, acting  under  ordinary  circumstances,  induces  impressions  on  the 
peripheral  extremities  of  the  cerebral  fibres,  the  influence  of  which  only 
is  conveyed  outwards  to  the  muscles  moved.  In  the  same  manner  the 
remembrance  of  sensations  can  always  be  called  up  by  the  mind ; but 
under  ordinary  circumstances  we  know  they  are  only  remembrances, 
from  the  exercise  of  judgment,  comparison,  and  other  mental  faculties ; 
but  these  being  exhausted,  in  the  condition  under  consideration,  while 
the  suggested  idea  is  predominant,  leave  the  individual  a believer  in  its 
reality. 

In  this  manner  we  attribute  to  the  faculties  of  the  mind  a certain 
power  of  correcting  the  fallacies  which  each  is  liable  to  fall  into,  in  the 
same  way  that  the  illusions  of  one  sense  are  capable  of  being  detected  by 
the  healthy  use  of  the  other  senses.  We  further  believe  that  the  appa- 
ratus necessary  for  the  former  operations  consists  of  the  nerve  fibres, 
which  unite  different  parts  of  the  hemispherical  ganglion,  whilst  that 
necessary  for  the  latter  are  the  nerve  fibres  connecting  together  the 
organs  of  sense  and  the  ganglia  at  the  base  of  the  encephalon.  A healthy 
and  sound  mind  is  characterised  by  the  proper  balance  of  all  the  mental 
faculties,  in  the  same  manner  that  a healthy  body  is  dependent  on  the 
proper  action  of  all  the  nerves.  There  are  mental  illusions  and  sen- 
sorial illusions,  one  caused  by  predominant  ideas,  and  corrected  by  proper 
reasoning ; the  other  caused  by  perversion  of  one  sense,  and  corrected 
by  the  right  application  of  the  others.  Both  these  conditions  are  inti- 
mately united,  and  operate  on  each  other,  inasmuch  as  voluntary  and 
emotional  movements  and  sensations  are  mental  operations. 

This  tlTeory,  if  further  elaborated,  appears  to  me  consistent  with  the 


292 


GENERAL  THERAPEUTICS. 


facts  described  at  the  commencement  of  this  lecture,  and  capable  of 
explaining  them  on  physiological  principles.'^ 

We  may  now  ask  ourselves  whether  the  facts  which  have  been 
ascertained,  and  the  generalisations  which  flow  from  them  are  capable 
of  being  rendered  useful  in  the  practice  of  medicine  ? The  beneficial 
influence  of  hope  and  confidence  over  disease  is  as  well  known  to  medical 
men  as  is  the  injurious  tendency  of  fear  and  despondency.  This  effect 
of  mind  on  the  body  has  from  the  earliest  periods  been  seized  upon  by 
individuals  as  a ground  for  veneration  or  astonishment.  In  ancient 
times  the  heathen  priests  were  the  physicians,  and  the  temples  were  con- 
verted into  so  many  dispensaries,  at  which  the  sick  applied  for  relief. 
In  catholic  countries,  during  the  middle  ages,  the  offices  of  priest  and 
physician  were  frequently  united  in  one  person,  so  that  the  powerful 
effects  of  certain  shrines,  and  the  benefits  of  pilgrimages  in  cases  not 
admitting  of  simple  cure,  met  with  every  encouragement.  From  what 
has  preceded,  it  must  be  allowed,  that,  so  far  froui  its  being  improbable 
that  real  cures  were  so  effected,  all  that  we  know  of  the  effects  of  con- 
fident promises  on  the  one  hand,  and  belief  on  the  other,  renders  it  very 
likely  that  many  such  occurred.  The  legends  of  the  saints,  the  history 
of  witchcraft,  the  journal  of  Mr.  Wesley,  the  accounts  of  celebrated  pil- 
grimages, and  of  the  virtues  of  particular  shrines,  and  the  WTitings  of 
religious  enthusiasts  generally,  abound  in  wonderful  recoveries.  Charms, 
amulets,  and  relics,  are  stated  to  have  at  once  banished  all  kinds  of 
agony,  and  removed  numerous  nervous  diseases ; and  the  same  has  re- 
sulted from  intense  religious,  political,  or  martial  excitement.  Many  of 
these  tales  are  certainly  incredible,  whilst  others  are  perfectly  conceiv- 
able. The  royal  touch,  the  bezoar  stone,  zinc  rings,  wearing  the  mistle- 
toe and  other  sacred  plants,  have  all  been  lauded  as  means  of  cure. 
The  benefits  of  the  royal  touch  are  confirmed  by  the  observations  of 
Richard  Wiseman,  and  the  cures  performed  by  Greatrakes  are  warranted 
by  Robert  Boyle.  In  all  these  cases,  there  can  be  little  doubt  that  any 
benefit  which  did  occur  may  be  attributed  to  a strong  belief,  on  the  part 
of  the  patient,  in  the  efScacy  of  the  means  employed.! 


* It  was  proposed  by  Mr.  Braid  to  call  the  condition  of  which  we  have  been 
speaking,  and  which  results  from  a dominant  idea — m on oi deism..  The  term  monoi- 
deology  would  indicate  the  doctrine  of  the  influence  of  dominant  ideas  in  controlling 
mental  and  physical  action.  To  monoideise  might  express  the  act  of  performing  pro- 
cesses for  inducing  monoideism.,  and  monoideiser  designate  the  person  who  monoi- 
deises.  Then  monoideised  will  indicate  the  condition  of  the  person,  and  monoideody- 
namics  the  mental  and  physical  changes  which  result  from  the  process. 

f The  wonderful  cures  performed  by  Mesmer,  and  all  those  who  have  convinced 
themselves  and  others  of  the  advantages  of  the  ephemeral  systems  which  are  contin- 
ually springing  up  around  us,  are  much  indebted  to  belief  in  their  eflScacy  on  the 
part  of  the  patient.  Dr.  Haygartli,  of  Bath,  performed  all  the  cures  of  Mesmer  and 
Perkins  with  two  bits  of  wood  made  to  resemble  the  metallic  tractors  of  the  latter, — 
that  is,  so  long  as  he  kept  the  secret, — for  the  moment  he  published  his  book,  and 
the  imposition  was  known,  no  more  cures  were  accomplished.  In  the  same  manner 
there  is  every  reason  to  believe  that  the  efficacy  of  many  public  nostrums  resides  in 
the  reputation  which  surrounds  them.  Miss  Harriet  Martineau,  in  publishing  her 
own  case,  naively  remarks  : — “ If  at  any  time  during  my  illness  I had  been  asked, 
with  serious  purpose,  whether  I believed  there  was  no  resource  for  me  ? I should 
have  replied  that  Mesmerism  might  perhaps  give  me  partial  relief.” — {Letters  on  Ales- 


INFLUENCE  OF  THE  MIND  ON  THE  BODY. 


293 


In  recent  times  more  systematic  attempts  have  been  made  in  this 
way  to  relieve  pain,  control  nervous  excitement,  lessen  muscular  debility, 
and  stimulate  certain  secretions.  If  it  be  considered,  that  the  power  of 
producing  profound  sleep,  and  acting  on  the  nervous  functions,  may  be 
manifested  in  so  many  individuals  as  one  in  twenty  of  the  whole  popu- 
lation, it  must  be  evident  that  in  a class  of  persons  particularly  predis- 
posed, the  nuiiiber  capable  of  being  affected  would  be  much  greater. 
This  subject,  however,  is  yet  in  its  infancy,  and  has  to  be  separated  from 
the  charlatan  ism  which  has  hitherto  been  mingled  with  it.  The  labors 
of  Dr.  Eislale  am  mg  the  natives  of  India,  and  of  Mr.  Braid  in  Man- 
chester, exhibit  a worthy  commencement  to  the  rational  treatment  of 
disorders  by  the  means  now  alluded  to  ■ and  there  can  be  little  doubt 
that  in  no  long  time  its  influence,  when  further  studied,  will  be  acknow- 
ledged. Bat  how  far  this  influence  is  dependent  on  the  confidence  of 
the  patient ; on  the  belief  in  some  mysterious  circumstances,  which  is 
presumed  to  produce  the  effect,  or  on  some  unknown  law-regulating 
function  through  the  mind,  further  observation  alone  can  determine. 

In  the  meantime,  it  seems  to  me  that  we  are  indebted  to  Mr.  Braid 
not  only  for  having  first  clearly  demonstrated  that  the  phenomena 
described  are  wholly  occasioned  by  predominant  ideas  in  the  individual, 
but  for  the  first  contribution  of  any  value  to  the  mode  of  applying  this 
theory  to  the  cure  of  disease.  By  suggesting  thoughts  to  our  patients  in 
various  ways,  sometinies  by  speaking  so  that  they  may  hear  what  is  said, 
at  others  by  directing  their  thoughts  to  certain  subjects,  and  occasion- 
ally rendering  these  more  vivid  by  repetition  or  by  definite  physical  im- 
pressions, we  can  fix  certain  ideas  strongly  in  their  minds.  These  ideas 
act  as  stimulants  or  sedatives  according  to  their  purport,  and  the  cur- 
rent of  thought  directed  to  or  withdrawn  from  particular  organs  or  func- 
tions. liemarkable  cases  have  been  met  with,  where  a judicious  appli- 
cation of  this  doctrine  has  removed  insomnolence  or  various  kinds  of 
pain,  spasms,  and  other  evidences  of  excitement ; where  hysterical 
paralysis  of  the  limbs  or  special  organs  of  sense  have  been  relieved  or 
cured,  and  where  the  torpid  functions  of  lactation,  perspiration,  defseca- 
tion,  menstruation,  etc.,  have  been  rendered  more  active.'^  That  such 
results  may  be  induced  must  be  admitted  by  all  who  reflect — 1st,  On  the 
uido.ibted  fact  that  certain  persons  are  and  can  be  made  slaves  of 
dominant  ideas;  and,  2d,  On  the  equally  undoubted  fact,  that  such 
mental  ideas  are  known  by  universal  experience  to  exercise  a stimulat- 
ing or  depressing  effect  on  all  the  bodily  functions.  Hence,  many  drugs 
and  systems  of  treatment,  which  are  really  inert  or  uncertain  in  their 
action,  and  which  are  supposed  to  act  through  the  blood  or  on  the  tissues 
directly,  operate,  sometimes  beneficially,  by  exciting  expectant  ideas,  and 
through  these  ideas,  indirectly  on  the  part  disordered. 

A.S  an  illustration  of  what  can  be  done  in  this  way,  I may  mention 

merism,  1854,  p.  4.)  No  wonder,  therefore,  that  when  at  length  it  was  tried,  it  pro- 
duced the  desired  effect ; and  the  medical  attendant,  seeing  the  delusion  that  existed, 
perhaps  acted  judiciously  in  bringing  the  lady  en  rapport  with  the  first  magnetiser  he 
could  procure. 

* See  Braid  on  Hypnotic  Therapeutics — Monthly  Journal  of  Medical  Science,  July 
1853. 


294 


GENERAL  TEEEAPEUTICS. 


the  case  of  a young  lady  under  the  charge  of  the  late  Dr*  Johnston,  of 
Berwick-upon-Tweed,  affected  with  hysterical  paralysis,  who  had  for 
several  years  been  under  the  care  of  Sir  Benjamin  Brodie,  Mr.  Syme, 
and  other  eminent  surgeons,  who  recognised  the  nature  of  the  case,  but 
could  do  nothing.  Dr.  Johnston  read  some  remarks  on  “ Hypnotic 
Therapeutics,”  published  in  the  Edinburgh  Monthly  Journal  by  Mr. 
Braid,  and  sent  his  patient  to  him  at  Manchester.  By  giving  confidence 
to  this  lady,  inducing  her  to  walk  freely  and  trust  herself,  so  to  speak, 
on  her  limbs,  a perfect  cure  was  eftected  in  four  days,  when  she  moved 
about  without  any  lameness,  or,  as  it  was  said  by  the  reporter,  “ with  the 
grace  of  a queen  and  the  agility  of  a sylph.” 

I venture  to  say  that  cases  of  this  kind  constitute  one  of  the  great 
therapeutic  advancements  of  modern  times,  being  not  only  directly  appli- 
cable to  the  cure  of  maladies,  but  indicating  a most  important  principle 
explanatory  of  innumerable  recoveries  hitherto  too  much  neglected  by 
the  medical  profession,  and  accounting  for  the  well-known  fact  that  in 
many  instances  he  is  the  best  physician  who  succeeds  in  gaining  the  con- 
fidence of  his  patient. 

On  the  other  hand,  the  indiscriminate  performance  of  experiments 
on  nervous  individuals  may  be  injurious.  During  the  session  1850-51, 
society  in  Edinburgh  was  greatly  agitated  by  this  subject.  Fashionable 
parties  were  converted  into  scenes  of  experiments  on  the  cerebral  func- 
tions. Noblemen,  members  of  the  learned  professions,  and  respectable 
citizens,  amused  themselves  in  private,  whilst  public  discourses  and  ex- 
hibitions to  an  unusual  extent  were  got  up  for  the  entertainment  of  the 
public.  On  one  occasion  the  Royal  Medical  Society  was  operated  on ; 
and  if  a proof  of  the  correctness  of  the  facts  described  be  required,  it 
would  be  found  in  the  circumstance,  that  the  nervous  aberrations  noticed 
were  readily  exhibited  in  some  of  its  most  sceptical  members.  The 
result  of  this  excitement  was  an  increased  degree  of  nervousness  in  many 
individuals.  In  some  educational  establishments,  girls  and  boys  threw 
themselves  into  states  of  trance  and  ecstacy,  or  showed  their  fixed  eye- 
balls and  rigid  limbs,  for  the  amusement  of  their  companions.  Sensitive 
ladies  did  not  object  to  indulge  in  the  emotions  so  occasioned,  and  ex- 
hibited themselves  in  a like  way  for  the  entertainment  of  evening  parties. 
Several  instances  were  known  to  me  where  intelligent  young  men — 
students  in  this  University — were,  for  a longer  or  shorter  time,  incapaci- 
tated from  following  their  ordinary  occupations,  and  obliged,  from  want 
of  attention  and  mental  power,  to  stay  away  from  their  classes.  Some 
of  these,  from  a feeling  of  the  injury  they  have  sustained,  very  properly 
refused  to  allow  any  experiments  to  be  tried  on  them ; and  the  parents 
of  very  sensitive  young  persons,  from  the  obvious  detriment  their  health 
has  sustained,  also  forbade  a repetition  of  these  scenes.  One  young 
man  of  great  promise,  who  was  at  that  time  frequently  operated  on, 
became  insane,  and  subsequently  died  in  an  asylum.  I thought  myself 
warranted  in  calling  such  a state  of  things  “ The  Edinburgh  Mesmeric 
Mania  of  1851.” 

Such  experiments  cannot  be  considered  as  free  from  danger.  The 
great  object  of  all  who  seek  proper  self  education  is  to  control  the  emo- 
tions and  passions,  and  regulate  the  imagination  by  the  severer  faculties 


THE  NATUKAL  PEOGEESS  OF  DISEASE. 


295 


of  judgment,  comparison,  and  attention.  Hitherto  medical  men,  so  far 
from  exciting,  have  done  all  in  their  power  to  prevent  such  phenomena 
as  have  been  described ; but  now,  that  it  has  been  clearly  shown  that 
they  may  be  produced  in  numbers  of  people  by  the  ignorant  and  mer- 
cenary, every  effort  should  be  made  to  discourage  them.  It  is  well  known 
that  cases  are  on  record  of  individuals  who,  commencing  by  the  imita- 
tion of  hysterical  or  epileptic  convulsions,  have  at  length  found  them- 
selves really  laboring  under  those  diseases ; nor  is  it  unreasonable  to 
suppose,  that  the  mental  faculties  will  be  greatly  injured  in  persons  who 
frequently  surrender  up  their  own  wills,  and  act  in  accordance  with  the 
extravagant  ideas  suggested  to  them.  After  all,  the  pleasure  of  excite- 
ment principally  consists  in  feeling  that  it  can  be  regulated,  and  is  under 
command.  The  moment  it  ceases  to  be  so,  a sense  of  the  imperfection 
becomes  most  agonising  to  the  mind,  and  gives  rise  to  that  despoiidency 
so  common  among  the  insane.  Hence  those  only  who  have  studied  this 
subject,  and  are  prepared  as  medical  men  to  exercise  judiciously  the 
influence  they  may  possess  on  the  minds  of  their  patients,  ought  to 
attempt  the  cure  of  diseases  in  the  manner  now  referred  to. 


THE  NATURAL  PROGRESS  OF  DISEASE. 

It  may  be  laid  down  as  a general  law,  that  diseases  are  seldom 
stationary,  and  that  their  tendency  is  to  get  better  or  to  get  worse. 
While  many  disorders,  from  their  trifling  character,  or  in  consequence  of 
being  well  known,  are  at  once  recognised  as  capable  of  disappearing  spon- 
taneously, others  have  been  supposed  actually  to  have  a destructive  or 
injurious  tendency,  or  to  be  necessarily  fatal.  Now  the  study  of  disease 
in  modern  times  has  led  to  a great  change  in  our  views  on  these  heads. 
For  example,  it  was  formerly  supposed  that  acute  inflammations  had,  for 
the  most  part,  a destructive  tendency ; that  suppuration  was  a great  evil, 
and  always  required  the  interference  of  the  surgeon,  because  an  abscess, 
if  so  deep-seated  that  it  could  not  be  reached  with  the  knife,  seldom  got 
well,  and  if  it  burst  into  an  internal  cavity  caused  death.  Again,  if  in- 
flammation visited  the  skin,  the  mucous  or  serous  membranes,  or  the  in- 
ternal organs,  the  great  object  was  to  prevent  it  spreading  by  using  the 
most  violent  remedies,  such  as  blood-letting,  purging,  antimony,  and  low 
diet,  which  received  the  name  of  antiphlogistics.  On  the  other  hand,  a 
tubercular  disease,  especially  when  it  attacked  the  lung,  was  supposed  to 
be  almost  uniformly  fatal,  and  altogether  beyond  the  reach  of  art. 

Now  these  conclusions  are  erroneous.  We  have  previously  seen  that 
an  analeptic  treatment  frequently  cures  tubercular  diseases;  while  the 
antiphlogis  ic  treatment,  formerly  supposed  capable  of  cutting  short  in- 
flammations, not  only  fails  to  do  so,  but  constitutes  a most  fatal  practice. 
Much  of  this  error  depended  on  an  acquaintance  with  the  natural  progress 
of  disease.  Most  diseases  in  vigorous  constitutions,  so  far  from  having  a 
tendency  to  destroy,  have  a marked  tendency  to  get  well  of  themselves; 
whilst  instead  of  loss  of  blood,  weakness,  and  prostration  being  remedies, 
they  are  the  sources  of  danger,  and  the  chief  causes  of  the  fatal  result. 

Again  malignant  growths  were  supposed  to  be  seated  in  the  blood — 


296 


GENERAL  THERAPEUTICS. 


an  idea  which  rendered  operating  useless;  whilst  innocent  growths  were 
supposed  to  be  capable  of  going  away  of  themselves,  or  to  be  the  only 
ones  admitting  of  surgical  interference.  In  this,  also,  a great  change  in 
opinion  has  been  eifected ; so  that  cancers,  like  other  growths,  are  now 
known  to  have  been  successfully  extirpated. 

But  further,  how  is  it  possible  to  know  the  effect  of  any  remedy  what- 
ever, unless  it  be  ascertained,  in  the  first  instance,  not  only  what  is  the 
natural  termination,  but  also  the  natural  duration,  of  a disease?  We 
know  that  small-pox,  scarlatina,  measles,  and  similar  affections,  run  a 
certain  course,  and  no  one  thinks  of  cutting  them  short,  or  proposes  dif- 
ferent kinds  of  remedies  for  that  purpose.  The  real  principle  of  treat- 
ment is  to  conduct  them  to  a favorable  termination.  Should  not  the 
same  rule  apply  to  many  other  diseases  ? 

Some  years  ago  Dr.  Hamilton  Bell  stated,^  that  fifteen  drops  of  the 
tincture  of  muriate  of  iron  was  a valuable  remedy  in  erysipelas,  but  how 
valuable  was  not  shown,  because  it  was  not  attempted  to  be  proved  that 
the  remedy  diminished  the  mortality,  or  shortened  the  progress  of  the 
disease.  Notwithstanding,  this  remedy  was  at  once  largely  given,  and, 
it  was  said,  with  universally  good  results.  I remember  ac(ompanying 
M.  Louis,  many  years  ago,  in  his  visit  to  the  Hotel  Dieu,  and  was  much 
struck  by  seeing  many  cases  there  of  severe  erysipelas  of  the  scalp.  On 
asking  him  what  treatment  he  pursued,  he  answered,  none  at  all,  because 
they  all  rapidly  get  well  of  themselves  in  healthy  constitutions.  And, 
in  fact,  on  following  these  cases  from  day  to  day  T found  that  they  all 
did  so  get  well.  I need  scarcely  say  that  in  the  Royal  Infirmary  I have 
seen  many  severe  cases  of  erysipelas.  I have  never  given  the  tincture 
of  muriate  of  iron,  or  anything  but  good  diet,  with  lotions  of  acetate  of 
lead,  flour,  or  oil  locally  to  alleviate  irritation,  and  I have  not  h‘*d  a fatal 
case.  Nor  has  it  ever  appeared  to  me  that  the  tincture  of  muriate  of 
iron  could  have  shortened  the  progress  of  the  disease.  I need  scarcely 
say  that  any  remedy  might  easily  obtain  a great  reputation  if  given  in 
diseases  that  almost  always  get  well  of  themselves. 

Delirium  tremens  is  a disease  which,  within  a few  years,  has  under- 
gone several  modifications  in  its  treatment.  I remember  when  it  was 
supposed  to  arise  in  drunkards  from  leaving  off  the  accustomed  stimulus, 
and  the  treatment  consisted  in  giving  it  in  smaller  regulated  doses.  Then 
it  was  found  that  the  disease  was  treated  just  as  well  with  tartar-emetic, 
and  subsequently  opium  was  mainly  depended  on.  Ever  since  Dr.  Peddie 
showed  the  inutility  of  these  drugs,  I have  given  nothing  but  nourish- 
ment as  soon  as  the  patient  can  take  it,  and  all  the  cases  that  enter  my 
wards  recover. 

Again,  look  at  rheumatism.  Every  drug  and  every  system  of  treat- 
ment has  been  tried.  In  acute  cases,  bleeding,  purging,  antimony, 
mercury,  the  whole  class  of  sedatives  and  narcotics,  stimulants,  quinine, 
and  lemon  juice,  large  doses  of  alkalies,  numerous  specifics,  hot  baths, 
cold  baths,  dry  frictions  and  moist  applications  in  every  form.  Yet 
under  every  one  of  these  remedies,  however  opposite  in  their  nature, 
notable  cures  have  been  performed.  Is  not  the  conclusion  obvious,  that 
the  disease  follows  a certain  progress,  and  that  although  many  of  these 
* Monthly  Journal  of  Med.  Science,  June  1861. 


mFLTJENCE  OF  IMPROVED  DIAGNOSIS  AND  PATHOLOGY.  297 

remedies  may  retard  convalescence,  it  has  yet  to  be  proved  which,  if  any, 
shorten  its  duration,  even  one  hour  ? 

There  are  numerous  hospitals  scattered  through  the  country,  founded 
and  supported  at  large  expense,  for  the  purpose  of  carrying  out  some 
supposed  beneficial  treatment,  or  giving  to  the  poor  the  benefit  of  some 
celebrated  bath  or  spring.  Many  persons  are  treated  in  them,  and  are 
apparently  benefited,  both  physician  and  patient  firmly  believing  that  in 
every  case  the  cure  is  attributable  to  the  special  treatment.  Yet  in  no 
instance  has  it  ever  been  shown  that  such  patients  have  ever  recovered 
one  day  sooner  than  they  would  have  done  in  atiy  other  hospital,  or  than 
would  have  occurred  if  left  to  the  powerful  effects  of  rest,  warmth,  good 
food,  and  cleanliness. 

One  method  of  prosecuting  therapeutics,  therefore,  is  to  investigate 
— 1st,  How  long  a disease  naturally  takes  to  get  well  of  itself  under 
favorable  circumstances;  2dly,  What  is  its  progress  under  unfavorable 
circumstances  ; and  lastly,  this  being  known,  how  far  remedies  are  capable 
of  shortening  its  duration.  If  every  young  practitioner  would  dedicate 
his  life  to  the  careful  elucidation  of  the  natural  progress  of  only  one 
disease,  he  would  do  more  for  medical  practice  than  has  been  accomplished 
by  centuries  of  empirical  trials  of  remedies. 


THE  KNOWLEDGE  DERIVED  FROM  AN  IMPROVED 
DIAGNOSIS  AND  PATHOLOGY. 

This,  perhaps,  more  than  anything  else,  has  tended  to  alter  our  ap- 
preciation of  the  value  of  drugs.  When  we  consider  the  progress  made 
in  recent  times  in  the  art  of  detecting  diseases  with  exactitude,  and  re- 
member that  it  is  daily  becoming  more  and  more  manifest  that  mere 
symptoms  or  functional  disturbances  frequently  bear  no  relation  to  the 
pathological  lesion  which  produces  them,  we  shall  not  be  surprised  at 
this.  Instead  of  guessing  at  what  was  probably  the  matter,  we  now 
often  determine  with  certainty  what  exists.  Diagnosis  is  daily  becoming 
less  and  less  conjectural  by  the  use  of  instruments  which  bring  organic 
disease  directly  under  the  observation  of  the  senses.  Percussion  and 
auscultation,  specula,  the  microscope,  chemical  tests,  and  other  appli- 
ances, enable  the  well-educated  clinical  student  to  act  with  convictions 
altogether  unknown  to  his  predecessors. 

A person  complains  of  dyspnoea  on  exertion,  pain  or  uneasiness  in  the 
precordial  region,  with  palpitations  and  unfrequent  or  irregular  pulse. 
Formerly  a lowering  treatment — leeches,  and  especially  certain  sedatives, 
such  as  digitalis  or  aconite — was  adopted  to  remove  these  symptoms. 
At  present,  if  we  recognise  by  auscultation  that  these  symptoms  depend 
on  disease  of  a valve,  with  more  or  less  cardiac  hypertrophy,  we  see  that 
such  treatment  can  neither  remove  the  disease  nor  relieve  the  symptoms. 
Nay  more.  Pathology  tells  us  that  it  is  likely  to  be  prejudicial.  The 
ventricle  of  the  heart,  not  being  able  to  expel  its  contents  as  formerly, 
in  consequence  of  the  obstruction  or  regurgitation  in  a valve,  follows  the 
law  producing  increased  growth  ; having  more  work  to  do,  its  walls  are 
strengthened  and  increased  in  bulk  and  power — hypertrophy  is  the 


298 


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result,  and  thereby  an  adaptation  of  means  to  an  end,  which  is  the  sal- 
vation of  the  economy.  The  heart’s  action  is  increased  for  the  wisest  of 
purposes ; nothing  hut  an  acquaintance  with  pathology  could  induce  any 
one  to  lessen  it.  That  can  only  be  done  by  removing  the  obstruction  at 
the  valve;  and,  as  we  cannot  do  this,  sound  practice  requires  that  we 
should  abandon  all  attempts  to  act  on  the  heart  itself,  and  direct  our 
efforts  to  lessen  the  concomitant  symptoms  by  precautions  which  will  at 
least  prolong  life. 

But  if  the  same  symptoms  are  induced  without  organic  lesion  in  the 
heart,  we  recognise  that  they  are  the  effect  of  weakness,  arisemia,  or 
chlorosis.  Here,  again,  sedatives  and  lowering  the  constitution  only  add 
to  the  exhaustion ; a tonic  and  strengthening  treatment  is  required,  and 
above  all,  directing  attention  away  from  the  disordered  organ,  tranquilliz- 
ing the  mind,  and  inspiring  hope  and  confidence. 

It  would  be  easy  for  me  to  adduce  instances  where  not  only  the 
stethoscope  has  in  this  w^ay,  conjoined  with  pathology,  completely 
changed  our  practice,  but  how  almost  every  ingenious  instrument  which 
has  been  invented  has  done  the  same  thing.  What  it  has  effected  for 
pulmonary  and  cardiac  disorders,  the  microscope  has  accomplished  for 
renal  and  integumentary  diseases — the  speculum  for  uterine  and  aural, 
and  is  commencing  to  do  for  laryngeal,  affections.  By  means  of  the 
ophthalmoscope  we  now  explore  the  retina  and  transparent  lenses  of  the 
eye ; and  these  and  other  instruments,  conjoined  with  a knowledge  of 
chemistry  and  morbid  anatomy,  have  in  every  instance  modified,  if  they 
have  not  revolutionized,  the  mode  of  treatment.  In  all  these  cases  the 
result  has  been  brought  about  by  improving  diagnosis,  and  extending 
our  knowledge  of  pathology. 

Here  also  I would  endeavor  strongly  to  impress  upon  you  the  value 
of  <po8t  mortem  examinations,  with  a view,  not  only  to  diagnosis  and 
pathology,  but  to  forming  even  a just  estimate  of  treatment.  How  fre- 
quently has  it  turned  out,  when  we  have  supposed  our  remedies 
have  succeeded  in  curing  the  patient,  that  some  accident  has  demonstrated 
that  we  have  been  entirely  wrong  in  our  conclusion.  The  individual 
perhaps  has  died  suddenly  from  some  other  cause,  and  on  examining  the 
dead  body,  the  effect  we  have  attributed  to  our  treatment  has  evidently 
resulted  from  natural  causes.  Again,  how  frequently  has  it  been  shown 
that  mere  symptoms  are  deceptive,  and  that  a supposed  inflammation  is 
in  truth  no  inflammation  at  all.  Numerous  cases  in  the  subsequent  part 
of  this  work  afford  illustration  of  these  statements,  although  at  present  I 
can  only  allude  to  two  of  them.  Under  the  head  of  aneurism  will  be 
found  the  singular  case  of  Henry  Smith,  who,  on  admission,  had  a pul- 
sating tumor  in  the  abdomen.  This  I treated  after  the  method  of  Val- 
salva, and  had  the  satisfaction  of  seeing  the  tumor  get  smaller  and 
smaller,  become  more  solid,  and  pulsate  less  forcibly.  I was  anticipating 
a complete  obliteration  of  the  aneurism,  when  the  man  poisoned  himself 
with  aconite.  On  examination  of  the  body,  it  was  found  that  the  tumor 
was  in  fact  smaller,  quite  solid,  and  on  the  point  of  obliteration.  This 
effect,  however,  was  evidently  owing  to  the  growth  of  another  large 
aneurism  of  the  aorta  deep  in  the  thorax,  which,  by  retarding  the  current 
of  the  blood  in  the  tumor  below,  produced  coagulation  of  the  blood  in 


FALLACY  OF  THE  CHANGE  OF  TYPE  THEORY. 


299 


it.  Had  no  such  examination  been  made,  I myself  and  most  of  those 
who  witnessed  this  case  could  scarcely  have  escaped  from  the  impression 
that  the  result  had  been  owing  to  the  treatment  employed.  Again,  under 
the  head  of  Pleuritis,  will  be  found  the  remarkable  case  of  Allan  Brown, 
who,  a few  days  previous  to  his  death,  was  seized  with  all  the  symptoms 
of  perforation  of  the  bowel.  On  examining  the  body  after  death,  how- 
ever, acute  pain,  tympanitis,  and  other  symptoms  were  found  to  depend 
upon  an  enormous  distension  of  the  stomach,  with  emphysema  of  the 
coats  of  that  viscus,  caused  by  drinking  a large  quantity  of  effervescing 
lemonade.  It  is  the  multiplication  of  such  facts  in  hospital  practice  that 
must  induce  great  distrust  as  to  the  value  of  systems  of  treatment  directed, 
by  violent  remedies,  to  cut  short  and  suppress  diseases,  the  mere  detec- 
tion of  which  is  subject  to  such  difficulties. 

Indeed,  it  is  only  consistent  with  that  love  of  truth  and  exactitude 
which  must  ever  govern  an  honorable  profession  that,  if  once  it  be 
made  apparent  to  the  understanding  that  known  facts  are  opposed  to 
one  system,  and  are  reconcilable  with  another,  the  success  of  the  latter 
is  secured.  So  far  from  changes  in  practice  constituting  a reproach,  it 
must,  to  every  right  thinking  mind,  be  the  strongest  proof  that  our  art, 
like  that  of  all  others,  is  improved  in  proportion  as  its  fundamental  and 
collateral  sciences  advance.  If  we  regard  history,  we  shall  see  that  in 
all  ages  medicine,  though  empirical  in  detail,  has  been  scientific  in  the 
a^gre^ate.  It  has  been  chemical  with  the  chemical  school  of  science  ; 
mechanical  with  the  mechanics  ; vital  with  the  vitalists;  now  solidist,  now 
fluidist.  A cell  doctrine  of  growth  by  Schwann  inaugurates  a cell  patho- 
logy by  Virchow  and  a cell  therapeutics  by  Addison;  and  there  is  no 
doubt  that  a molecular  theory  of  organization  in  like  manner  must  induce 
a molecular  pathology  and  a molecular  therapeutics.  In  all  these  changes 
and  revolutions,  our  science  and  art  have  steadily  progressed  ; and  if  at 
the  present  time  a revolution  in  therapeutics  is  rapidly  being  effected,  it 
only  indicates  a state  of  things  upon  which  all  true  lovers  of  the  profes- 
sion have  every  reason  to  congratulate  themselves. 


FALLACY  OF  THE  CHANGE  OF  TYPE  THEOKY. 

Opposed,  however,  to  these  ideas  is  a doctrine  wliich  has  recently 
been  put  forth  by  a late  distinguished  Edinburgh  professor  (Alison),  and 
supported,  to  a large  extent,  by  the  senior  members  of  the  profession. 
This  doctrine  is,  not  that  recent  changes  in  practice  result  from  an  im- 
proved knowledge,  or  an  advance  in  diagnosis  and  pathology,  but  that 
diseases  themselves  change.  He  thought,  for  example,  that  inflammation 
is  no  longer  the  same  now  that  it  was  in  the  time  of  Cullen  and  Gregory ; 
that  the  human  constitution  (in  a manner  which  he  did  not  explain)  is 
fundamentally  altered,  and  has  become  weaker ; so  that  medical  men 
were  as  right  in  treating  disease  by  bloodletting  in  former  days  as  they 
are  now  in  abstaining  from  it.  So  satisfactory  did  this  theory  appear  to 
its  founder,  that  he  claimed  for  it  the  dignity  of  an  ultimate  fact  or  axiom. 
Thus,  says  Dr.  Alison,  changes  of  type  in  inflammatory  diseases  constitute 
a “ part  of  the  general  dispensations  of  Providence  as  to  those  diseases, 


300 


GENERAL  THERAPEUTICS. 


and  are,  as  far  as  yet  known,  an  ultimate  fact  in  their  history Dr. 
Watson  says,  no  less  emphatically,  in  the  last  edition  of  his  work  on  the 
“ Practice  of  Physic  “ I am  firmly  persuaded,  by  my  own  observations, 
and  by  the  records  of  medicine,  that  there  are  waves  of  time  through 
which  the  sthenic  and  the  asthenic  characters  of  disease  prevail  in  suc- 
cession ; and  that  we  are  at  present  living  amid  one  of  its  adynamic 
phases.” 

Let  us  fora  moment  consider  what  this  theory  implies — viz.,  that  the 
constitution  of  mankind  has  become  weaker  and  less  capable  of  bearing 
depletion  now  than  formerly ; that  the  human  pulse,  by  which  this  is 
tested,  beats  less  vigorously  when  diseased  than  it  did  for  hundreds  of 
years  before  the  days  of  Cullen  and  Gregory  ; that  when  a strong  man, 
now-a-days,  is  seized  with  an  inflammation,  he  presents  all  the  phenomena 
that  used  to  be  observed  in  a weak  one  : in  short,  that  the  human  race 
has  so  degenerated  during  the  last  five-and-twenty  years,  that  the  reaction 
which  formerly  used  to  take  place  in  the  economy,  no  longer  occurs,  and 
that  it  cannot  bear  depletion  so  well. 

But  surely  this  idea  may  be  said  to  repose  on  no  facts  whatever,  but 
merely  on  supposition : for,  when  we  investigate  the  effects  of  injuries  after 
the  battle  of  Waterloo  and  after  the  battle  of  the  Alma,  we  find  them,  in 
the  British  army,  identically  the  same.  Neither  has  any  change  been 
observed,  in  this  respect,  in  our  civil  hospitals.  Then  the  people,  generally, 
are  better  fed,  clothed,  and  housed,  than  they  used  to  be  ; the  comforts  and 
enjoyments  of  life  are  far  more  widely  diffused,  and  its  absolute  value, 
according  to  the  bills  of  mortality,  is  greatly  augmented.  Our  mental 
strength,  commercial  enterprise,  engineering  skill,  martial  daring,  and 
bodily  vigor  might  easily  be  shown  never  to  have  surpassed  what  this 
country  can  now  boast  of — facts  entirely  opposed  to  this  theory. 

Then  the  treatment  of  inflammation  without  antiphlogistics  has  also 
been  introduced  among  veterinary  practitioners.  Is  it  to  be  maintained, 
therefore,  that  our  horses  and  cattle  have  also,  as  the  result  of  civilisation, 
been  innervated,  and  that  in  them  also  the  type  of  disease  is  altered  ? 
We  nowhere  observe  this  any  more  among  them  than  among  mankind; 
they  still  draw  the  same  loads — still  plough  with  the  same  depth  of 
furrow — still  run  with  the  same  if  not  greater  speed. 

Besides,  it  should  not  be  forgotten  that  the  antiphlogistic  was  a fatal 
practice — in  acute  pneumonia,  amounting  to  one  death  in  three  cases. 
In  my  wards  the  deaths  only  amount  to  one  in  thirty  or  forty,  as  will  be 
subsequently  shown.  To  prove  that  this  is  a result  of  treatment,  and  not 
of  change  of  type,  it  is  only  necessary  to*  consider  that,  in  countries  such 
as  Spain  and  Italy,  where  the  old  practice  is  still  followed,  it  produces  the 
same  fatal  result.  Have  we  not  all  recently  been  startled  by  the  death 
of  Count  Cavour,  which  followed  five  bleedings  for  a fever  ? Are  we 
then  to  believe  that,  whilst  the  people  of  Britain,  France,  and  Germany 
have  degenerated,  those  of  Spain  and  Italy  have  retained  their  pristine 
vigor  ? In  Paris,  M.  Bouillaud  continues  to  pursue  his  system  of  bleed- 
ing by  the  coup-sur-coup  method.  He  is  the  only  one  in  that  capital  who 
does  so.  Can  we,  on  this  account,  believe  that  in  his  wards  the  type  of 
disease  has  not  changed,  whilst  in  every  other  hospital  and  ward  it  has  ? 
On  the  contrary,  we  find  that  wherever  large  bleedings  are  practised  at 


FALLACY  OF  THE  CHANGE  OF  TYPE  THEOEY. 


301 


present,  the  like  great  mortality  exists  as  used  to  prevail — showing  that 
the  disease  is  still  the  same. 

Then  it  has  been  argued  that  epidemic  fevers  change  their  type,  and 
so  they  unquestionably  do,  but  it  in  no  way  follows  that  organic  diseases 
should  do  so  likewise.  The  morbid  poisons  in  the  atmosphere  arising 
from  various  sources  are  more  powerful  at  one  period  than  another,  and 
not  only  induce  symptoms  varying  in  intensity,  but  cause  varied  symp-| 
toms  such  as  occur  in  typhus  or  typhoid  fevers.  It  is  the  latter  changes 
which  constitute  difference  in  type.  But  there  have  been  strong  and 
weak  men  in  all  ages ; while  blows,  injuries,  and  changes  of  temperature 
have  similarly  affected  them,  occasioning  symptoms  proportioned  to  their 
bodily  vigor,  but  in  no  way  altering  the  character  of  the  symptoms 
themselves.  Have  cancer,  tubercle,  or  other  structural  changes  under- 
gone a change  of  type.  Tubercular  diseases  of  the  lung  were  until  lately 
considered  to  be  almost  always  fatal ; now,  owing  to  an  improved  treat- 
ment, it  is  known  that  they  frequently  recover.  Are  we  therefore  to  be- 
lieve that,  while  persons  affected  with  inflammations  are  weaker,  those 
affected  with  phthisis  and  scrofula  are  stronger  than  they  used  to  be  ? 

But  it  is  stated  that  the  pulse  has  altered ; formerly  it  was  found  to 
be  strong,  now  it  is  comparatively  weak.  Why,  within  the  last  twent}^- 
five  years,  nature  should  have  changed  the  pulse  of  man  and  animals  is 
not  very  clear.  J udging  from  the  circumstances  to  which  I have  alluded, 
especially  the  more  abundant  food  and  prosperity  of  the  people,  it  ought 
to  be  stronger  instead  of  weaker.  But  some  have  already  brought  for- 
ward ideas  to  explain  the  supposititious  fact.  Thus  it  has  been  said  the 
use  of  tea  instead  of  malt-liquor,  spirits,  and  wine,  renders  people  weaker 
and  more  nervous.  Some  have  thought  that  the  use  of  potatoes,  and 
others  the  employment  of  railways,  has  something  to  do  with  it.  Dr. 
Watson  is  of  opinion  that  it  is  attributable  to  the  epidemics  of  cholera, 
which,  in  a manner  he  has  not  sought  to  explain,  “ leave  traces  of  their 
operation  on  the  health  and  vitality  of  a community  long  after  they  have 
ceased  to  prevail  as  epidemics.”  (Pneumonia,  vol.  ii.  p.  97.)  Mr. 
Robertson,  of  Manchester,  is  satisfied  from  experience  that  it  is  the  boil 
epidemic  which  has  caused  this  remarkable  change  of  type.  Some  suppose 
that  it  is  dependent  on  the  altered  relations  between  our  urban  and  rural 
populations.  Would  it  not  be  well  for  those  who  are  already  discussing  the 
causes  of  a change  that  is  by  no  means  apparent,  to  ask  themselves,  in  the 
first  instance,  how  they  establish  the  fact  that  the  pulse  is  changed  at  all  ? 

I need  scarcely  say  that  memory  and  mere  opinion  in  a case  of  this 
kind  are  not  of  much  value.  How  often  do  our  senses  deceive  us  when 
objects  are  at  hand ; how  little  can  they  be  depended  on  when  it  is  simply 
asserted,  that  in  the  memory  of  this  or  that  practitioner  a pulse  was 
stronger  twenty  years  ago  than  it  is  now.  And  yet,  gentlemen,  we  have 
no  further  evidence  than  this  advanced  by  the  supporters  of  a theory 
which  claims  as  its  fundamental  fact  a diminished  vital  force  in  the  heart 
and  pulse  of  man  and  animals,  to  explain  a change  of  practice.  But 
what  say  science  and  positive  observation  of  these  assertions  ? It  so 
happens  that  there  is  no  subject  in  all  physiology  with  regard  to  which  we 
possess  more  elaborate  and  more  exact  information  than  we  do  concerning 
the  pulse.  In  1732  Stephen  Hales  published  a remarkable  series  of  experi- 


302 


GENEKAL  THERAPEUTICS. 


merits  regarding  the  static  force  of  the  pulse,  and  the  rapidity  of  the  blood 
through  arteries  of  different  calibres.  In  1828-29,  similar  observations 
were  made  by  Poisseulle  with  an  instrument  invented  for  that  purpose, 
which  he  called  the  “ hsemadynamometer,”  that  led  him  to  the  same  con- 
clusion as  that  arrived  at  by  Hales.  In  these  experiments  the  force  of 
the  pulse  was  determined  by  the  height  to  which  the  impulse  of  the  blood 
could  elevate  a column  of  mercury.  It  resulted  that  the  static  force  with 
which  the  blood  is  impelled  in  the  human  aorta  is  equal  to  the  pressure 
of  41bs.  4oz.  on  the  square  inch,  and  in  the  radial  pulse  is  equal  to  about 
4 drachms.  Valentin  confirmed  these  results  in  1844,  Ludwig  in  1847, 
and  Vierordt  so  late  as  1855 ; so  that  not  only  is  there  no  fact  whatever 
in  support  of  the  notion  that  the  pulse  of  man  or  animals  is  weaker  now 
than  formerly,  but  all  positive  researches  during  a period  of  one  hundred 
and  thirty  years  prove  the  very  contrary.  It  appears  to  me,  therefore, 
that  the  theory  of  change  of  type,  so  far  from  being  established  on  well- 
known  facts,  is,  on  the  contrary,  altogether  fallacious,  and  entirely  op- 
posed to  all  the  accurate  data  which  histology,  physiology,  and  pathology 
have  accumulated  in  modern  times. 


ON  THE  DIMINISHED  EMPLOYMENT  OF  BLOOD-LET- 
TING, AND  ANTIPHLOGISTIC  BEMEDIES,  IN  THE 
TREATMENT  OF  ACUTE  INFLAMMATIONS. 

It  must  be  admitted  by  all  who  contemplate  the  actual  state  of 
medical  practice  in  this  country,  that  the  use  of  blood-letting,  and  of 
other  antiphlogistic  remedies,  has  within  a recent  period  greatly  declined. 
According  to  Dr.  Alison,'^  such  remedies,  and  more  especially  blood-let- 
ting, were  formerly  highly  successful  in  arresting  the  progress  of  acute 
inflammations,  but  fail  to  do  so  now,  and  are  even  injurious.  The  in- 
ference he  drew  from  these  supposed  facts  was  that  inflammation  itself 
is  no  longer  the  same,  that  its  type,  and  more  especially  the  febrile 
symptoms  accompanying  it,  have  altered  from  an  inflammatory  to  a 
typhoid  character.  In  short,  it  was  Dr.  Alison’s  opinion,  that  our  ad- 
vanced knowledge  of  diagnosis  and  pathology  has  had  little  influence  in 
producing  this  great  revolution  in  our  treatment,  but  that  the  human 
constitution  is  fundamentally  altered,  and  that  medical  men  were  as 
right  in  bleeding  twenty  years  ago  as  they  are  correct  in  now  abstaining 
from  it.  In  opposition  to  these  views,  it  will  be  my  endeavor  to  show 
— 1st,  That  little  reliance  can  be  placed  on  the  experience  of  those  who, 
like  Cullen  and  Gregory,  were  unacquainted  with  the  nature  of,  and 
mode  of  detecting,  internal  inflammations.  2d,  That  inflammation  is 
the  same  now  as  it  has  ever  been,  and  that  the  analogy,  sought  to  be 
established  between  it  and  the  varying  types  of  essential  fevers,  is  falla- 
cious. 3d,  That  the  principles  on  which  blood-letting  and  antiphlogistic 
remedies  have  hitherto  been  practised  are  opposed  to  pathology.  4th,  That 
an  inflammation  once  established  cannot  be  cut  short,  and  that  the  object 
of  judicious  medical  practice  is  to  conduct  it  to  a favorable  termination. 


* Edinburgh  Medical  Journal,  March  1856. 


FALLACIOUS  CHARACTER  OF  PAST  EXPERIENCE. 


303 


6th,  That  all  positive  knowledge  of  the  experience  of  the  past,  as  well 
as  the  more  exact  observation  of  the  present  day,  alike  establish  the 
truth  of  the  preceding  propositions  as  guides  for  the  future. 

Proposition  1. — That  little  reliance  can  he  placed  on  the  experience  of 
those  who.  like  Cullen  and  Gregory^  were  unacquainted  with  the 
nature  of^  and  the  mode  of  detecting  internal  inflammations. 

Inflammation  for  many  years  was  generally  recognised,  especially  in 
external  parts,  by  the  existence  of  pain,  heat,  redness,  and  swelling,  and 
in  internal  parts  by  fever,  accompanied  by  pain,  and  impeded  function 
of  the  organ  affected.  In  short,  groups  of  symptoms,  in  accordance  with 
the  nosological  systems  of  the  day,  constituted  inflammation.  But  the 
school  of  morbid  anatomy,  by  showing  that  inflammation  was  a diseased 
condition  of  a part,  entirely  overthrew  the  errors  and  confusion  inherent 
in  all  such  nosological  systems.  Clinical  observation,  based  on  a more 
correct  diagnosis  and  pathology,  has  sinee  demonstrat  d that  artificial 
nosological  groups  of  symptoms  bear  no  relation  whatever  to  the  internal 
inflammations  they  were  formerly  supposed  to  indicate,  and  has  led  to  a 
mass  of  information,  connected  with  internal  disease,  which,  up  to  this 
time,  has  never  been  correctly  systematised.  Again,  more  recent  his- 
tological research,  by  exhibiting  to  us  that  inflammation  is  in  truth  a 
disease  of  nutrition,  governed  by  the  same  laws  that  determine  the 
growth  and  functions  of  cells,  as  they  exist  in  the  embryo  and  in  healthy 
tissues,  has  united  physiology  and  pathology  into  one  science,  and  has 
removed  our  present  knowledge  still  further  from  the  traditional  errors 
of  the  past.  Why,  then,  should  we  in  our  onward  course  be  governed 
by  the  opinions  of  Cullen  and  Gregory,  of  Gaubius  and  Sydenham,  of 
Aretseus  and  Hippocrates  ? These  distinguished  men  all  advanced  medi- 
cine in  their  day,  as  far  as  they  were  enabled  to  do  so  by  the  then  state 
of  science  and  the  means  within  their  reach ; but  the  pirnciples  which 
guided  them  ought  no  more  to  be  considered  laws  to  be  followed  now  by 
practical  physicians,  than  should  the  exploded  astronomical  doctrines  of 
the  ancients  be  acted  on  by  practical  navigators.  It  is  not  my  intention, 
therefore,  to  enter  into  a lengthened  refutation  of  the  opinions  of  former 
writers,  or  even  of  any  modern  ones,  in  determining  what  pathologists 
now  understand  by  the  term  inflammation.  What  I mean  by  it  in  the 
following  remarks,  is  an  exudation  of  the  normal  liquor  sanguinis^  for  the 
reasons  previously  stated.  (See  Inflammation,  p.  160.) 

As  regards  diagnosis,  it  must  be  acknowledged  by  all  parties  that,  up 
to  a recent  period,  internal  inflammations  were  sought  to  be  recognised 
only  by  symptoms.  But  medical  men,  who  have  of  late  years  studied 
these  inflammations  by  physical  signs  as  well  as  by  symptoms,  must 
have  come  to  a conclusion,  that  symptoms  alone  are  altogether  insuffi- 
cient to  enable  us  to  determine  the  existence  of  internal  inflammations. 
This  is  a point  which,  if  necessary,  could  be  established  by  innumerable 
facts,  which  show — 1st,  That  all  the  symptoms  of  inflammation  may  be 
present,  and  yet  post  mortem  examination  demonstrate  the  absence  of 
lesion  ; and,  2dly,  That  inflammation  has  been  the  cause  of  numerous 
deaths,  without  one  of  the  symptoms  generally  supposed  to  be  its  accom- 


304 


GENERAL  THERAPEUTICS. 


paniments  having  been  present.  But  here,  also,  it  is  unnecessary  for 
me  to  enter  at  any  length  into  this  question,  because  it  was  admitted  by 
Dr,  Alison  that  we  can  now  detect  inflammation  of  the  lungs  “ in  cases 
where  there  is  so  little  of  pain,  or  cough,  or  dyspnoea,  or  inflammatory 
fever,  that  we  should  not,  in  former  times,  have  given  them  the  name  of 
pneumonia.”  But  when  he  goes  on  to  say  that  “ the  cases  of  pneumonia 
thus  overlooked  were  attended  with  little  or  no  immediate  danger,”  I am 
constrained  to  dissent  from  this  opinion,  for  it  appears  to  me  that  many 
of  these  cases,  especially  such  as  are  complicated  and  occur  in  old  age 
(so-called  latent  pneumonia),  are,  at  this  moment,  the  most  fatal,  and 
that  they  always  must  have  been  so.  On  the  other  hand,  the  symptoms 
which  formerly  were  supposed  to  indicate  pneumonia — viz.,  pain,  cough, 
dyspnoea,  rusty  sputa,  and  fever — we  now  know  are  met  with  in  a variety 
of  lesions,  independent  of  pneumonia,  especially  in  certain  cases  of  bron- 
chitis in  young  subjects,  or  engorgements  and  apoplexy  of  the  lung,  asso- 
ciated with  fever  or  heart  disease  in  older  persons.  Hence,  formerly  bleed- 
ing was  not  practised  in  many  cases  where  pneumonia  was  present,  whilst  it 
was  largely  resorted  to  in  others  where  that  disease  never  existed  at  all. 

Other  writers  besides  Dr.  Alison  have  endeavored  to  show,  and  not 
unsuccessfully,  that  what  was  formerly  understood  by  pneumonia  or  peri- 
pneumonia, is  altogether  different  from  what  we  now  mean  by  these 
terms.  But  they  have  not  been  so  successful  in  deducing  from  the  ex- 
perience possessed  by  former  pliysicians  in  treating  symptoms,  what 
ought  to  be  the  rule  of  practice  for  those  in  modern  times  who  recognise 
the  anatomical  lesions  of  organs.  If,  indeed,  it  could  be  shown  that  the 
group  of  symptoms  formerly  called  inflammatory  always  indicated  the 
same  morbid  lesion,  former  experience  might  still  be  useful  to  us.  But 
we  contend  that  this  is  what  clinical  observation  proves  to  be  impossible. 
Such  are  the  contradictory  statements  and  the  confusion  resulting  from 
the  unacquaintance  of  the  past  race  of  practitioners  with  a correct  diag- 
nosis and  pathology,  that  no  confidence  whatever  can  be  placed  in  their 
impressions,  as  to  what  cases  were  or  were  not  benefited  by  bleeding. 

Hence,  although  I am  far  from  repudiating  experience  in  cases  which 
in  the  present  day  are  clearly  recognizable  as  true  inflammations,  it  is 
surely  unreasonable  to  be  guided  by  that  experience  in  cases  where  it  is 
acknowledged  that  the  observations  are  imperfect  and  vague,  and  which, 
even  among  those  who  desire  to  take  advantage  of  it,  causes  endless 
diflPerences  of  opinion  as  to  what  was  meant  or  intended.  Medicine  is 
not  a scientific  art  which  is  dependent  for  its  principles  on  the  study  of, 
and  commentary  on,  the  old  writers.  AVhat  they  thought  and  what 
they  said,  are  not,  and  ought  not,  in  a question  of  this  kind,  to  be  our 
guide,  as  to  what  was  or  is.  On  the  contrary,  it  is  the  book  of  nature, 
which  is  open  to  all,  that  we  ought  to  peruse  and  study,  and  why  should 
we  read  it  through  the  eyes  of  past  ages,  when  the  light  of  science  was 
comparatively  feeble  and  imperfect,  instead  of  bringing  all  the  advanced 
knowledge  of  the  present  time  to  elucidate  her  meaning  ? The  lesson, 
which  the  careful  study  of  the  history  of  medicine  has  forced  upon  me,  is 
the  necessity  of  re-investigating,  with  all  our  improved  modern  appli- 
ances, the  correctness  or  incorrectness  of  existing  dogmas,  in  order  to 
establish  an  improved  practice  for  the  future. 


THE  UNCHANGEABLE  NATURE  OF  INFLAMMATION. 


305 


Proposition  2. — That  injlammation  is  the  same  now  as  it  has  ever  heen^ 
and  that  the  analogy  sought  to  he  established  between  it  and  the 
varying  types  of  fevers  is  fallacious. 

The  essential  nature  of  inflammation  has  been  already  alluded  to, 
viz.,  a series  of  changes  in  the  nervous,  sanguineous,  vascular,  and 
parenchymatous  functions  of  a part  terminating  in  exudation  of  the 
liquor  sanguinis,  or  what  some  call  effusion  of  lymph.  If  these  changes 
have  been  materially  modified  in  recent  times,  I again  urge  that  such 
modifications  have  not  been  shown  ; and  if  they  have  not.  in  what  can 
it  be  said  that  inflammation  and  its  results  have  changed  within  the  last 
twenty  years?  To  this  question  no  answer  has  ever  been  made.  It  is 
true  that  Dr.  Alison  pointed  out  that  the  symptoms  of  pneumonia  of 
Cullen  differed  from  those  of  the  pneumonia  of  Grisolle.  He  also  con- 
tended, that  it  is  only  from  the  symptoms  that  we  can  judge  of  the 
effects  of  remedies.  But  before  we  can  draw  a comparison  between 
variations  in  such  symptoms  as  indications  of  the  value  of  treatment,  or 
found  upon  them  a doctrine  like  a change  of  type  in  any  given  disease,, 
it  must  be  shewn  that  the  symptoms  observed  formerly,  and  those  seem 
now,  belong  to  the  same  lesion.  No  such  comparison,  however,  can  be 
drawn,  because  what  Cullen  meant  by  pneumonia  were  the  symptoms, 
themselves,  whereas  now  such  symptoms  are  known  to  be  in  no  way 
necessarily  indicative  of  pneumonia,  as  I have  previously  explained. 

Under  these  circumstances  nothing  can  be  more  unsatisfactory  than 
to  enter  into  an  inquiry  as  to  whether  the  inflammatory  fever  and  hard 
pulse  of  Cullen’s  pneumonia — which  may  or  may  not  have  been  pneu- 
monia at  all — does  or  does  not  differ  from  a true  inflammation  of  the 
Inng,  as  we  now  recognise  it.  Dr.  Alison,  by  drawing  a comparison 
between  the  two,  seemed  at  least  to  think  they  were  allied,  and  he 
argued  that  the  fever  accompanying  the  one  was  inflammatory,  whilst 
that  accompanying  the  other  was  typhoid.  Hence  the  reason  why  he 
thinks  the  first  did,  whilst  the  last  does  not  bear  bleeding.  He  also 
long  argued  * that  these  differences  are  still  observable  in  private  or 
dispensary,  if  not  in  hospital  practice.  But  I have  had  abundant  op- 
portunity of  satisfying  myself  that  a true  pneumonia  is  the  same  under 
every  circumstance.  During  a seven  years’  tolerably  constant  atten- 
dance as  physician  to  the  Boyal  Dispensary  of  this  city,  I have  seen 
pneumonia  as  typhoid  as  it  can  well  be ; and  in  the  Infirmary,  during 
the  last  nine  years,  I have  seen  it  attack  vigorous,  healthy  young  men, 
and  present  all  the  characters  of  the  inflammatory  type.  These  last  are 
exactly  those  cases  which  do  best  without  blood-letting,  whilst,  at  the 
same  time,  they  are  those  also  which  bear  bleeding  well.  The  expla- 
nation of  these  (to  some)  apparently  contradictory  facts  will  be  given 
subsequently. 

Another  idea  very  extensively  prevails  on  this  subject,  and  was  urged 
by  Dr.  Alison,  viz.,  that  inasmuch  as  fevers  undoubtedly  present  changes 
in  type,  inflammations  may  do  so  likewise.  That  essential  fevers  at  dif- 
ferent times  are  typhus,  typhoid,  or  ephemeral,  cannot  be  doubted,  but 
this  is  evidently  produced  by  variations  in  the  intensity  or  the  nature 

* Outlines  of  Pathology  and  Practice  of  Medicine.  First  Edition,  p.  221. 

20 


3C6 


GENEKAL  THEEAPEUTICS. 


of  the  exciting  cause.  On  what  these  differences  depend  is  not  yet 
determined.  I have  watched  extensive  epidemics  of  fever  in  France  and 
in  the  Rhenish  provinces,  where  almost  every  case  was  typhoid,  and 
connected  with  intestinal  lesion,  and  observed  others  in  Edinburgh, 
where  nearly  every  case  was  typhus,  and  free  from  organic  lesion.  I 
also  noticed  that,  when  owing  to  failure  in  the  potato  crop,  as  in  1846, 
the  food  of  the  people  was  materially  changed  for  the  worse,  the  fever  in 
Ediuhurgli  assumed  far  more  of  the  typhoid  type  ; and  I have  no  doubt 
that  changes  in  diet,  in  locality,  in  climate,  in  atmospheric  influences,  and 
a variety  of  causes,  may  induce  modifications  in  fever.  But  surely  no 
analogy  ought  to  be  drawn  between  the  undoubted  changes  producing 
such  varieties  of  fever,  and  those  causing  an  inflammation,  which  in  all 
countries,  and  under  every  variety  of  external  circumstances,  are  always 
the  same.  Even  the  results  are  said  to  he  distinguishable  only  by  a 
change  in  the  force  of  the  pulse,  the  occurrence  of  which  we  have  pre- 
viously shown  to  be  erroneous  (p.  302.) 

I am  therefore  firmly  of  opinion,  that  inflammation  in  a part  is  the 
same  now  as  it  has  ever  been,  and  is  only  subject  to  the  variations  which 
occur  in  all  diseases,  such,  for  instance,  as  are  dependent  on  differences 
of  age,  sex,  vigor  of  constitution,  complications,  etc.  etc.  These  are  also 
alike  at  all  times,  and  consequently  the  recent  revolution  in  the  treat- 
ment of  inflammation  by  bleeding  cannot  be  accounted  for  by  the  theory 
of  change  of  type. 

Proposition  3. — That  the  principles  on  which  blood-letting  and  anti- 
phlogistic remedies  have  hitherto  been  practised  are  opposed  to  a 
sound  pa  thology. 

Large  and  early  bleedings  have  been  practised  under  the  idea  that 
by  diminishing  the  amount  of  the  circulating  fluid — 1st,  The  materies 
morhi  in  the  blood  would  be  diminhshed;  2dly,  Less  blood  would  flow 
to  the  inflamed  parts;  3dly,  The  increased  quantity  of  blood  in  the 
part  would  be  lessened ; and  4thly,  That  the  character  of  the  pulse  was 
the  proper  index  to  the  amount  of  blood  that  ought  to  be  drawn.  Let 
us  examine  these  four  principles  of  practice — 

1^^,  Can  the  Materies  Morbi  in  the  blood  be  diminished  by  bleeding? 
It  was  to  its  influence  on  the  blood  that  the  older  writers  especially 
attributed  the  good  effects  of  venesection.  This  fluid,  according  to  them, 
was  thrown  into  a state  of  ebullition  or  fermentation,  which  worked  off 
the  morbid  elements ; and  this  termination  was  favored  by  removing 
so  much  of  it  by  blood-letting.  On  the  other  hand,  if  the  morbid  mat- 
ters were  not  readily  removed,  they  fell  upon  internal  organs  causing 
inflammation.  This  idea  led  to  the  abstraction  of  blood  under  the  no- 
tion that  that  fluid  was  diseased  first,  and  local  lesions  supervened,  as  in 
the  case  of  plague  or  small-pox.  Thus  Sydenham  apparently  had  no 
idea  of  inflammation  distinct  from  fever.  He  says  : “ I think  pleurisy  is 
a fever  originating  in  a proper  and  peculiar  inflammation  of  the  blood — an 
inflammation  by  means  of  which  nature  deposits  the  peccant  matters  on 
the  pleurae.  Sometimes  she  lays  it  on  the  lung  itself,  and  then  there 


FORMER  REASONS  FOR  BLEEDING  ERRONEOUS. 


307 


comes  a peripneumony.  This  differs  from  pleurisy  only  in  degree. 
They  exhibit  the  results  of  the  same  cause  with  greater  intensity.  In 
ray  treatment  I have  the  following  aim  in  view — to  repress  the  inflam- 
mation of  the  blood,  and  to  divert  those  inflamed  particles,  which  have 
male  an  onset  upon  the  lining  membrane  of  the  ribs  (and  have  there  lit 
up  so  much  mischief),  into  their  proper  outlets.  For  this  reason  my 
sheet  anchor  is  venesection.”  ^ Such  was  the  pathology  and  practice  of 
Sydenham,  the  latter  following  consistently  enough  on  the  former;  and 
the  essential  idea  of  diminishing  the  morbid  matters  in  the  blood  has  not 
only  descended  from  Hippocrates  to  the  days  of  Sydenham,  but  has  come 
down  from  his  to  our  own  times. f 

Now,  in  one  sense,  it  is  true  that  there  is  no  disease  whatever,  even 
the  most  local,  that  is  not  also  associated  with  a general  change  of  the 
system.  As  before  stated  (p.  136),  all  the  nutritive  functions  are  con- 
nected with  one  another,  and  an  excess  or  diminution  of  local  growth, 
by  subtracting  from  or  adding  to  the  constituents  of  the  blood,  must 
produce  an  alteration  in  that  fluid  both  as  to  quantity  and  quality.  The 
idea  of  Treviranus,  viz.,  that  “ each  single  part  of  the  body,  in  respect 
of  its  nutrition,  stands  to  the  whole  body  in  the  relation  of  an  excreted 
substance,”  has  been  ably  shown  by  Mr.  Paget  to  account  for  various 
processes  in  health,  under  the  name  of  “ complemental  nutrition. The 
sam3  notion  has  been  still  further  extended  by  Dr.  Wm.  Addison,  who 
correctly  points  out  that  in  the  distinctive  eruptive  fevers,  such  as  small- 
pox, the  numerous  small  abscesses  in  the  skin  eliminate  the  morbid 
poison  which  formerly  existed  in  the  blood,  and  are  in  this  way  essential 
to  the  cure.  This  provident  action  he  denominates  ‘‘  cell-therapeutics.”  § 
In  all  such  cases  experience  has  shown  that  time  and  a natural  sequence 
of  changes  is  necessary  for  a restoration  to  health,  and  it  is  now  recog- 
nised that  the  idea  of  cutting  short  such  changes  by  bleeding,  is  alike 
erroneous  in  theory  and  injurious  in  practice. 

Now  exactly  the  same  principles  ought  to  guide  us  in  cases  of  inflam- 
mation, where,  in  addition  to  the  local  changes  in  the  part,  there  must 
necessarily  be  more  or  less  disturbance  of  secretion  and  excretion.  The 
blood  in  consequence  must,  and  does,  as  is  now  well  known,  undergo  de- 
flnite  alterations,  which,  it  is  true,  organic  chemistry  has  not  yet  fully 
explained  to  us,  although  we  have  at  least  learnt  by  it  that  the  parti- 
cular secretion  suppressed  is  always  accumulated  in  the  blood,  which  also 
contains  an  excess  of  fibrin.  The  careful  investigations  of  chemists,  and 
especially  of  Becquerel  and  Rodier,  have  further  shown  us,  that  whilst 
venesections  greatly  deteriorate  the  blood,  rendering  it  poorer  in  cor- 
puscles and  richer  in  water,  they  have  no  effect  on  the  fibrin  whatever. 
It  follows  that  an  elimination  of  the  morbid  products  can  only  be  accom- 
plished in  inflammation  by  the  conjoined  action  of  cell  growth  in  the 

* Sydenham  Society’s  Translation.  Vol.  i.  p.  247. 

f This  statement  has  been  denied  by  some  of  my  critics,  but  I have  no  doubt  of 
its  correctness.  Indeed,  Dr.  Hibberd  of  Richmond,  Ind.,  in  the  United  States,  has 
quoted  passages  from  the  writings  of  Marshall  Hall,  Professor  Wood,  and  Dr.  Cham- 
bers of  London,  in  order  to  prove  that  venesection  in  their  opinion  was  useful  in  re- 
storing the  quality  of  the  blood. 

f Lectures  on  Surgical  Pathology,  Lecture  iL 

§ Addison  on  Cell-Therapeutics.  1866. 


308 


GENERAL  THERAPEUTICS. 


part,  and  a peculiar  vital  chemistry  going  on  in  the  blood  (as  will  be 
subsequently  explained),  neither  of  which  can  in  any  way  be  facilitated, 
but,  on  the  contrary,  are  both,  in  the  vast  majority  of  cases,  impeded  by 
blood-letting. 

Is  it  good  practice  to  diminish  the  flow  of  blood  to  the  part  ? 
The  increased  throbbing  and  circulation  of  blood  in  the  neighborhood 
of  the  inflamed  part  may  be  shown  not  to  be  the  cause  of  inflammation, 
but  the  result  of  it.  The  idea  of  so-called  determination  of  blood  being 
the  cause  of  disease  is  thus  set  forth  by  Dr.  C.  T.  B.  Williams  “ In 
the  frog’s  web,  gently  irritated  by  an  aromatic  water,  we  see  the  arteries 
become  enlarged,  supplying  a larger  and  more  impulsive  flow  of  blood  to 
the  capillaries  and  veins,  which  all  become  enlarged  also ; and  the  whole 
vascular  plexus,  including  vessels  which  before  scarcely  admitted  red 
particles,  then  become  the  channels  of  a much  increased  current.  This 
is  determination  of  blood  ” — P.  203.  Again,  “ We  may  affirm  from 
direct  observation,  as  well  as  from  reasoning,  that  determination  of  blood 
is  caused  by  enlargement  of  the  arteries;  and  this  enlargement  is  the 
effect  of  the  pressure  of  the  arterial  distension  from  behind  acting  on  a 
tube,  which  has  lost  some  of  its  contractile  power” — P.  203.  Again, 
“ One  patient  was  subject  to  attacks  of  determination  of  blood,  which 
caused  him  so  much  suffering  and  loss  of  moral  control,  that  he  cut  his 
throat  to  destroy  his  life.  When  recovering  from  the  wound,  attacks 
sometimes  came  on ; first  with  beating  of  the  carotids,  then  flushing  of 
the  face  and  head,  suffusion  of  the  eyes,  and  sensations  of  distraction  in 
the  head.”  “ Fits  of  epilepsy  and  convulsive  hysteria  are  immediately 
preceded  by  throbbing  of  the  carotids,  which  shows  that  determination 
of  blood  is  the  proximate  cause  of  the  paroxysm  ” — P.  201.  Now,  if  I 
am  correct  in  supposing  that  the  meaning  of  these  passages  is,  that  the 
larger  arteries  assume  the  initiative,  take  upon  themselves  the  action  of 
a forcing  pump,  and  send  or  determine  more  blood  to  the  part,  then  it 
appears  to  me  there  must  be  error  both  in  observation  and  reasoning. 
So  far  from  the  enlargement  of  arteries  and  increased  arterial  current 
preceding  the  changes  going  on  in  the  capillaries — so  far  from  being 
connected  with  the  causes  of  inflammation — I venture  to  affirm  that  they 
are  the  results. 

In  all  cases  the  primary  stimulus  producing  inflammation  is  applied 
to  the  vessels  of  the  part,  either  directly  (as  from  injuries  or  irritants) 
or  indirectly,  that  is  by  reflex  action  (as  in  the  case  of  internal  inflam- 
mations following  exposure  to  cold,  etc.),  and  in  consequence — that  is  to 
say,  as  a result — of  the  local  change  in  the  part  thereby  occasioned,  there 
follows  the  throbbing  of  the  neighboring  arteries.  Let  us  attend  to 
what  takes  place  in  the  finger  from  a thorn  entering  the  skin,  and  re- 
maining unextracted ; the  irritating  body  first  acts  upon  the  nerves  and 
blood-vessels  of  the  part,  then  comes  on  the  stoppage  of  blood  and 
exudation,  and  lastly  follows  the  throbbing  of  the  artery  in  the  finger. 
Surely  this  throbbing,  which  is  the  evidence  of  so-called  determination, 
is  a result  of  the  inflammation,  and  not  a cause  of  it.  The  blood  in  this 
case,  instead  of  being  sent  by  a vis  a tergo^  is  in  fact  drawn  by  a vis  a 

* Principles  of  Medicine.  (Tliird  Edition.) 


FOEMER  REASONS  FOR  BLEEDING  ERRONEOUS. 


309 


fj'Oiite,  and,  as  we  shall  endeavor  subsequently  to  show,  for  the  most 
important  purposes.  Whether  would  it  be  reasonable  to  treat  such  an 
inflammation  by  opening  the  artery — or  by  favoring  the  transforma- 
tion of  the  exudation  thrown  out  into  pus,  whereby  the  irritating  cause 
and  its  results  are  both  got  rid  of?  All  experience  shows  that  the 
latter  is  the  proper  treatment,  and  that  wounding  the  artery  under 
such  circumstances  would  be  highly  injurious  and  perhaps  occasion 
gangrene. 

But  why  should  nature,  in  cases  of  inflammation,  draw  an  increased 
amount  of  blood  towards  the  part?  She  does  so,  it  seems  to  me,  in 
obedience  to  one  of  her  wisest  laws,  but  one  which  has  been  too  much 
ignored  by  medical  practitioners.  It  must  be  obvious,  however,  that, 
an  inflammation  having  occurred,  the  great  work  now  to  be  accom- 
plished is  an  increased  growth  by  cell  formation,  whereby  that 
exudation  is  to  be  broken  up,  the  pressure  it  exerts  on  the  nerves  and 
blood-vessels  removed,  and  the  whole  rendered  capable  of  being  elimi- 
nated from  the  economy,  either  directly  by  discharge  externally,  or  in- 
directly, 1st,  by  passage  into  the  blood,  and  2d,  by  excretion  through 
the  emunctories.  To  perform  this  work  of  increased  growth,  an 
augmented  flow  and  amount  of  nourishing  fluid  is  necessary,  the  same 
as  is  observable  at  the  period  of  heat  in  animals,  to  ripen  the  Graafian 
vesicles;  in  the  stag’s  scalp  during  the  growth  of  the  antlers;  in  the 
mamma  when  milk  is  first  secreted ; in  the  gums  during  the  process 
of  dentition ; in  the  ascent  of  the  sap  during  spring  in  plants,  etc.  etc. 
In  all  these  cases,  especially  the  last,  the  fluid  is  not  sent  or  deter- 
mined, but  drawn  to  the  part,  in  consequence  of  the  increased  growth 
of  cells  imperatively  requiring  a greater  amount  of  blastema.  So,  in 
inflammation,  an  exudation  having  been  poured  out,  which  has  to  be 
transformed  by  a process  of  cell  growth,  in  order  that  it  may  be 
removed  or  rendered  subservient  to  the  wants  of  the  economy,  it  is 
absolutely  imperative  that  the  part  in  which  these  nutritive  changes 
go  on  should  receive  more  blood,  to  enable  it  to  accomplish  them. 
Hence  the  increased  current.  But  hitherto  medical  practitioners  have 
supposed  that  this  phenomenon  is  injurious,  and  ought  to  be  checked 
by  blood-letting  and  antiphlogistics.  The  rapid  flow  of  blood,  which 
is  so  necessary,  they  have  sought  to  diminish;  and  the  increased 
amount  in  the  neighborhood  of  the  part,  which  is  so  essential  for 
the  restoration  to  health,  it  has  been  their  object  to  destroy.  In  doing 
so,  we  argue  the  act  in  opposition  to  sound  theory,  and,  as  we  shall 
afterwards  attempt  to  show,  to  good  practice  also. 

Sd,  Can  general  hlood-letting  diminish  the  amount  of  hlood  in  the 
inflamed  part  ? It  is  vain  to  deny  that  the  notion  of  lessening  the 
amount  of  blood  in  the  inflamed  part  has  constituted  one  of  the  chief 
reasons  for  blood-letting,  and  given  rise  to  long  discussions  as  to 
whether  this  or  that  vein  shall  be  opened,  and  whether  leeches  shall 
be  applied  to  the  occiput  or  to  the  feet.  Now,  it  requires  to  be 
shown  that  draining  the  body  of  blood  can  in  the  slightest  degree 
influence  the  congestion  in  the  inflamed  part.  There  the  vessels  are 
enlarged,  the  current  of  blood  is  arrested,  the  blood-corpuscles  are 


310 


GENERAL  THERAPEUTICS. 


closely  aggregated  together  and  distend  the  vascular  tube,  and  are  in 
no  way  alfected  by  the  arterial  current,  even  when  increased  in  its 


neighborhood.  That  opening  a 


Fig.  399. 


vein  can  alter  this  state  of  matters 


Fig.  398.  Longitudinal  plan  of  the  arteries  of  the  trunk.  The  left  side  shows 
both  the  longitudinal  and  transverse  anastomosing  arteries  of  the  wall ; the  right 
side  only  the  longitudinal  and  diaphragmatic  anastomoses  belonging  to  the  wall,  and 
the  various  visceral  arteries  springing  from  the  aorta. 

Leftside. — 1,  Internal  mammary;  and  2,  deep  epigastric;  connected  behind  to 
the  aorta  by  a series  of  intercostal,  lumbar,  and  diaphragmatic  arteries.  3,  Super- 
ticial  epigastric.  4,  Circumflex  iliac.  6,  Ilio-lumbar  from  internal  iliac. 

Right  side. — Branches  of  abdominal  aorta,  from  above  downwards ; diaphragmatic 
coeliac  axis,  superior  mesenteric,  right  supra-renal  and  renal,  right  spermatic  or 
ovarian  and  inferior  mesenteric. — {J.  Struthers.) 

Fig.  399.  Transverse  plan  of  the  arteries  of  the  abdomen  opposite  to  the  liver, 
spleen,  and  stomach.  1,  Aorta  giving  off  from  its  back  part  the  arteries  (2,  2)  for 
the  wall,  which  unite  in  'front  with  branches  of  the  internal  mammary  arteries  (3,  3). 
4,  Coeliac  axis,  coming  from  the  front  of  the  aorta,  and  supplying  the  spleen,  stomach, 
and  liver,  the  latter  also  receiving  the  vena  portae. — (J.  Struthers.) 

Fig.  400.  The  same,  lower  down,  showing  a portion  of  the  small  intestine  and 
sections  of  the  ascending  and  descending  colon  and  of  the  kidneys.  1,  Aorta, 
giving  off,  beliind  the  lumbar  arteries  (2,  2),  which  join  in  front  with  branches  of 
the  deep  epigastric  (3,  3).  In  front,  as  if  coming  from  the  aorta  at  the  same  part, 
are  shown  the  superior  and  inferior  mesenteric,  and  at  the  sides  the  renal  arteries. 
Fig.  376  shows  the  order  in  which  these  visceral  arteries  come  off  at  different  stages 
of  the  aorta,  and  their  relative  size. — {J.  Struthers.) 


The  anatomist  will  notice  that  it  is  chiefly  the  anastomosing  branches  of  the  arteries 
of  the  wall  which  are  shown,  and  also  that  these  are  represented  proportionally  larger 
than  natural. — {Struther's  Anatom,  and  Physiol.  Observations.  Edin.,  8vo,  1864.) 


FORMER  REASONS  FOR  BLEEDING  ERRONEOUS. 


311 


is  scarcely  to  be  conceived;  and  if  it  could,  how  would  this  assist  in 
removiog  the  exudation,  which  has  coagulated  outside  the  vessels? 

A consideration  of  the  connection  and  distribution  of  the  large 
vessels  in  the  body  will  still  further  show  the  little  probability  there 
is  of  either  general  or  local  blood-letting,  as  usually  practised,  being 
capable  of  influencing  the  amount  of  blood  in  the  part  actually 
inflamed.  How  is  it  possible,  for  instance,  that  venesection  in  the 
arm  can  directly  diminish  the  amount  of  blood  sent  from  the  heart  by 
the  great  pulmonary  artery  to  the  lungs,  by  the  carotids  and  vertebrals, 
to  the  brain,  or  by  the  coronaries  to  the  heart  itself?  In  inflammation 
of  those  organs,  blood-letting,  to  produce  any  effect,  must  be  large,  so  as 
to  act  on  the  general  system  indirectly  by  weakening  the  heart’s  action 
and  producing  syncope,  and  this  at  a time  when,  from  no  nourishment 
being  taken  in  consequence  of  fever,  great  prostration  of  the  vital 
powers  is  to  be  expected.  But  whilst  this  result  may  certainly  be 
induced  by  large  bleedings,  the  inflammation  in  the  part  is  altogether 
unafi'ected.  The  exudation,  under  such  circumstances,  which  requires 
more  blood  in  order  that  it  may  undergo  the  necessary  transformations 
previous  to  removal,  is  then  arrested  in  its  development,  and,  so  far 
from  being  rapidly  removed,  remains  stationary,  or  dies  in  proportion 
as  the  economy  is  exhausted.  If,  on  the  other  hand,  small  or  mode- 
rate bleedings  are  practised,  how  can  they  operate  even  on  the  prin- 
ciples of  those  who  advocate  them  ? These  do  not  affect  the  heart,  or 
lower  the  force  of  the  circulation,  even  in  the  neighborhood  of  the 
inflamed  part ; how,  then,  can  they  operate  on  the  stagnant  blood  in 
the  inflamed  part  itself? 

As  to  local  bleeding,  its  supposed  effects  are  inexplicable  on  the 
supposition  of  drawing  blood  from  the  inflamed  internal  parts.  A man 
has  pneumonia  or  eupliritis,  resulting  from  changes  in  the  vessels  which 
are  supplied  direct  from  the  aorta,  and  leeches  are  applied  to  the  in- 
teguments supplied  by  vessels  derived  from  the  mammary  or  lumbar 
arteries.  Any  direct  anastomosis  between  the  vessels  on  the  surface 
and  those  in  the  parts  inflamed  is  not  to  be  thought  of,  as  has  been 
shown  anatomically  by  Dr.  J.  Struthers.  (See  Figs.  398  to  400,  with 
the  explanations  on  the  previous  page.)  How,  then,  does  the  loss  of 
this  small  amount  of  blood  operate  in  these  important  cases  ? It  can- 
not be  by  any  conceivable  theory  of  diminishing  either  the  current  to, 
or  the  amount  of  blood  in,  the  part.  As  in  the  majority  of  cases,  there- 
fore, the  loss  is  not  large  enough  to  affect  the  general  circulation, 
and  as  anatomy  prevents  our  belief  in  the  idea  that  it  can  influence 
the  inflammation  directly,  it  may  well  be  asked,  how  can  local  blood- 
letting be  of  any  beneflt  at  all  ? Is  it  not  more  probable  that  leeches 
and  cupping  do  no  good  by  drawing  blood,  but  that  the  relief  to  pain 
which  they  undoub^tedly  occasion  is  owing  to  the  reflex  influence  of 
counter-irritation,  and  in  the  vast  majority  of  cases  to  the  soothing  and 
sedative  influence  of  the  warm  fomentations  which  generally  follow  their 
employment  ? Dry  cupping  is  often  as  effectual  as  local  blood-letting. 

From  these  considerations,  it  follows  that  neither  general  nor  local 
blood-letting  can  possibly  be  supposed  to  diminish  the  amount  of  blool 
in  internal  parts  affected  with  inflammation. 


312 


GENERAL  THERAPEUTICS. 


AtJiy  Should  the  character  of  the  pulse  indicate  the  propriety  of 
bleeding  ? That  an  accelerated  and  strong  pulse  in  inflammation  de- 
mands interference  on  the  part  of  the  medical  practitioner,  seems  to  he 
a principle  which  has  been  very  generally  acted  on.  In  other  words, 
because  nature  accelerates  and  strengthens  the  pulse,  it  has  been 
thought  that  art  ought  to  interfere  to  diminish  its  foice  and  frequency. 
But  here,  again,  as  it  appears  to  me,  the  result  has  been  mistaken  for 
the  cause ; and  so  far  from  getting  rid  of  inflammation  by  weakening 
the  pulse,  we  not  only  do  not  check  it,  but  prolong  the  time,  as  pre- 
viously explained,  for  the  transformation  of  the  exudation.  This,  indeed, 
is  proved  by  the  cases  of  Louis,  Chomel,  and  Grisolle,  which  distinctly 
show  that  the  progress  of  a pneumonia  is  never  shortened  by  bleeding. 
Dr.  Alison  also  admits  that  he  has  seen  the  dulness  and  crepitation  go 
on  increasing  after  bleeding.  But  the  inconsistency  of  the  therapeuti- 
cal rales  on  this  head  will  become  more  manifest  when  we  remember 
that  it  is  necessary,  in  the  opinion  of  many  medical  practitioners,  not 
only  to  weaken  the  pulse  when  it  is  strong,  but  to  strengthen  it  when 
it  has  been  made  weak.  Now,  although  it  is  obviously  good  practice 
to  support  the  strength  when  the  calls  upon  the  nutritive  functions 
have  exhausted  the  economy,  it  is  injurious  to  diminish,  by  bleeding, 
the  nutritive  processes  themselves,  when  they  are  busily  engaged  in 
operating  on  the  exudation  and  eliminating  the  morbid  products.  In 
short,  the  phenomena  of  fever  and  excitability  accompanying  inflamma- 
tion have  been  wrongly  interpreted,  and  danger  is  to  be  apprehended 
from  them  not  directly,  but  from  the  subsequent  exhaustion  which  all 
great  exertions  of  the  animal  economy  produce.  In  themselves,  these 
exertions  are  sanative,  and  indicate  the  struggle  which  the  economy  is 
engaged  in  when  attempting  to  get  rid  of  the  diseased  processes;  and 
whenever  we  lessen  the  vital  powers  at  such  a critical  juncture,  we 
diminish  the  chances  of  that  struggle  terminating  favorably.  This 
proposition  seems  to  be  universally  admitted  in  the  case  of  essential 
and  eruptive  fevers;  and  its  truth  ought  to  be  accepted  equally  in 
cases  of  inflammation. 

It  has  been  argued,  however,  that  the  immediate  beneficial  effects  of 
blood-letting  justify  the  practice.  This  is  a therapeutic  question  of  the 
greatest  importance,  and  one  which,  I venture  to  think,  has  not  been 
sufficiently  considered  by  medical  men.  No  doubt  pain  is  a great  evil ; 
and  mankind  instinctively  seek  for  its  relief,  and  sometimes  at  any  cost. 
But  if  the  possession  of  life  be  an  advantage,  it  is  ofttimes  only  to  be 
maintained  at  the  price  of  more  or  less  privation  and  suffering,  and  in 
this  point  of  view  disease  may  frequently  be  considered  as  a benefit  and 
a great  good,  mercifully  sent  by  a wise  providence  to  reconcile  man, 
under  a variety  of  circumstances,  to  death  itself,  as  to  a great  relief  from 
bodily  pain.  But  such  is  not  the  correct  way  of  considering  the 
question  in  a therapeutic  or  curative  point  of  view ; the  great  object  of 
the  physician  \9>  first  to  cure,  and,  should  his  attempts  in  that  direction 
fail,  then  to  relieve  his  patient.  If  both  objects  can  be  accomplished,  so 
much  the  better ; but  if  the  means  of  relieving  symptoms  are  opposed  to 
those  of  curing  the  disease,  then  to  obtain  the  latter,  the  former  must  be 
unhesitatingly  sacrificed.  I have  pointed  out  in  another  place  how 


NATURAL  PROGRESS  OF  INFLAMMATION. 


313 


much  this  principle  has  been  overlooked  in  the  treatment  of  pulmonary 
tuberculosis;*  and  in  no  case  does  it  appear  to  have  been  more  dis- 
reo-arded  than  in  inflammation.  For  assuming  it  as  granted  that  in 
some  cases  the  pain  is  for  a time  relieved  by  bleeding,  and  that  in  pneu- 
monia the  respiration  temporarily  becomes  more  free,  at  what  a cost  are 
these  advantages  obtained,  should  the  patient  be  so  weakened  as  to  be 
unable  to  rally.  Even  if  he  does  rally,  a large  bleeding  almost  always 
prolongs  the  disease.  Of  course  I am  now  speaking  of  a true  pneu- 
monia, and  not  of  that  combination  of  symptoms  which  was  called 
pneumonia  by  Cullen  and  Gregory.  I do  not  consider  it  necessary  to 
cite  cases  in  proof  of  the  fact  that  in  many  instances  bleeding  has  done 
great  mischief,  because  this  will  be  readily  admitted  by  all  candid 
medical  men. 

But  whilst  large  and  repeated  bleedings,  practised  with  a view  of 
arresting  the  disease,  appear  to  me  opposed  to  a correct  pathology, 
small  and  moderate  bleedings,  directed  to  palliate  certain  symptoms, 
and  especially  excessive  pain  and  dyspnoea,  may  reasonably  be  had 
recourse  to,  and  unless  there  be  great  weakness,  without  any  fear  of 
doing  injury.  I have  often  been  struck,  especially  in  cases  where  large 
thoracic  aneurisms  cause  these  symptoms,  with  the  small  loss  of  blood 
which  will  occasion  marked  relief.  The  same  result  may  be  hoped  for 
in  other  cases  where  there  is  much  congestion,  either  with  or  without 
exudation.  But  I need  scarcely  remark  that  this  mere  palliative  object 
of  blood-letting  is  not  the  ground  on  which  the  practice  has  hitherto 
been  based,  and  that  in  this  point  of  view  it  requires  to  be  very 
differently  explained.  To  this  subject  I shall  again  allude.  (See  p. 
317.)  In  the  meantime  it  follows,  from  the  arguments  which  have  been 
adduced  under  the  present  head,  that  the  principles  which  have  hereto- 
fore guided  the  practice  of  bleeding  in  inflammation  are  erroneous.  It 
now  remains  for  me  to  advance  and  endeavor  to  establish  to  the  satis 
faction  of  my  readers  what  appear  to  me  to  be  the  true  principles  of 
treatment  in  inflammation. 

Proposition  4. — That  an  inflammation  once  established  cannot  he  cut 

short,  and  that  the  object  of  judicious  medical  treatment  is  to  conduct 

it  to  a favorable  termination. 

There  was  a time  when  it  was  supposed  that  the  progress  of  typhus 
fever,  small  pox,  and  many  other  diseases,  which  are  now  alwa^'s  allowed 
to  run  their  natural  course,  could  be  arrested  by  medical  interference. 
But  with  regard  to  them,  there  has  been  established  the  principle,  1st, 
of  prevention,  and  2d,  when  this  fails,  of  simply  conducting  them  to  a 
favorable  termination.  It  appears  to  me  that  the  same  rule  ought  to 
hold  with  regard  to  internal  inflammations,  and  that  this  will  be 
admitted  when  it  is  made  apparent,  not  only  that  every  inflammation 
once  formed  runs  through  a definite  course,  but  what  that  course  is. 
This  I now  proceed  shortly  to  consider. 

If,  then,  we  watch  the  natural  progress  of  inflammation  in  any  of 

* On  Pulmonary  Consumption,  by  the  Author.  Second  edition.  Edinburgh, 
1859,  p.  143,  et  seq. 


314 


GENERAL  THERAPEUTICS. 


the  textures  of  the  body,  we  observe  that  it  terminates  in  two  ways,  viz., 
1st,  by  vital  changes  of  growth  of  different  kinds  in  the  exudation, 
constituting  what  has  hitherto  been  called  suppuration,  adhesion, 
granulation,  cicatrization,  the  healing  processes,  etc.  etc. ; and,  2dly,  by 
death  of  the  exudation,  which,  if  rapid,  putrefies,  producing  gangrene,  or, 
if  slow,  disintegrates,  causing  ulceration.  (See  p.  164,  et  seq.)  The  first 
series  of  changes  are  not  destructive,  but  formative  and  reparative. 
Suppuration  especially  should  be  looked  upon  as  a kind  of  growth, 
which  enables  the  exuded  and  coagulated  blood-plasma  to  be  rapidly 
broken  up,  and  eliminated  from  the  economy.  If  so,  instead  of  being 
checked,  it  should  be  encouraged  as  much  as  possible — a very  differei  t 
doctrine  from  what  has  hitherto  prevailed.  Again,  every  thing  that 
lowers  the  vital  strength  and  weakens  the  economy,  must  impede  the 
nutritive  processes  of  growth,  and  tend  more  or  less  to  a slow  or  rapid 
death  of  the  exudation.  Blood-letting  especially  has  this  tendency,  and 
must  therefore  be  wholly  opposed  to  the  rapid  disappearance  of  inflam- 
mation ; for  example — 

If  a bone  be  fractured,  inflammation  occurs  around  the  injured  part, 
and  exudation  is  poured  out,  which  undergoes  vital  changes,  whereby 
ultimately  it  is  transformed  into  bone.  If  soft  parts  are  destroyed  or 
removed,  the  exudation  poured  out  from  the  injured  vessels  undergoes 
other  vital  changes,  whereby  it  is  transformed  into  fibrous  tissue,  consti- 
tuting first  granulations,  and  then  a cicatrix.  After  subcutaneous’ 
section  of  tendon,  with  separation  of  its  extremities,  the  transformation 
is  more  perfect,  producing,  as  in  the  case  of  bone,  a growth  exactly 
similar  to  the  one  which  was  injured.  If  a violent  blow  or  ii  jury  has 
been  received,  a greater  or  less  amount  of  exudation  is  infiltrated  among 
the  contused  and  torn  tissues,  which  is  transformed  by  cell  growth  into 
pus,  which,  if  it  can  be  evacuated  externally,  is  soon  got  rid  of,  but  if 
not,  is  on  the  disintegration  of  the  cells  absorbed  and  excreted  from  the 
economy.  If,  under  other  circumstances,  pus  is  absorbed  soon  after 
it  is  formed,  the  inflammatory  swelling  is  said  to  be  resolved  or  dis- 
cussed; if  not,  it  collects  in  the  form  of  a fluid,  and  constitutes  an 
abscess.  Surely  it  cannot  be  maintained  that,  in  any  of  these  cases,  we 
can  favor  these  reparative  processes  by  blood-letting  and  lowering  the 
strength  of  the  economy?  On  the  contrary,  they  have  always  been 
found  to  be  best  perfected  in  individuals  of  vigorous  constitution,  whilst 
in  scrofulous  or  broken-down  and  weak  persons,  they  proceed  slowly  or 
not  at  all. 

But  in  internal  inflammations,  say  of  the  lungs  or  pericardium,  are 
the  processes  different  ? Certainly  not.  In  the  one  case  the  exudation 
is  converted  into  pus  cells  and  absorbed,  and  in  the  other  into  fibrous 
texture,  causing  adhesions.  (See  p.  165.)  But  because  these  processes 
have  been  hid  from  view,  physicians  have  supposed  that,  instead  of 
treating  the  inflamed  parts  as  the  surgeon  does,  he  ought  to  attack  the 
general  symptoms  which  result  from  the  lesion.  In  cases  of  fracture 
and  contusion,  there  are  also  febrile  symptoms,  increased  pulse,  and  so 
on ; but  does  the  surgeon  imagine  that  callus  will  form  better,  or  an 
abscess  be  resolved,  or  reach  maturity  sooner,  by  general  blood-letting 
and  antiphlogistics  ? Experience  teaches  him  otherwise,  and  in  the 


NATUEA.L  PROGRESS  OF  INFLAMMATION. 


315 


same  manner  it  may  be  most  reasonably  argued  that  such  treatment 
cannot  favor  the  natural  termination  of  internal  inflammations. 

But,  argued  Dr.  Alison,  if  we  abandon  blood-letting,  as  recommended 
by  so  many  practical  authors  in  obedience  to  this  doctrine,  “ we  shall  be 
trusting  to  a pathological  view  of  a vital  process,  still  very  imperfectly 
known,  in  opposition  to  a therapeutical  principle,  founded  no  doubt 
on  empirical  observation  only;  requiring  no  doubt,  as  all  powerful 
remedies  do,  an  exercise  of  judgment  of  the  practitioner  in  applying  it ; 
because  it  may  easily  do  harm  by  enfeebling,  and  at  the  same  time  render- 
ing more  irritable,  all  the  vital  actions  involved  in  the  disease,  more  than 
good,  by  restraining  the  amount  of  the  exudation;  but,  nevertheless, 
much  more  to  be  depended  on,  as  guiding  practice  in  these  circumstances ^ 
than  any  principle  in  pathology.”  If,  however,  instead  of  being  imper- 
fectly known,  as  he  supposed,  it  should  turn  out  that  the  pathological 
view  I am  contending  for  is  true,  and  is  extensively  known  among  the 
younger  members  of  the  profession,  then  the  admission  here  made  by  Dr. 
Alison  of  how  easily  blood-letting  may  do  harm  and  enfeeble,  may  be 
expected  to  produce  an  effect  prejudicial  to  its  employment.  Besides, 
the  moment  a pathological  law  can  be  successfully  established,  empirical 
rules  are  overthrown.  Dr.  Alison,  who  has  done  so  much  in  attempting 
to  establish  the  supremacy  of  vital  laws,  is  too  good  a logician  not  to 
know  this.  Hence  his  objection  is  directed  against  the  uncertainty  and 
want  of  general  information  of  the  theoretical  view  as  a guide  to  practice, 
when  compared  with  the  advantages  which  he  considers  the  empirical 
rule  has  produced,  as  tested  by  past  experience.  This,  then,  leads  me  to 
abandon  pathological  research  and  deduction,  and  inquire  how  far  actual 
facts  indicate  which  is  the  best  practice — blood-letting  in  obedience  to 
empirical  rules,  or  abstaining  from  it,  in  accordance  with  the  pathological 
principles  now  brought  forward. 

Proposition  5. — That  all  positive  hnowledge  of  the  experience  of  the 
past^  as  well  as  the  more  exact  ohservcition  of  the  present  dag^  alike 
establish  the  truth  of  the  preceding  principles  as  guides  for  the 
future. 

In  endeavoring  to  determine  from  experience  what  is  the  value  of 
bleeding  in  acute  inflammations,  it  must  be  remembered  that,  whilst  past 
experience  has  declared  it  to  be  the  sine  qua  non,  the  smnmum  remedium, 
the  only  certain  means  of  cutting  short  the  disease,  and  so  on — present 
experience  declares  by  almost  universal  consent  that  now-a-days  in- 
dividuals laboring  under  them  recover  rapidly  without  bleeding  at  all. 
This  admission  constitutes  the  basis  of  the  theory  advanced  by  Dr.  Alison, 
viz.,  that  acute  inflammations  within  the  last  twenty  years  have  changed 
their  type.  So  that  the  question  now  is  not  whether  no  bleeding  is  good 
practice,  but  how  the  admission  of  this  fact  is  to  be  reconciled  with  the 
experience  of  twenty  years  ago.  But  inasmuch  as  for  the  reasons  pre- 
viously given  we  cannot  suppose  for  a moment  that  inflammation  has 
ever  undergone  any  change  whatever  among  mankind,  it  necessarily 
follows,  if  modern  practice  in  this  matter  be  correct,  that  former  bleed- 
ings must  have  been  inert  or  injurious. 


316 


GENERAL  THERAPEUTICS. 


Before  it  is  possible,  however,  to  determine  with  exactitude  the  value 
of  any  practice,  it  is  essential  to  ascertain  the  natural  duration  of  the 
disease  we  propose  to  treat.  Fortunately  we  have  now  some  data  which 
will  enable  us  to  arrive  at  this  information  with  regard  to  one  of  the 
most  frequent  and  important  kinds  of  inflammation,  viz.,  pneumonia. 
Very  severe  cases  of  this  disease  were  observed  by  Dr.  Geoi-ge  Balfour, 
in  the  Homoeopathic  Hospital  of  Vienna,  under  a treatment  that  no 
reasonable  medical  man  can  suppose  to  be  anything  else  than  inert.  Yet 
most  of  these  cases  got  well,  and  may  be  considered  as  excellent  studies 
of  the  disease  left  entirely  to  nature.^  We  have  also  the  accounts  of  the 
expectant  systems  of  treating  this  disease  in  Vienna  under  Skodaf 
and  Dietl.| 

Here  it  is  important  to  consider  that  the  violence  of  the  symptoms 
bears  no  necessary  relation  to  the  extent  or  intensity  of  the  disease. 
Some  persons  present  great  fever  and  constitutional  disturbance  when 
one  lung  is  only  slightly  involved,  and  recover  rapidly ; whereas  others 
may  have  an  entire  lung  inflamed,  or  portions  of  both  lungs,  and  exhibit 
comparatively  trifling  fever  and  few  marked  symptoms,  until  impeded 
respiration  occurs,  ushering  in  death.  It  is  a knowledge  of  this  im- 
portant fact  which  serves  to  clear  up  much  of  the  discrepancy  existing 
between  past  and  present  practice,  especially  when  conjoined  with  another, 
viz.,  that  however  bleeding  may  relieve  symptoms,  it  has  no  influence  in 
shortening  the  duration  or  diminishing  the  extent  of  the  disease.  Of 
this  fact  the  observations  of  Louis,  Grisolle,  and  Dr.  Alison,  can  leave  us 
in  no  doubt;  and  I have  frequently  satisfied  myself  of  their  correctness. 
It  follows  that,  as  the  past  race  of  practitioners  considered  pneumonia 
only  demonstrable  by  symptoms,  which  furnished  the  sole  evidence  of 
the  advantage  of  bleeding,  as  soon  as  these  symptoms  were  diminished 
by  venesection,  they  thought  benefit  was  accomplished.  Whereas  now 
it  has  become  apparent  that  such  is  no  certain  evidence  of  recovery  from 
the  disease,  which  may  linger,  notwithstanding,  for  weeks,  give  rise  to  a 
tedious  convalescence,  and  even  induce  death  by  exhaustion  after  active 
functional  symptoms  have  for  the  most  part  disappeared. 

The  real  tests  of  successful  practice,  therefore,  are  not  to  be  sought 
for  in  the  relief  of  symptoms,  but  in  the  removal  of  the  disease;  and 
that  treatment  will  be  best  which  cceteris  parihus^  causes  fewest  deaths, 
and  recovery  in  the  shortest  time.  Now  on  looking  at  the  results — 1st, 
of  the  antiphlogistic  treatment  as  formerly  practised  by  bleedings,  and 
tartar  emetic ; 2d,  at  the  expectant  system,  or  what  ought  to  be  called  a 
dietetic  system ; and  3d,  at  the  treatment  directed  to  further  the  natural 
progress  of  the  disease — we  find  that  a vigorous  antiphlogistic  treatment  of 
pneumonia  as  formerly  practised,  was  followed  by  a mortality  of  1 in  3 
cases;  that  the  result  of  a treatment  by  tartar  emetic  in  large  doses, 
according  to  Rasori,  and  more  recently  according  to  Dietl,  is  a mortality 
of  1 in  5 cases — but  according  to  Laennec,  1 in  10  cases;  that  the  result 
of  moderate  bleedings,  as  in  the  treatment  of  Grisolle,  is  a mortality  of  1 
in  cases ; and  that  the  result  of  a dietetic  treatment  with  occasional 

* Brit,  and  For.  Medical  Review,  vols.  22  and  23. 

f Dr.  G.  Balfour  in  Edin.  Medical  and  Surgical  Journal.  1847. 

X Der  Aderlass  in  der  Lungenentziindung.  Wien,  1849. 


BLOOD-LETTING  USEFUL  AS  A PALLIATIVE.  31'J 

bleedings  and  emetics  in  severe  cases,  as  with  Skoda,  is  a mortality  of 
1 in  7,  and  if  pure,  as  under  Dietl,  a mortality  of  1 in  13  cases,  all  carried 
on  in  large  public  hospitals.  Further,  that  the  mortality  from  pneumonia 
in  the  army  and  navy,  occurring  generally  among  healthy  able-bodied 
men,  has  been  also  a mortality  of  1 in  13  cases.  Lastly,  that  the  result 
of  a treatment  directed  to  further  the  natural  progress  of  the  disease  as 
I have  explained  it,  is,  in  the  clinical  wards  of  the  Royal  Infirmary  of 
Edinburgh,  when  under  my  care,  up  to  this  time  (July  1864)  a mortality 
of  1 in  40  cases ; but,  taking  only  uncomplicated  cases,  presents  no 
mortality  at  all. 

From  these  facts  it  fallows  that  uncomplicated  pneumonia,  especial- 
ly in  young  and  vigorous  constitutions,  almost  always  gets  well,  if,  in- 
stead of  being  lowered,  the  vital  powers  are  supported,  and  the  excre- 
tion of  eifete  products  assisted.  It  is  exactly  in  these  cases,  however, 
that  we  were  formerly  enjoined  to  bleed  most  copiously,  and  that  our 
systematic  works  even  now  direct  us  to  draw  blood  largely  and  repeat- 
edly in  consequence  of  the  supposed  imminent  danger  of  suppuration 
destroying  the  texture  of  the  lung.  Such  danger  is  altogether  illusory, 
and  t'lj  destruction  to  lung  tissue,  so  far  from  being  prevented,  is  far 
m)re  likely  to  be  produced  by  the  practice.  In  fact,  the  only  cases  in 
waich  it  occurs  are  in  aged  or  enfeebled  constitutions,  in  which  nutrients 
and  not  antiphlogistics  are  the  remedies  indicated.  We  can,  however, 
readily  understand  how  blood-letting,  practised  early  and  in  young  and 
vigorous  constitutions,  does  less  harm,  or,  to  use  a common  expression, 
“ is  borne  better,”  than  when  the  disease  is  advanced  or  the  patient 
weak,  and  this,  because  then  the  vital  powers  are  less  afi’ected  by  it. 
Hence  the  diminished  mortality  in  the  second  series  of  Louis’s 
cases,  and  probably  in  the  army  and  navy  cases.  But  that  it  cures 
the  greater  number  of  persons  attacked,  or  shortens  the  duration 
of  the  disease,  is  disproved  by  every  fact  with  which  we  are  acquaint- 
ed. 

At  the  same  time  there  are  cases,  which  were  formerly  often  mis- 
taken for  inflammation,  in  which  blood-letting  may  still  be  useful.  I 
allude  to  those  where  an  obstruction  to  the  circulation  exists  in  the 
heart  and  lung  dependent  on  over-distension  of  the  right  side  of  the  for- 
mer organ,  or  on  venous  congestion,  engorgement,  and  perhaps  oedema 
of  the  latter;  also  certain  cases  of  bronchitis  preventing  aeration,  of  an- 
eurisms, and  of  asphyxia.  Although  even  here  the  true  value  of  the 
remedy  has  yet  to  be  positively  ascertained,  the  special  cases  de- 
manding it  more  carefully  discriminated,  and  the  mechanical  principles 
which  justify  the  practice  determined.  The  temporary  benefit  occa- 
sioned in  many  of  these  cases  by  the  loss  of  a trifling  amount  of  blood 
is  often  very  remarkable,  and  has  been  previously  referred  to  (p.  313). 
I have  seen  instances  where  great  dyspnoea  and  pain,  caused  by  large 
thoracic  aneurisms  in  vigorous  men,  have  been  greatly  alleviated,  and 
inexpressible  relief  produced  for  from  twelve  to  twenty-four  hours,  by 
a bleeding  to  the  extent  of  only  five  ounces.  It  seems  probable  that 
this  may  arise  from  diminishing  for  a time  the  tension  of  the  whole 
vascular  system.  But  whatever  be  the  explanation  of  this  fact,  I hold 
that,  as  a palliative,  and  practised  to  a limited  extent  in  cases  where 


318 


GENERAL  THERAPEUTICS. 


HO  great  debility  exists,  blood-letting  may  still  be  had  recourse  to.  So 
with  regard  to  antimonials,  although  in  the  large  doses,  which  weaken 
the  heart  and  force  of  the  pulse,  they  are  not  serviceable — in  smaller 
doses,  together  with  other  neutral  salts,  they  may  assist  in  diminishing 
the  viscosity  of  the  blood,  and  in  favoring  the  excretion  of  the  effete 
matters  by  the  skin  and  kidneys. 

As  to  mercurials,  the  confident  belief  in  their  power  of  causing 
absorption  of  lymph,  by  operating  on  the  blood,  is  not  only  opposed  to 
sound  theory,  as  formerly  explained,  but,  like  blood-letting,  is  not  sup- 
ported by  that  experience  which  has  been  so  confidently  appealed  to  in 
their  favor.  They  have  been  most  praised  in  the  treatment  of  serous 
inflammations  and  in  iritis.  But  recent  careful  observation  has  demon- 
strated that  the  moment  these  diseases  are  treated  without  mercury, 
they  are  uninfluenced  (except  in  certain  cases  for  the  worse)  by  this 
drug.  Thus,  from  an  analysis  of  40  cases  of  pericarditis,  treated  with 
mercury,  and  recorded  with  unusual  care  by  the  late  Dr.  John  Taylor, 
only  4 appear  even  coincidently  to  have  benefited  in  any  way.*  And 
of  64  cases  of  iritis,  of  every  degree  of  severity,  including  its  idiopathic, 
traumatic,  rheumatic,  and  syphilitic  varieties,  treated  without  mercury, 
by  Dr.  H.  W.  Williams  of  Boston,  U.  S.,  the  results — with  four 
exceptions,  which  were  neglected  at  the  commencement — were  perfectly 
good.f. 

I cannot,  therefore,  resist  the  conclusion  that  the  principles  which 
led  to  an  antiphlogistic  practice  in  acute  inflammations  were  erroneous, 
and  are  no  longer  in  harmony  with  the  existing  state  of  pathology. 
I think  it  has  been  further  shown  that  in  recent  times  our  success  in 
treatment  has  been  great,  just  in  proportion  as  we  have  abandoned 
heroic  remedies,  and  directed  our  attention  to  furthering  the  natural 
progress  of  the  disease.  Thus,  in  our  large  public  hospitals,  under  cir- 
cumstances pretty  much  the  same,  it  has  been  shown  that  the  mortality 
of  pneumonia  has  been  diminished  from  1 in  3 to  1 in  7 cases,  then  to 
1 in  13,  and  lastly,  to  1 in  40  cases.  In  other  words,  death  from  this 
acute  inflammation  is  now  very  rare,  whereas  formerly  it  occurred  in 
one  out  of  every  three  cases,  a high  rate  of  mortality.  I am  satisfied  also 
that  deaths  from  acute  pericarditis  are  far  less  common  now  than  for- 
merly, and  that  post-mortem  examinations  as  a consequence,  demon- 
strate adhesions  of  the  pericardium  much  more  frequently.  This  great 
improvement  in  practice,  it  appears  to  me,  is  attributable — 1st,  To  the 
greater  accuracy  with  which  we  can  now  detect  inflammations  of  the 
lung  and  heart ; and  2d,  To  our  better  acquaintance  with  their  patho- 
logy — and  the  result  is  not  the  less  certain  with  men  of  experience, 
because  these  causes  operate  insensibly  to  themselves.  How  often, 
during  the  last  twenty  years,  have  we  been  asked,  of  what  use  are 
your  stethoscopes,  your  microscopes,  and  your  chemical  analyses  at  the 
bedside  ? In  reply  we  point  to  the  revolution  now  going  on  in  the 
practice  of  medicine,  to  the  establishment  of  scientific  laws  instead  of 


* British  and  Foreign  Medical  Review,  vol.  xxiv,  p.  566  ; and  Lancet,  May  1846  to 
October  1846. 

f Boston  Medical  and  Surgical  Journal.  1866. 


THE  BLOOD-LETTING  CONTROYEESY. 


319 


empirical  rules,  and  to  the  abandonment  of  a palliative  in  favor  of  a 
curative  plan  of  treatment. 

Note. — For  an  account  of  the  blood-letting  controversy  which  followed  the  author’s 
enunciation  of  the  preceding  views  in  1857,  he  must  refer  to  the  last  edition  of  this 
work,  and  to  the  Monthly  Medical  Journal  for  the  years  1857-58.  Conceiving  that 
the  lengthened  argument  then  given  would  now  excite  little  interest,  he  has  consider- 
ably shortened  the  text,  and  placed  several  of  the  descriptions  of  facts  under  other 
heads,  in  order  to  avoid  repetition.  So  far  from  retracting  anything  however  of  what 
was  then  stated,  he  is  bound  to  say  that  extended  discussion  has  only  tended  to  con- 
vince him  of  the  correctness  of  his  statements,  which  now  seems  to  be  tacitly  ad- 
mitted. Anxious  however  to  furnish  the  most  rigorous  proof  as  to  the  exactitude  of 
his  statistics,  he  will  occupy  the  space  gained  by  the  omission  of  controversial  matter, 
in  giving  a table  containing  all  the  cases  of  pneumonia  he  has  treated  in  the  Royal 
Infirmary  since  the  year  1848.  This  he  trusts  will  satisfy  his  medical  brethren  as  to 
the  value  of  his  cases,  and  serve  to  establish  the  important  practical  conclusion  to 
which  he  has  arrived.  The  recent  observations  and  criticisms  of  M.  Grisolle,  in  the 
second  edition  of  that  physician’s  work  on  pneumonia  will  also  be  referred  to.  (See 
Pneumonia.) 

It  would  appear,  however,  that  his  lecture  on  the  diminished  amount  of  blood- 
letting, etc.,  has  excited  warm  discussion  in  America,  France,  and  in  other  countries. 
In  the  United  States  more  especially  Professor  Lawson  of  the  Medical  College  of  Ohio, 
Cincinnati,  has  distinguished  himself  by  his  vehement  opposition  to  the  author’s 
doctrines.  He  has  been  spared  however  from  the  necessity  of  replying  to  it,  in  con- 
sequence of  a most  able  and  temperate  paper  published  by  Dr.  llibberd  of  Richmond, 
Ind.,  in  the  Cincinnati  Lancet  and  Observer  for  April  1860,  in  which  every  one  of 
Professor  Lawson’s  arguments  are  refuted.  Dr.  Hibberd  is  of  opinion  that  the 
change  of  practice  in  acute  inflammations,  was  initiated  by  the  experience  physicians 
obtained  through  witnessing  the  practice  of  charlatans.  Without  denying  that 
many  physicians,  more  especially  in  America,  who  may  have  had  opportunities  of 
observing  such  practice,  might  be  predisposed  to  alter  their  opinions  on  that  account, 
I do  not  believe  that  such  was  the  case  to  any  extent  in  this  country.  I am  satis- 
fied it  was  no  such  observation  that  induced  change  in  my  own  views  previous  to 
1848,  but  that  it  entirely  resulted  from  a careful  study  and  long-continued  research 
into  the  nature  of  the  inflammatory  process. 

There  is  only  one  point  in  Professor  Lawson’s  paper  which  it  is  necessary  to  notice, 
and  this  merely  to  explain  an  occurrence  which  has  doubtless  tended  to  excite  some 
surprise.  Referring  to  the  author,  Professor  Lawson  concludes  his  paper  by  saying, 
“ Inflammation  came  stealthily  upon  him,  when  lo ! Dr.  Bennett’s  case  demands 
blood-letting ! His  colleague.  Professor  Miller,  informs  us  that  his  sthenic  constitu- 
tion nobly  sustained  depletion.  Thus,  the  hand  of  Providence  becomes  a more 
potent  teacher  than  statistical  tables  or  microscopical  revelations.”  Dr.  Hibberd 
observes  of  this  passage,  “ The  inference  is,  that  God  afflicted  Professor  Bennett  with 
inflammation  as  the  most  efficient  means  of  convincing  him  of  the  error  of  his  thera- 
peutical opinions.  Passing  by  the  impiousness  of  this  sentence,  there  are  two  other 
reasons  why  it  should  not  have  been  written.  In  the  first  place.  Professor  Bennett 
admits  that  bleeding  relieves  pain,  and  is  proper  for  that  purpose,  if  it  can  be  so  used, 
without  protracting  the  disease  or  retarding  convalescence ; and,  secondly,  when  he 
placed  himself  under  the  care  of  Professor  Miller,  he  was,  doubtless,  treated  according 
to  Professor  Miller’s  views,  and  not  his  own.” 

The  facts  are,  that  having  in  1858  been  attacked  by  a slight  pleurisy  in  the 
left  side,  the  author  was  induced  by  his  medical  attendant  (who  was  not  Professor 
Miller)  to  try  the  effect  of  applying  six  leeches  for  the  relief  of  his  pain.  Only 
four  of  the  leeches  took  blood,  and  he  might  have  lost  altogether  about  two  ounces. 
Certainly  he  obtained  no  relief  of  any  kind  from  the  operation.  The  blood-letting 
controversy  was  then  at  its  height,  and  the  rumor  that  the  author  had  himself  been 
bled  for  a pleurisy,  was  too  good  a joke  to  be  lost  sight  of.  Accordingly,  it  may 
be  judged  with  what  intense  amusement  the  following  passage  was  received  by  the 
Medico-Chirurgical  Society,  when,  in  his  valedictory  address.  Professor  Miller  said, 

“ The  antiphlogistic  abstraction  of  blood  has  not  wholly  ceased  in  the  skilful  practice 
of  medicine  and  surgery.  Even  in  the  former,  cases  ever  and  anon  emerge — though 
much  less  frequently  than  of  yore — in  which  bleeding  is  greatly  conducive,  if  not 


820 


GENERAL  THERAPEUTICS. 


absolutely  essential,  to  speedy  and  satisfactory  cure.  We  grieve  to  think  that  this 
fact  has  recently  met  a confirmation  in  the  personal  experience  of  the  very  Coryphseus 
of  the  abolitionists.  We  grieve  that  for  such  a malady  he  should  have  needed  such  a 
remedy ; and  yet  we  are  glad  to  be  assured  thus  certainly  of  what,  from  his  ante- 
cedents, we  had  confidently  predicted,  that  his  system  remains  wholly  of  the  sthenic 
type,— not  only  permitting  but  demanding  the  heroic  remedy,  and  bearing  its  applica- 
tion with  perfect  impunity.  Long  be  it  so  ! ” 


AN  INQUIRY  INTO  OUR  PRESENT  MEANS  OE 
TREATMENT. 

The  recent  advances  in  diagnosis  and  pathology  have  not  failed  to 
suggest  to  medical  men  the  reasonableness  or  unreasonableness  of  former 
modes  of  treatment,  for  when  the  principles  which  guided  our  prede- 
cessors were  shown  to  be  incorrect,  there  was  every  reason  to  suppose 
that  their  practice  was  incorrect  also.  Accordingly,  modern  experience 
has  demonstrated  that  many  of  those  rules  for  treating  various  disorders 
which  were  almost  universally  sanctioned  by  the  profession  twenty  years 
ago,  are  not  applicable,  and  that  the  properties  ascribed  by  tradition 
to  numerous  drugs  are,  in  not  a few  cases,  fabulous.  The  time,  therefore, 
has  now  arrived  for  ascertaining  the  results  of  former  teaching  and  of 
past  empirical  observations,  so  that  we  may  not  only  continue  to  study 
disease  at  the  bed-side,  with  all  the  aids  of  our  existing  knowledge,  but 
do  what  we  can  to  arrive  at  other  and  better  rules  of  practice  for  the 
future.  To  this  end  I propose  making  a few  observations  on  the  means 
of  treatment  at  our  disposal,  arranged  under  the  three  heads  of  Dietetica, 
Hygienica,  and  Materia  Medica. 

Dietetica. 

It  has  been  previously  stated  that  of  all  the  means  of  cure  at  our 
command,  a regulation  of  the  quantity  and  quality  of  the  diet  is  by  far 
the  most  powerful  (p.  126).  So  little,  however,  has  this  fact  been  con- 
sidered, that,  generally  speaking,  food  has  been  too  little  regarded  as  a 
remedial  agent.  In  many  histories  of  disease,  and  in  most  of  our  re- 
corded cases,  no  notice  whatever  is  taken  of  the  diet,  all  the  improve- 
ment being  ascribed  to  the  drugs  administered.  There  can  be  no 
question,  however,  that  there  are  many  diseases  that  require  nothing 
more  than  a properly  regulated  diet  to  secure  their  removal,  and  one 
of  the  next  great  advances  in  our  art  will  be  a knowledge  of  what  those 
diseases  are.  We  may  consider  this  subject  under  the  two  heads  of  food 
and  drink. 

Food. — Several  of  those  diseases  formerly  treated  by  antiphlogistics 
are  now  ascertained  to  be  removable  by  introducing  at  the  proper  time 
a carefully  graduated  nutritious  food.  Among  these  I would  class  the 
great  majority  of  inflammations,  internal  and  external;  the  essential  and 
eruptive  fevers,  and  numerous  nervous  diseases  characterised  by  delirium, 
convulsion,  and  perversion  of  sense.  A considerable  number  of  disorders 
arising  from  morbid  poisons  require  the  body  to  be  supported  until  the 
poison  has  time  to  be  eliminated.  This  is  the  explanation  of  many 
recoveries  from  small-pox,  measles,  and  similar  alfections.  The  same 
treatment  applies  to  poisoning  by  opium,  mercury,  lead,  alcohol,  and  the 


DIETETICA. 


321 


like,  all  attempts  to  discover  antidotes  having  failed,  as  we  shall  subse- 
quently see.  For  many  years  my  only  treatment  for  delirium  tremens 
has  been  the  administration  gradually  of  nutritive  substances,  and  almost 
every  uncomplicated  case  now  recovers.  (See  Delirium  Tremens.) 

There  are  other  diseases  which  are  curable  by  adding  to  or  sub- 
tracting from  the  diet  those  constituents  of  the  food  whieli  have  been 
in  diminution  or  excess.  The  whole  class  of  scrofulous  and  tubercular 
diseases  appears  to  me  to  be  of  this  kind.  They  originate  in  deficient  or 
imperfect  nutrition,  in  which  we  find  non-assimilatioii  of  fatty  matters 
to  be  the  faulty  ehmaut.  These  we  supply  either  directly  in  the  form  of 
cod-liver  oil,  or  by  milk,  eggs,  bacon,  and  other  substances  rich  in  fat. 
Cod-liver  oil,  therefore,  may  be  regarded  as  a dietetic  remedy.  In  the 
same  way  scurvy  breaks  out  from  deficiency  of  fresh  animal  or  vegetable 
food.  In  supplying  lemon-juice  and  fresh  vegetables,  we  simply  restore 
to  the  diet  what  was  deficient,  and  thereby  cure  the  disease.  In  the 
Perth  Penitentiary,  Dr.  Christison  discovered  that  scurvy  originated 
among  the  prisoners  from  substituting  treacle  for  fresh  milk.  On  re- 
storing the  latter  fluid  the  malady  was  removed. 

In  the  same  manner  numerous  diseases  originate  in  an  excess,  either 
of  the  whole  or  of  particular  substances  in  food.  A too  highly  animal- 
ized  diet  predisposes  to  gout  and  plethora.  Indulgence  in  wine  or 
spirits  leads  to  indigestion  and  various  diseases.  The  constant  drinking 
of  tea  excites  the  nervous  system,  and  so  on.  Abstinence  in  such  cases 
from  the  exciting  cau^e  is  often  sufficient  for  the  cure.  In  other  cases, 
promoting  exercise,  or  stimulating  some  excretion  or  secretion  to  remove 
the  residue  of  digestion  becomes  necessary,  in  accordance  with  the 
physiological  knowledge  of  the  function  of  nutrition  previously  detailed 
(p.  124  ) It  is  enough  to  have  here  indicated  how  a regulation  of  the  diet 
is  remedial  and  directly  curative  of  many  diseases.  It  should  not,  there- 
fore, any  longer  be  considered  as  subordinate  to  a treatment  by  drugs, 
but  recognised  as  a principal  means  of  cure  in  many  of  our  severest  dis- 
eases. The  notion  that  whatever  is  cured  by  diet  is  cured  by  nature, 
independent  of  the  assistance  of  the  physician,  is  erroneous.  In  one 
sense,  it  is  true,  all  diseases  are  cured  by  nature.  But  it  often  requires 
a higher  medical  knowledge  to  regulate  diet  in  special  disease  in  order  to 
promote  recovery  insensibly,  than  it  does  to  give  drugs  which  produce 
more  evident,  though  perhaps  less  efficacious  results.  Indeed,  the  con- 
stant recourse  to  drugs  to  remove  symptoms,  though  they  may  cause  tem- 
porary relief,  not  unfrequently  ends  in  rendering  the  latter  permanent, 
and  even  produces  lesions  that  did  not  previously  exist,  of  which  the 
abuse  of  purgatives  offers  constant  examples. 

The  recent  researches  of  Dr.  E.  Smith  have  exhibited  the  great  in- 
sufficiency of  the  knowledge  which  prevails  as  to  what  constitutes  a 
good  and  sufficient  diet,  for  individuals  under  varied  circumstances — 
especially  for  soldiers,  sailors,  laborers,  })risoners,  and  paupers.  Not 
only  are  the  diets  of  these  classes  often  improper,  but  young  persons  at 
our  schools — public  and  private — are  too  frequently  underfed  at  a period 
when  growth  requires  abundant  nourishment.  The  mistaken  prejudices 
of  some  parents,  also,  have  led  them  in  many  cases  to  restrict  their 
children’s  food,  with  the  idea  of  benefitmg  them,  but  with  the  effect,  in 
21 


322 


GENERAL  THERAPEUTICS. 


fact,  of  producing  a constitutional  debility  under  which  sooner  or  later 
they  have  all  sunk.  The  public  ignorance  of  dietetics  has  recently  been 
well  illustrated  by  their  rash  adoption  of  a system  recommended  to 
them  to  reduce  obesity  by  a Mr.  Banting.  Had  this  gentleman  been  a 
medical  or  scientitic  man,  it  is  probable  that  not  the  slightest  attention 
would  have  been  paid  to  his  suggestions ; but  for  no  better  reason  than 
because  he  is  neither  the  one  nor  the  other,  his  system  has  been  largely 
adopted,  and  the  experiment  thus  presented  to  us  has  shown  that  what 
proved  beneticial  to  one  person,  has  greatly  shaken  the  health  of  numer- 
ous othei  s for  whom  it  was  not  adapted.  These  and  similar  facts  can 
only  tend  to  convince  us  of  the  paramount  importance  of  diet,  not  only 
in  preserving  health,  but  when  correctly  used,  in  curing  disease. 

An  exact  knowledge,  however,  of  the  therapeutical  effects  of  diet, 
including  the  albuminous,  fatty,  and  mineral  constituents  of  food,  wheth- 
■ er  animal  or  vegetable,  and  of  the  various  kinds  of  drinks,  is  yet  to  be 
arrived  at.  For  certain  physiological  generalizations  regarding  it,  I 
must  refer  to  p.  125 ; but  these  are  far  from  pertect.  What  we  require 
to  learn  is  the  influence  of  the  various  substances  which  enter  into  our 
food  on  the  molecular  constituents  of  the  tissues,  as  well  as  the  chemi- 
cal and  structural  metamorphoses  these  undergo  during  the  acts  of  as- 
similation, secretion,  and  excretion.  As  our  investigations  proceed, 
these  will  be  rendered  apparent,  and  then  we  shall  be  better  prepared  to 
determine  in  what  way  dietetic  substances  may  be  en)ployed  in  the 
treatment  of  pathological  conditions.  Attention  in  recent  times  has 
been  strongly  directed  to  this  topic,  and  I trust  its  practical  bearing, 
not  only  in  reference  to  nutrition,  but  as  a means  of  preventing  and  of 
curing  disease,  will  constantly  be  kept  in  view. 

Drinks. — Under  this  head  we  may  consider — 1st,  Nutritive  cbhiks, 
including  milk,  soup,  broths,  as  well  as  farinaceous  and  mucilaginous 
drinks.  These  are  liquid  or  diluted  food,  the  stomach  having  first  to 
absorb  the  water,  and  then  act  upon  the  residue  as  it  does  upon  solid 
food.  On  this  account  they  are  not  applicable  for  use  in  certain  cases 
of  indigestion;  where  the  gastric  juice  is  deficient,  or  secreted  with  diffi- 
culty. 2d,  Alcoholic  drinks.^  including  beer,  wine,  and  spirits.  Great 
discussion  has  taken  place  as  to  whether  these  beverages  are  nutritive  or 
only  stimulant;  that  is,  whether  their  carbonaceous  elements  enter  into 
new  combinations  with  the  tissues,  and  support  growth,  or  wdiether  the 
alcohol  is  excreted  as  alcohol,  undergoing  no  change  in  the  animal 
economy.  It  is  admitted  that  much  of  the  alcohol  is  exhaled  or  passes 
out  of  the  body  unchanged,  but  all  that  enters  cannot  be  shown  to  do 
so.  However  this  discussion  may  terminate,  there  can  be  little  doubt 
that  these  drinks  are  of  great  importance  in  a therapeutic  point  of  view, 
most  persons  allowing  that  they  are  useful  as  medicines  in  disease,  even 
should  they  be  injurious  or  unnecessary  as  food  in  health.  In  all  ex- 
hausted conditions  of  the  body,  whether  from  acute  or  chronic  disease, 
they  frequently  support  the  system  under  circumstances  in  which  food, 
or  even  nutritive  drinks,  cannot  be  tolerated,  and  their  large  consumption 
at  present  as  tonics  and  restoratives  constitutes  a leading  feature  in 
modern  medical  practice.  3d,  Aromatic  or  astringent  drinks^  include 


HYGIENICA. 


323 


tea,  coffee,  chicory,  cocoa,  chocolate,  and  acidulated  drinks,  such  as 
lemonade.  It  is  a curious  fact  that  in  proportion  as  the  use  of  beer  and 
spirits  has  diminished  among  civilized  nations,  that  of  tea  and  coffee 
has  increased.  Chemistry  has  failed  in  telling  us  why,  and  all  that 
physiology  informs  us  is,  that  they  are  highly  stimulating  to  the  ner- 
vous system,  without  the  narcotizing  effects  of  alcohol.  Like  the  latter, 
however,  if  used  to  excess,  they  tend  to  produce  indigestion,  diminished 
appetite  and  disordered  stomach.  Their  therapeutical  effects  are  most 
valuable.  4th,  Mineral  waters.  All  kinds  of  water  contain  in  solu- 
tion certain  mineral  constituents,  and  being  used  as  drink,  these,  on  en- 
tering the  body,  are  absorbed,  and  form  combinations  with  the  animal 
fluids  and  tissues.  When  such  constituents  are  in  excess,  the  term  min- 
eral water  has  been  used ; and  as  they  vary  greatly  in  their  chemical 
composition,  so  do  they  in  their  therapeutical  effects,  some  being  laxa- 
tive, others  astringent,  some  impregnated  with  earthy  salts,  others  with 
various  metals.  Even  new  metals  have  been  discovered  in  certain  min- 
eral springs,  by  means  of  spectrum  analysis,  such  as  coesium,  rubidium, 
thallium,  and  indium,  to  minute  quantities  of  which  some  persons  have 
not  failed  to  ascribe  medical  virtues.  On  this  point  we  cannot  here  enter. 
We  need  only  remark  that  in  the  same  manner  that  improper  food  is  a 
fertile  source  of  disease,  so  is  an  impure  or  bad  water,  to  which  also  in 
recent  times  the  attention  of  sanitarians  has  been  strongly  directed. 

Hygienica. 

Under  this  head  I would  group  numerous  physical  conditions,  neces- 
sary not  only  for  maintaining  animal  life,  but  for  preserving  it  in  a 
state  of  health.  These  conditions  also,  though  not  neglected,  lave  been 
too  much  undervalued  by  medical  practitioners,  who,  in  their  desire  to 
discover  remedies  in  the  materia  medica,  have  too  often  overlooked  those 
causes  of  disease,  the  removal  of  which  is  the  obvious  method  of  induc- 
ing recovery.  I can  only  venture  to  allude  shortly  to  the  more  impor- 
tant of  these. 

Exercise. — The  necessity  of  keeping  the  muscular  system  in  a suffi- 
ciently active  condition  must  be  obvious  to  the  physiologist,  who  is 
acquainted  with  the  fact  that  the  constant  pressure  thus  kept  up  upon 
the  veins  is  one  of  the  direct  forces  which  secures  the  return  of  venous 
blood  to  the  heart.  But  in  connection  with  this  important  influence 
on  the  circulation,  we  must  consider  its  effect  on  the  respiration,  the 
condition  of  the  blood,  and  nutrition  generally,  and  through  that  on 
animal  heat.  Then  muscular  exercise  involves  a certain  expenditure  of 
the  contractile,  electrical,  and  nervous  forces,  while  it  more  or  less  in- 
fluences the  mental  powers.  We  observe  that  persons  who  spend  their 
lives  in  bodily  labor  are  for  the  most  part  incapacitated  for  mental  exer- 
tion, whilst  such,  on  the  other  hand,  as  overstrain  the  intellectual  facul- 
ties, are  generally  thin,  weak,  and  indisposed  to  personal  activity.  In 
medical  practice  we  are  constantly  meeting  with  ill  health  originating 
from  a disturbance  of  the  correct  balance  which  ought  to  be  preserved 
between  a certain  amount  of  muscular  exertion  and  the  strength  of  the 


324 


GENERAL  THERAPEUTICS. 


individual.  It  may  be  in  excess  or  in  diminution,  may  be  general  or 
local.  In  cases  of  debility,  either  of  the  whole  or  part  of  the  body, 
various  kinds  of  exercise  have  been  enjoined,  and  will  be  found  detailed 
in  special  works  on  this  subject.  Its  benefit  in  different  kinds  of  dis- 
tortion in  the  young  is  unquestionable.  In  the  numerous  forms  of  dys- 
pepsia and  weakness,  originating  in  too  much  application  to  business  or 
sedentary  employments,  as  a stimulant  to  appetite  in  cachectic  maladies, 
in  cases  of  paralysis  and  innumerable  other  forms  of  disease,  active 
exercises,  such  as  walking,  riding,  running,  swimming,  climbing,  gym- 
nastics generally,  etc.  etc.,  are  most  beneficial.  In  other  instances 
passive  exercise  has  been  found  useful,  as  in  driving,  having  the 
body  shampooed,  kneaded,  rubbed,  etc.  etc.  To  enter  into  the  multi- 
tudinous modes  in  which  exercise,  active  or  passive,  is  applicable  as 
a therapeutic  agent,  is  here  impossible.  They  will  be  found  detailed 
at  great  length  in  works  on  Hygiene,  and  as  a system  of  treatment 
for  almost  every  known  malady,  they  have  been  treated  of  by  Ling 
and  others  under  the  name  of  kenisipathy — (Kevew,  to  move ; Traces, 
disease.) 

Best. — In  the  economy  of  the  organized  world,  we  especially  observe 
that  periods  of  activity  alternate  with  periods  of  repose.  This  depends 
upon  the  circumstance  that  action  produces  waste  of  tissue,  and  hence 
the  necessity  of  pause  in  action,  in  order  that  substance  may  be  added. 
All  growth  and  secretion  seem  to  proceed  by  a succession  of  actions  and 
pauses.  The  movements  of  the  heart,  which  appears  to  be  continually 
beating,  really  consist  of  contractions,  relaxations,  and  pauses,  which 
follow  each  other  in  regular  order.  The  functions  of  the  nervous  system 
follow  the  same  law.  After  exercising  the  powers  of  thought,  after  the 
reception  of  sensations  or  the  performance  of  voluntary  motion  for  any 
time,  we  are  not  only  disposed,  but  are  imperatively  obliged,  to  submit 
to  their  suspension  for  a certain  period.  This  state  of  suspension  is 
sleep. . On  awaking  we  feel  refreshed, — new  strength  is  imparted  to  the 
muscles,  higher  sensibility  to  the  nerves,  and  greater  power  to  the  mind. 
Now,  disease  is  also  a state  of  action,  and  more  especially  predisposes  to 
waste  of  tissue,  so  that  not  only  is  exercise  opposed,  but  rest  is  conducive, 
to  recovery.  Nothing  so  rapidly  exhausts  the  body  as  a high  fever. 
To  Mr.  Hilton  we  are  indebted  for  an  excellent  work,  entitled,  “ On 
the  Influence  of  Mechanical  and  Physiological  Rest  in  the  Treatment  of 
Accidents  and  Surgical  Diseases,”  etc.,  the  perusal  of  which  I strongly 
recommend  to  you  ; therein,  also,  he  alludes  to  the  diagnostic  value  of 
pain.  I believe  a very  interesting  chapter  might  also  be  written  on  the 
therapeutical  value  of  pain,  which,  in  many  cases,  by  constraining  the 
individual  to  keep  motionless,  thereby  provides  for  that  rest  so  necessary 
for  recovery.  But  the  principle  or  rule  treated  of  by  Mr.  Hilton  as  a 
surgeon,  admits  of  equally  wide  application  in  medical  practice.  In- 
ternal organs,  when  diseased,  should  for  the  most  part  not  be  called  into 
action.  Sometimes,  however,  this  is  necessary  ; when,  for  example,  in 
order  to  remove  mechanical  obstruction,  we  must  stimulate  them,  as 
in  the  case  of  constipation,  or  blocking  up  of  the  renal  tubes.  No 
wider  error  prevails  among  mankind  than  the  idea  that  incipient  disease 


HYGIENICA. 


325 


of  a part  being  manifested,  continued  or  increased  exertion  may  get  rid 
of  it.  Among  the  laboring  population,  as  we  find  them  in  our  hospitals, 
how  often  are  pneumonias  and  other  severe  disorders  neglected  in 
the  beginning,  under  the  hope  that  they  will  go  away  ? They  continue 
their  exhausting  labor,  struggle  against  the  disease  as  long  as  possible, 
and  when  at  length  they  are  obliged  to  yield,  the  morbid  condition  is 
intensified,  whilst  there  is  diminished  vital  force  to  resist  the  evil. 
Such  are  the  worst  and  most  tedious  cases  of  recovery  from  acute  aifec- 
tions  iUv*t  with.  On  the  other  hand,  cessation  from  exhausting  pursuits, 
and  immediately  g >ing  to  bed  and  remaining  there,  are,  under  similarcir- 
cumstances,  the  best  aids  to  successful  treatment.  Another  idea  of  rest 
should  not  be  overlooked,  viz. — that  implied  in  giving  repose  to  one 
organ  by  calling  others  into  action,  as  is  exemplified  by  the  pleasure  ex- 
cited in  the  minds  of  those  employed  in  bodily  labor  or  monotonous 
toil,  by  literary  pursuits,  or  change  of  scene.  Or,  again,  the  refreshment 
and  invigorating  result  of  walking,  rowing,  or  other  muscular  exertion,  to 
those  condemned  to  sedentary  employment  or  long-continued  mental 
labor.  Thus  it  may  happen  that,  to  some  men,  true  rest  consists  in 
digging  a garden  or  climbing  a mountain — in  having  a hard  day’s 
sport,  or  taking  a long  journey. 

Climate. — The  influence  of  climate  in  therapeutics,  involves  the  con- 
sideration of  many  circumstances  connected  with  the  physical  condition 
of  numerous  localities,  such  as  their  dryness  or  humidity,  the  purity  of 
the  atmosphere,  t|ie  amount  of  wind,  equability  or  changes  in  temperature, 
the  elevation  or  depression  of  the  land,  its  geological  formation,  quality 
of  the  springs,  nature  of  the  vegetation,  etc.  etc.,  which  cannot,  from  its 
extent,  be  entered  upon  in  this  place.  At  the  same  time,  there  can  be 
n ) doubt  that  the  production  and  progress  of  diseases  are  greatly  in- 
fluenced by  locality,  some  existing  in  one  place,  while  they  are  absent  in 
another.  It  may  also  be  observed  that  particular  circumstances  in  a 
1 )cality  have  modified  existing  disorders,  have  banished  some  and  intro- 
duced others.  Thus,  draining  the  various  lochs  and  marshes  that  for- 
merly existed  in  Edinburgh,  has  entirely  removed  intermittent  fever, 
which  used  to  prevail,  while,  within  the  last  twenty  years,  we  have 
seen  typhoid  fever  become  common,  which  was  formerly  unknown. 
The  geographical  distribution  of  disease  is  a subject  which  has  scarcely 
been  studied  medically,  although  the  labors  of  Mr.  Keith  Johnston  of 
this  city  have  done  much  to  introduce  it  to  the  notice  of  scientific 
men. 

The  wide  possessions  of  the  British  empire  have  made  us  familiar  with 
the  fatal  or  injurious  effects  upon  Europeans  of  a residence  in  particular 
localities,  more  especially  in  the  swampy  plains  of  the  East  and  West 
Indies,  on  the  coasts,  and  in  the  interior  of  tropical  Africa,  in  the  more 
temperate  regions  of  Australia,  and  in  the  prolonged  winter  and  extreme 
cold  of  North  America.  The  public  and  private  enterprising  spirit  of 
the  nation,  has  also  led  to  numerous  exploring  expeditions  in  all  parts  of 
the  world,  which  have  exhibited  to  us  under  what  opposing  conditions 
of  climate  and  surrounding  circumstances  man  may  contrive  to  exist. 
But  when,  in  any  given  case,  the  question  comes  to  be,  to  what  place 


326 


GENERAL  THERAPEUTICS. 


you  shall  send  your  patient  in  order  to  save  or  prolong  his  life,  it  -must 
be  confessed  we  are  often  puzzled  by  contradictory  or  erroneous  informa- 
tion. When  in  foreign  countries,  the  health  becomes  impaired  from  the 
long  excessive  heat,  a return  home  for  a period  is  the  obvious  proceeding. 
When  malaria  causes  fever  in  swampy  jungles  or  pestiferous  marshes, 
hastening  from  the  spot  to  healthy  plains  or  to  the  open  sea  becomes 
necessary.  And  when,  in  our  own  country,  the  question  arises,  where 
we  shall  send  the  consumptive  patient,  in  order  to  avoid  our  changeable 
climate  and  cold  winter  winds,  in  winter,  we  naturally  say,  to  a land 
where,  during  that  portion  of  the  year,  the  weather  is  warm  and  equable. 
On  this  point,  I shall  speak  at  length  under  the  general  treatment  of 
phthisis,  to  which  I must  refer  the  reader,  as  well  as  to  the  numerous 
works  written  on  climatology. 

Ventilation. — I believe  that  a proper  ventilation  of  the  rooms,  and 
especially  of  the  sleeping  rooms,  occupied  by  invalids  is  a matter  of  the 
greatest  importance  in  treatment.  The  prevalent  notion  that  coughs 
and  colds,  sore  throat,  and  indeed  most  diseases,  should  be  combated  by 
wrapping  up,  confinement  to  close  heated  apartments,  or  to  beds  sur- 
rounded by  curtains,  is  most  injurious.  A perfect  oxygenation  of  the 
blood  by  the  introduction  of  pure  air  into  the  lungs  is  not  only  neces- 
sary to  healthy  persons,  but  is  especially  so  to  those  who  are  unhealthy. 
When  it  is  considered  that  most  persons  spend  one-third  of  their  life  in 
bed,  the  importance  of  breathing  a pure  air  during  that  long  period  must 
become  evident.  Yet  how  frequently  do  we  see  families  make  great 
sacrifices  to  obtain  what  is  called  fresh  air,  by  going  into  the  country  for 
some  months  or  weeks  every  year,  yet  when  there  crowd  three  or  four 
persons  together  in  confined  sleeping-rooms.  They  get  their  fresh  air,  it 
is  true,  in  the  day,  but  never  think  of  avoiding  foul  air  at  night.  In 
bronchitic  and  phthisical  cases,  the  relief  experienced  by  sleeping  all 
night  with  the  window  slightly  open  at  the  top,  is  often  remarkable,  as 
was  first  pointed  out  by  Dr.  M’Cormack  of  Belfast.  On  this  account  I 
have  satisfied  myself  of  the  great  superiority,  as  means  of  ventilation,  of 
the  sash  windows  in  England  over  the  windows  formed  of  two  lateral 
halves,  opening  side  ways,  so  common  on  the  continent.  On  the  other 
hand,  while  securing  free  air,  the  utmost  care  should  be  taken  to  avoid 
draughts,  and  violent  currents  of  wind  so  frequently  encountered  in 
foreign  hotels,  with  long  corridors,  and  doors  exactly  facing  the  windows. 
Although  much  still  remains  to  be  done  notwithstanding  the  labors  of 
Arnot  and  others  in  bringing  about  a perfect  system  of  ventilation  in 
English  houses,  they  must  be  admitted  to  be  more  comfortable,  and  by 
means  of  their  sash  windows  capable  of  renewing  fresh  air  with  less  risk 
to  the  delicate  than  what  exists  elsewhere.  In  Italy,  where  the  climate 
is  so  fine,  the  houses  are  too  often  unbearable. 

Heat  and  Gold. — The  influence  of  the  atmospheric  temperature  belongs 
essentially  to  climate.  Here,  I shall  only  refer  to  the  therapeutic  effects 
of  heat  and  cold  applied  locally.  In  this  respect  they  operate  in  three 
-^ays — 1st,  As  stimulating  or  retarding  growth ; 2d,  As  alleviating  pain  ; 
and,  3d,  As  a nervous  stimulant,  or  sedative.  An  elevated  temperature, 


HYGIENIC  A. 


327 


especially  when  combined  with  moisture,  is  well  known  to  favor 
growth  both  in  the  vegetable  and  animal  worlds,  and  thus  I pointed 
out  many  years  ago — (Treatise  on  Inflammation) — is  to  be  explained 
how  warm  poultices  favor  suppuration,  that  is,  the  growth  of  pus 
cells.  On  the  other  hand,  cold  and  a low  temperature  are  opposed 
to  growth,  and  act  as  astringents,  and  hence  why  their  application 
immediately  after  the  receipt  of  blows  or  injuries  restrains  inflam- 
matory action,  and  checks  exudation  and  its  subsequent  development. 
The  immediate  good  effect  of  cold  water  applied  to  the  eye,  when  it 
has  been  irritated  by  dust  or  sand,  is  a good  example  of  the  therapeutic 
action  of  cold. 

The  influence  of  cold  and  heat  in  alleviating  pain  is  difficult  to 
explain,  especially  how  in  some  cases  a diminished,  and  in  others  an 
elevated  temperature  causes  so  much  relief  Thus  some  kinds  of  cepha- 
lalgia and  nervous  pain  are  at  once  alleviated  by  cold.  I know  of 
nothing  that  produces  such  immediate  ease  and  comfort  in  cases  of 
typhus  fever,  with  headache,  as  gently  pouring  cold  water  over  the 
scalp.  In  other  cases,  apparently  similar,  it  is  warmth  which  operates. 
I was  summoned  to  a married  lady  who,  during  the  day,  had  expe- 
rienced several  rigors,  and  found  her  in  the  evening  with  a burning 
skin,  rapid  pulse,  furred  tongue,  intense  headache,  in  short,  all  the 
symptoms  of  fever.  To  alleviate  the  intolerable  headache  I poured 
cold  water  over  the  head,  which  to  my  surprise  caused  no  relief  what- 
ever. I then  immediately  changed  the  cold  for  hot  water,  and  as  if 
by  magic  the  pain  at  once  disappeared.  This  led  me  to  suppose  that, 
after  all,  the  case  might  not  be  one  of  fever,  although  at  the  time  I 
could  obtain  no  information  from  the  patient  to  satisfy  my  doubts. 
But  in  a week  she  aborted,  having  been  unconscious  that  she  was  preg- 
nant. The  only  practical  rule  I know  as  to  this  matter  is,  if  cold  fails, 
to  try  warmth.  Most  assuredly,  as  alleviators  of  local  pain  they  are 
among  the  most  powerful  means  possessed  by  the  physician. 

Both  heat  and  cold  in  excels,  by  their  application  to  the  skin,  may 
be  made  either  stimulative  or  sedative.  Thus  the  actual  cautery  acts  as 
a counter-irritant,  and  exposure  of  any  part  of  the  surface  to  a high 
temperature  causes  redness  and  congestion  of  the  part.  In  this  manner 
heat  excites  the  functions  of  organs,  and  favors  the  external  flow  of 
blood,  as  in  menstruation,  or  after  the  application  of  leeches.  In  the  same 
manner  the  sudden  application  of  cold  is  one  of  the  most  powerful 
exciters  of  reflex  action.  Dashing  cold  water  on  the  face  or  breast 
excites  inspiration,  and  favors  recovery  from  syncope  or  apnoea.  The 
slow  and  long- continued  action  of  these  same  agents  is  sedative,  the 
tendency  to  somnolence  in  warm  weather,  or  in  front  of  a good  fire,  and 
the  benumbing  effects  of  cold  are  well  known.  Dr.  James  Arnott  has 
ably  pointed  out  that  congelation  of  parts  from  intense  cold  constitutes 
a means  of  producing  insensibility  in  surgical  operations,  without  the 
danger  arising  from  the  inhalation  of  narcotic  vapors. 

Clothing. — Medical  men  have  too  frequently  an  opportunity  of  ob- 
serving not  only  how  habitually  deficient  or  improper  clothing  is  a 
cause  of  disease,  but  in  satisfying  themselves  how  under  certain  circum- 


328 


GENEEAL  THERAPEUTICS. 


stances  extra  clothing  is  often  therapeutic.  The  carelessness  of  young 
and  delicate  women  at  balls  and  parties,  renders  it  necessary  to  caution 
them  as  to  shawls  and  coverings.  In  bronchitis  a piece  of  flannel  worn 
over  the  chest,  and  in  rheumatism  over  the  shoulders,  have  ameliorated 
and  even  removed  these  aifections.  Respirators  are,  in  truth,  extra 
pieces  of  clothing,  and  carrying  a shawl  in  the  hand  to  protect  the  face 
from  wind  or  cold  chills,  is  at  once  preventive  of  accessions  of  cough. 
Keeping  the  lower  extremities  warm  also,  when  driving  or  riding,  may 
prevent  or  check  disease. 

Bathing. — From  the  earliest  times  bathing  has  been  employed  as 
conducive  to  health,  as  a means  of  cleanliness  and  as  securing  the  proper 
action  of  the  skin.  In  recent  times  it  has  been  more  attended  to  than 
ever,  and  even  raised  into  a special  system  of  treatment  for  almost  every 
malady,  under  the  name  of  hydropathy.  This,  however,  also  includes 
attention  to  dietetic  rules,  exercise,  and  even  medication  when  necessary, 
in  consecjuence  of  which  any  good  effects  produced  by  the  system  are 
often  attributable  to  a variety  of  circumstances  not  comprised  in  the 
meaning  of  the  name  it  bears.  The  skin  is  not  an  absorbing  membrane, 
and  it  has  been  proved  by  experiment  that  long  immersion  of  the  body 
in  water  causes  a very  trifling  addition  to  its  weight.  Even  with  the  aid 
of  friction,  medicines  diffused  in  grease  or  oil  enter  only  in  minute 
quantities.  The  constant  application  of  water  to  the  cutaneous  surface, 
however,  care  being  taken  to  prevent  dryness  by  a layer  of  oil-silk,  or 
gutta  percha,  is  emollient,  removes  irritations,  favors  the  natural  secre- 
tions of  the  texture,  and  is  highly  conducive  to  slow  and  perfect  healing 
by  granulations,  as  shown  in  what  is  now  called  the  water-dressing  of 
sores.  For  this  reason  in  1849"*'  I introduced  this  method  of  treating 
vesicular  and  pustular  eruptions  of  the  skin,  which  I have  successfully 
practised  ever  since,  (See  Treatment  of  Skin  Diseases).  JJ^arm  Baths 
combine  with  the  effects  of  water  those  of  warmth,  and  are  highly 
emollient,  soothing  to  the  nervous  system,  and  relaxant.  They  are 
taken  advantage  of  to  relieve  muscular  spasm  and  rigidity,  as  in  the 
convulsions  of  children  and  strangulated  heruim  of  adults.  Cold  Baths^ 
on  the  other  hand,  if  used  for  a short  time,  are  tonic  and  astringent,  pro- 
ducing reaction  and  warmth  of  the  body,  but  if  too  long  continued,  occa- 
sion all  the  bad  effects  of  prolonged  cold,  continued  pain,  feebleness  of 
pulse  and  coma.  The  exercise  of  swimming  in  cold  water  would,  to  a 
certain  extent,  counteract  these  effects.  Affusion — the  shoiver  hath.,  the 
douche^  and  washes  of  various  kinds,  whether  warm,  cold,  or  tepid,  are 
other  modes  of  bathing  the  surface  generally  or  topically.  Mineral 
Baths — these,  like  mineral  waters,  have  been  greatly  extolled,  but  there 
are  grave  doubts  whether  any  salt  of  an  earth  or  a metal  can,  to  any 
extent,  enter  the  body  in  this  way,  and  the  same  may  be  said  of  medi- 
cated baths.  Locally,  these  latter  baths  may  be  useful,  as  in  the  case  of 
the  alkaline  bath  which,  in  certain  skin  diseases,  is  directly  curative  by 
its  superior  emollient  properties.  Vapor  Baths  have  long  been  em- 
ployed as  sudorifics,  and  the  bath  in  chambers  of  heated  air  called  the 
Turkish  bath,  has  recently  been  extensively  introduced  among  us.  This 
* Monthly  Journal  of  Medical  Science.  August  1849. 


HYGIEXICA. 


329 


also,  after  producing  perspiration,  is  combined  with  friction,  shampooing, 
the  tepid  and  cold  douche  in  a variety  of  forms.  The  therapeutical  ad- 
vantages of  these  baths  have  yet  to  be  determined.  Oil,  mud,  and 
numerous  other  kinds  of  baths,  have  been  employed  in  special  cases,  as 
well  as  the  electro-chemical  bath,  by  which  it  has  been  pretended  that 
mercury,  lead,  and  other  metallic  poisons  may  be  drawn  out  of  the  body. 

Light. — The  remarkable  stimulating  effect  of  solar  light  to  the  animal 
and  vegetable  worlds  must  also,  under  certain  circumstances,  be  thera- 
peutical. It  is  difficult  to  estimate  this,  although  its  exhilarating  influ- 
ence may  often  be  observed  in  sick  persons.  On  the  other  hand,  dark- 
ness is  advisable  in  acute  affections  of  the  eye,  and  in  cases  of  mental 
irritation.  It  is  also  favorable  to  sleep,  and  depression  of  the  vital 
powers.  Death  most  fre(|uently  occurs  during  the  night.  I was  much 
struck  when  examining  the  private  asylum  of  Messrs.  Falret  and  Voisin, 
some  years  ago,  near  Paris,  to  observe  how  carefully  their  melancholic 
cases  were  placed  in  light  rooms,  with  brilliant-colored  papers,  and  that 
the  private  garden  outside  was  blooming  with  the  gayest  flowers,  whereas 
the  maniacal  and  excitable  cases  inhabited  sombre  apartments,  while  the 
garden  outside  was  furnished  only  with  dark  evergreens. 

Electricitg. — The  living  tissues  of  the  body  are  saturated  with  saline 
fluids,  whereby  the  operations  of  static,  galvanic,  and  electro-magnetic 
currents  easily  reach  them,  producing  two  orders  of  phenomena — viz.,  1st, 
chemically  decomposing  or  destructive ; and  2d,  alterative  or  stimulant. 
In  the  latter  case  the  peculiar  property  of  each  texture  is  excited  by  action 
on  its  molecular  constituents.  The  sensible  effects  of  electricity,  how- 
ever, are  greatly  modified  by  the  mode  of  its  application.  That  is  to  say, 
whether  the  individual  subjected  to  it,  be  or  be  not  insulated — whether 
the  form  of  application  be  that  of  sparks,  shocks,  aura,  or  current — the 
shape  and  nature  of  the  electrodes  employed — whether  the  current  be 
continuous,  interrupted,  or  reversed  ; its  direction,  amount,  duration,  and 
how  introduced  or  drawn  from  the  economy.  Though  electricity  has 
been  employed  empirically  in  a great  variety  of  diseases  since  the  year 
1745,  when  its  accumulation  within  the  Leyden  jar  was  first  known,  we 
are  still  deficient  in  such  exact  observations  as  wdl  positively  determine 
its  therapeutical  value.  It  would  appear,  however,  to  be  most  useful  in 
the  various  forms  of  nervous  and  muscular  paralysis,  neuralgia,  and 
different  kinds  of  spasm  and  convulsion.  One  of  the  most  interesting 
facts  which  the  experiments  of  John  Reid  demonstrated  was,  that  in  cases 
of  muscular  paralysis  from  injury  to  the  nervous  system,  the  muscles 
will,  if  left  to  themselves,  become  atrophied  in  a certain  time,  and  lose 
their  contractility ; but  if  from  time  to  time  they  be  galvanised  so  as  to 
contract,  they  will  remain  contractile  and  well  nourished  for  months. 
Hence  the  importance,  in  cases  of  paralysis,  of  calling  the  limbs  into 
action  from  time  to  time  ; and  hence  the  therapeutic  effects  of  electricity 
in  such  cases.  It  is  important,  however,  in  applying  this  agent,  to  re- 
member that  what  is  required  is  its  stimulating,  and  not  its  exhaustive 
influence  ; and  that  as  the  former,  if  too  long  continued,  produces  the 
latter,  so  action  thus  occasioned  must  be  carefully  proportioned  to  the 


330 


GENEEAL  THERAPEUTICS. 


muscular  strength  and  general  health.  This  has  not  been  sufficiently  at- 
tended to.  Many  persons  have  been  subjected  so  long  to  the  influence  of  an 
interrupted  current  that  increased  weakness  rather  than  vigor  has  been 
the  result. 

The  proper  use  of  electricity  in  any  of  its  forms,  galvanic  orgalvano- 
magnetic,  requires  not  only  a profound  knowledge  of  the  natural  laws 
regarding  it,  but  of  anatomy  and  physiology.  If  applied  locally  to  the 
muscles,  their  origin  and  insertion  must  be  well  known  to  the  operator,  and 
if  made  to  act  through  the  nerves,  their  connection  with  the  nervous  centres, 
their  course,  anastomoses,  and  termination,  must  also  be  familiar  to  him. 
The  brilliant  researches  of  Metteuci,  Becquerel,  but  more  especially  of 
Du  Bois  Beymond  and  his  numerous  followers,  have  advanced  science  by 
the  discovery  of  many  laws  which  regulate  the  electrical  currents  in  the 
muscle  and  nerve  tissues,  and  the  relation  of  these  laws  to  the  vital  and 
physical  forces.  Among  these  the  following  may  be  considered  as 
important — 

A single  electrical  shock  may  last  only  the  y^^’^^th  part  of  a second, 
but  the  muscular  shortening  reaches  its  maximum,  and  returns  to  its 
former  state  in  about  one-fourth  of  a second.  If  two  shocks  are  given, 
the  one  immediately  after  the  muscle  has  returned  to  a state  of  rest,  then 
there  are  two  contractions.  If  the  second  stroke  is  given  during  the 
muscular  movement  caused  by  the  first,  and  there  is  either  contraction 
or  relaxation,  it  causes  increased  shortening.  But  if  the  second  stroke 
follow  very  rapidly  on  the  first  (that  is,  within  the  g i^tli  of  a second), 
the  shortening  is  not  greater  than  with  one  stroke.  If  several  shocks 
are  given  before  a muscle  has  time  to  be  relaxed,  it  becomes  hard,  and 
permanently  contracted,  constituting  tetanus.  The  less  fatigued  the 
muscle,  the  more  rapid  is  the  shortening.  Interrupted  currents  or  shocks 
of  electricity  therefore  cause  permanent  or  tetanic  spasms  in  muscle, 
whether  applied  directly  to  itself,  or  indirectly  through  a nerve,  and  the 
intensity  of  this  will  depend  on  (1)  the  intensity  and  rapidity  of  the  cur- 
rent; (2)  the  amount  of  contractile  power  in  the  muscle;  and  (8)  the 
mechanical  resistance  the  muscle  may  have  to  overcome,  as  from  the 
distance  or  weight  of  parts  to  which  it  may  be  attached.  On  the  other 
hand  a continuous  current  of  electricity  only  excites  muscular  contraction 
when  the  electrical  circuit  is  closed  or  broken.  In  the  interval  it  seems 
to  flow  through  the  tissue  without  causing  any  sensible  effect. 

When  a continuous  current  of  electricity  is  caused  to  pass  through  a 
portion  of  nerve,  it  is  thrown  into  a peculiar  condition,  which  Du  Bois 
Beymond  called  an  electro-tonic  state.  If  this  current  be  sent  through 
a portion  of  a nerve  in  the  same  direction  as  its  own  proper  current,  then 
the  latter  is  increased,  as  may  be  shown  by  the  galvanometer ; but  if  in 
the  opposite  direction,  it  is  diminished.  Again,  where  the  nerve  comes 
in  contact  with  the  positive  electrode,  the  electro-tonic  state  is  diminished 
{aneletrotonus)  ; where  it  comes  in  contact  with  the  negative  pole,  it  is 
increased  (catelectrotonus).  Between  the  poles,  at  the  point  where  the 
two  variations  meet  (point  of  indifference),  the  normal  state  of  the 
nerve  is  preserved.  Both  the  increased  and  diminished  excitability  of 
the  nerves  so  caused  bear  a relation  to  the  force  and  rapidity  of  the 
current.  Further,  the  power  of  conduction  in  the  nerve  is  diminished 
in  the  state  of  aneletrotonus ; but  on  breaking  the  current,  the  con- 


MATERIA  MEDICA. 


331 


ducting  power  returns  there,  while  it  is  diminished  where  formerly  it 
was  in  the  state  of  catelectrotonos.  Hence  we  can  influence  the  con- 
tractions of  muscles  by  a continuous  current  through  the  nerve,  accord- 
ing to  its  force  and  direction.  It  can  also  be  easily  shown  that  the 
further  from  a muscle  a motor  nerve  be  irritated,  the  greater  is  its  ex- 
citability, so  that  a feeble  current  applied  to  a nerve  at  a distance  from 
a muscle  will  excite  more  contraction  than  a stronger  one  applied  close 
to  it.  The  stimulation  of  sensitive  nerves  by  electricity  excites  their 
special  functions,  on  the  forming  and  breaking  a circuit  in  proportion  to 
its  amount  and  rapidity.  Hence  we  can  excite  pain  through  the  ordi- 
nary sensitive  nerves,  flashes  of  light  through  the  optic,  noise  through 
the  auditory,  and  taste  through  the  gustatory  nerves.  As  with  muscles 
also  during  the  interval,  no  sensible  etfect  is  occasioned. 

With  regard  to  the  proper  method  of  applying  electricity  in  disease, 
great  difference  of  opinion  prevails.  Huclienne  strongly  supports  the 
use  of  an  interrupted  current  applied  locally  to  the  muscles ; while 
Remak  maint.iins  the  importance  of  a strong  continuous  current  applied 
to  the  nerves  and  nerve  centres.  Both  modes  of  procedure  require  to  be 
more  generally  tested  by  experience.  In  one  class  of  cases  originating 
in  the  nervous  centres,  as  in  hemiplegic  paralysis,  Remak’s  plan  may 
be  most  useful ; whereas  in  another  class  dependent  on  a primary  mor- 
bid action  affecting  the  muscles,  as  in  saturnine  paralysis,  that  of 
Duchenne  may  prove  the  best.  It  has  also  to  be  ascertained  what  is 
owing  to  direct  and  what  to  reflex  action  during  the  topical  application 
of  electricity.  I need  scarcely  remark  that  a thorough  knowledge  of 
diagnosis  should  be  possessed  by  him  who  undertakes  the  difficult  task 
of  employing  so  powerful,  although  manageable,  an  agent  for  the  relief 
and  cure  of  diseases.  On  this  head  medical  practitioners  should  consult 
the  practical  works  of  Remak,  Duchenne,  Althaus,  and  Garratt. 

In  concluding  this  short  summary  of  what  may  be  considered  our 
chief  hygienical  means  of  cure,  it  may  be  observed,  that  although  their 
influences  on  the  human  economy,  in  its  diseased  as  well  as  healthy  con- 
ditions, cannot  admit  of  doubt,  there  is  scarcely  any  of  them  with  which 
we  are  so  thoroughly  acquainted  as  to  render  their  application  exact  in  any 
given  class  of  cases.  On  the  medical  applications  of  nearly  any  one  of 
them  volumes  might  be  written,  and  several  have  been  raised  into  sys- 
tems of  treatment,  under  the  names  of  Kenesipathy,  Climatology,  Hydro- 
pathy, Electro-pathy,  etc.  Their  sanative  influence  on  morbid  conditions, 
however,  as  determined  by  a careful  diagnosis,  and  by  prolonged  observa- 
tion as  to  their  superiority  over  the  natural  progress  of  disease,  is  a work 
yet  to  be  accomplished.  In  this  point  of  view  there  is  still  open  for  the 
clinical  student,  favorably  circumstanced,  an  extensive  field,  which,  if 
properly  cultivated,  cannot  but  prove  rich  in  useful  therapeutical  results. 

Materia  Medic  a. 

By  the  Materia  Medica  we  understand  those  agents  derived  from  the 
animal,  vegetable,  and  mineral  worlds,  which,  forming  no  essential  part  of 
diet,  or  being  necessary  to  life  or  health,  are  used  as  medicines  or  reme- 


332 


GENERAL  THERAPEUTICS. 


dies  for  tlie  relief  or  cure  of  diseases.  It  is  to  the  discovery  and  employ, 
ment  of  these  means  that  medical  men  have,  for  the  most  part,  directed 
their  energies,  and,  in  consequence,  a multitude  of  substances  have  been 
extolled  by  some  and  repudiated  by  others,  with  the  qualities  of  which 
medical  men  are  expected  to  be  familiar.  Several  of  these  are  of  un- 
questionable value  in  the  treatment  of  diseases;  many  of  them  possess 
doubtful  qualities,  which  have  been  ascribed  to  them  by  tradition  or  by 
long  usage,  whilst  a vast  number  are  positively  worthless,  if  not  injuri- 
ous. Bichat  says,  “ There  have  been  no  general  systems  in  the  materia 
medica ; but  this  science  has  been  alternately  influenced  by  the  prevail- 
ing theories  in  physic.  From  hence  proceeds  that  indefiuiteness  and  un- 
certainty which  mark  it  even  in  the  present  day.  It  is  an  incoherent  mass 
of  incoherent  opinions,  and,  probably,  of  all  physiological  sciences,  that  in 
which  the  inconsistencies  of  the  human  mind  are  most  glaring.  What  do 
I say  ? It  is  not  a science  for  a methodical  and  philosophical  mind;  it  is 
an  incongruous  combination  of  erroneous  ideas,  observations  often  puerile, 
means,  at  the  least  fallacious,  and  formulae  as  fantastically  conceived  as 
they  are  preposterously  combined.  It  is  said,  that  the  practice  of  com- 
bined physic  has  something  repelling  in  it.  I will  say  more  : in  those 
principles  which  connect  it  with  the  materia  medica,  it  is  absolutely  re- 
volting to  a rational  mind.”^  Magendie  observes  that  one  chemist  is 
in  accord  with  another  as  to  his  fundamental  facts,  and  that  the  pheno- 
mena observed  in  his  laboratory  are  the  same  in  Paris  as  in  New  York, 
in  London  as  in  Calcutta.  But,  he  adds,  it  would  be  a painful  task  to 
pass  in  review  the  different  modes  of  medical  treatment  employed  in 
different  localities  for  the  same  disease.  Even  in  Paris,  should  an  indi- 
vidual be  attacked  by  typhoid  fever,  the  treatment  would  vary,  accord- 
ing as  he  was  sent  to  this  or  that  hospital. f Most  of  our  scientific 
anatomists  and  physiologists,  like  Bichat  and  Magendie,  have  continued 
to  distrust  the  influence  of  medicines  in  disease,  and  have  taken  too  little 
interest  in  therapeutics.  The  consequence  has  been,  that  the  generality 
of  medical  practitioners  are  educated  in  a blind  faith  as  to  the  proper- 
ties and  uses  of  drugs,  a faith  which  has,  in  most  cases,  descended  to  us 
from  a barbarous  age,  has  become  traditional,  and  possesses  no  relation 
to  the  present  state  of  medical  science. 

All  those  who  have  acquainted  themselves,  in  recent  times,  with  what 
is  known  of  the  structure  and  chemical  composition  of  the  tissues,  the 
laws  of  nutrition,  and  the  pathological  changes  which  occur  in  organs 
during  disease,  must  feel  astonished  at  the  unfounded  assumptions,  want 
of  evidence,  and  even  unreasonableness  which  characterise  writings  on 
the  action  of  medicines.  They  are  constantly  asking,  on  what  grounds 
the  assertions  as  to  the  properties  of  this  drug  or  that  treatment  are 
based,  and  too  frequently  can  obtain  no  response  whatever.  We  observe 
also  that  what  now  occurs  in  our  hospitals  is  so  often  at  variance  with 
such  assertions,  as  to  create  a wholesome  scepticism  as  to  the  correctness 
cf  what  is  taught  of  the  materia  medica. 

As  an  example  of  the  writings  and  teachings  on  this  branch  of  our 
subject,  let  us  examine  the  third  and  last  edition  of  a work  by  Dr.  Head- 

* General  Anatomy,  Translated  by  Coffyn,  p,  xiv. 

\ Phenomenes  physiques  de  la  vie.  Tome  2me,  pp.  4 et  6. 


MATERIA  MEDICA. 


333 


land,  which  gives  what  is  admitted  to  be  one  of  the  best  and  most  recent 
systematic  accounts  of  the  actions  of  medicines  in  our  language."^  We 
may  at  least  regard  it  as  an  intelligent  and  careful  resume  of  the  present 
state  of  our  knowledge. 

At  p.  161,  he  says  : “ Another  remedy  has  been  used  in  all  the  dis- 
eases in  which  quina  is  admissible,  proving  in  some  cases  superior  and 
in  other  instances  second  only  to  it  in  its  beneficial  action.  This  is 
mercury ; used  in  remittent  and  yellow  fevers  ; of  the  first  importance  in 
dysentery ; employed  by  Dr.  Baillie  in  ague,  and  pronounced  by  him  to 
be  in  some  cases  superior  even  to  quina.  In  small  doses  it  is  frequently 
of  use  in  cases  of  debility  and  scrofula.  And  mercury  is  a cholagogue  ; 
i.  e.,  an  agent  which  is  known  to  have  the  elfect  of  promoting  the  secretory 
function  of  the  liver.”  “ Under  such  a course,  judiciously  enforced,  we 
may  see  the  dilated  pupil  contract  to  its  normal  size,  and  the  pale  ener- 
vated countenance  become  rosy  and  lively,  and  feel  the  weak  compressible 
pulse  become  hard  and  firm.  Perhaps  mercury  in  such  a case  may  be 
indirectly  tonic,  by  restoring  to  the  blood  the  natural  tonic  principle  of 
the  bile.”  Again,  at  p.  213 — ‘‘  Mercury,  which  restores  the  secretion  of 
the  liver,  may  be  for  this  reason  useful  in  arthritic  diseases.”  Here,  you 
will  observe,  that  arguing  on  the  principle  that  whatever  restores  to  the 
blood  such  of  its  constituents  as  are  deficient  is  tonic,  mercury  is  recom- 
mended in  cases  of  debility,  scrofula,  and  gout,  because  it  is  a cholagogue. 
But  no  facts  are  given  to  show  that  mercury  is  a cholagogue,  and  if  that 
assumption  be  incorrect,  its  alleged  value  in  those  diseases  falls  to  the 
ground  as  a speculation,  while  no  cases  are  given  to  demonstrate  it  as  a 
matter  of  observation.  At  p.  383,  it  is  said,  that  mercury  has  been 
found  in  the  bile  of  dogs  by  Burcheim.  But  any  facts  to  show  that  the 
drug  increases  the  flow  of  bile,  I have  vainly  sought  for. 

At  p.  373,  Headland  says:  “It  is  by  the  production  of  nausea  that 
antimony  becomes  so  valuable  an  agent  in  the  control  of  high  fevers  and 
acute  inflammations.  The  force  of  the  heart  being  diminished,  the  fever 
is  allayed ; and  the  active  congestion  of  the  vascular  system,  whether 
local  or  general,  which  was  produced  by  the  inflammation  and  maintained 
by  the  violent  action  of  the  heart,  is  eff’ectually  subdued.  At  the  same 
time  absorption  is  favored  by  the  removal  of  the  pressure  from  the 
capillary  circulation.”  Here,  you  observe,  it  is  said  that  inflammation  is 
cured  by  nauseants ; that  subduing  the  force  of  the  heart  subdues  fevers, 
and  so  on.  I trust  you  have  satisfied  yourselves  in  the  clinical  wards 
that  all  depressants  and  nauseants  are  opposed  to  the  correct  treatment 
of  inflammations  and  fevers,  and  that  recoveries  take  place  just  in  pro- 
portion as  we  can  support  the  system,  and  sustain  rather  than  subdue  the 
heart’s  action. 

At  p.  385,  we  are  told  that  in  treating  inflammation,  “ the  imme- 
diate effect  of  bloodletting  is  mechanical ; that  of  antimony,  nervous ; 
that  of  mercury,  haematic.  Bloodletting  weakens  the  force  of  the  heart, 
by  diminishing  the  pressure  on  the  blood-vessels;  antimony  diminishes 
the  pressure  on  the  vessels,  by  weakening  the  force  of  the  heart ; and 
mercury  does  both  of  these  things,  by  impoverishing  the  blood.”  But 
it  is  nowhere  shown  that  any  of  these  drugs  either  act  in  the  way  stated, 

* London,  1859. 


334 


GENEEAL  THERAPEUTKIS. 


or  cure  inflammation  at  all.  So  far  as  modern  experience  is  concerned 
I hold  it  on  the  other  hand  to  be  demonstrated,  that  weakening  the 
pulse,  or  impoverishing  the  blood  to  cure  inflammation,  is  a most  fatal 
practice.  I hope  you  have  satisfied  yourselves  from  the  results  of  treat- 
ment carried  on  in  these  wards,  that  inflammation  may  be  successfully 
combated  without  the  use  of  bloodletting,  antimony,  or  mercury. 

At  p.  390,  we  are  told  that  mercurials  “ no  doul3t  stimulate  the  for- 
mation of  the  pancreatic  secretion,  which  is  similar  in  nature  to  the 
saliva.”  Now,  as  to  their  causing  salivation  we  can  have  no  doubt, 
because  we  see  it;  but  as  to  its  causing  a flow  of  pancreatic  juice,  is  it 
sufl&cient  to  say  there  can  be  no  doubt  it  does,  because  that  fluid  resem- 
bles saliva  ? 

At  p.  425,  it  is  said : “ In  delirium  tremens,  and  in  all  cases  of 
delirium  unattended  with  high  fever,  opium  may  be  said  to  be  our  sole 
reliance.”  Our  sole  reliance  ! Why,  gentlemen,  during  this  summer  ses- 
sion of  three  months  (1864),  you  have  seen  no  less  than  twenty  cases  of 
delirium  tremens  enter  my  wards — some  of  them  very  severe,  and  yet  they 
have  all  got  perfectly  well  without  the  use  of  opium  in  any  way.  Nay 
more,  I will  venture  to  say  that  this  favorable  result  is  in  great  part  attri- 
butable to  no  opium  having  been  administered.  (See  Delirium  Tremens.) 

At  p.  284  we  are  told  of  hemlock,  that  its  “ paralyzing  action  on 
the  nerves  of  motion  is  directly  the  reverse  of  the  stimulating  action  of 
strychnia;  it  is  thus  of  use  in  cases  of  convulsion  and  spasm.”  Now 
the  poisonous  effects  of  hemlock  are  very  peculiar,  paralyzing  motion 
from  the  feet  upwards,  as  was  shown  in  the  case  of  Socrates,  and  in 
another  well  observed  case  I have  myself  recorded  subsequently  in  this 
work,  whereas  strychnia  produces  no  such  progressive  effect  in  any  direc- 
tion. Neither  is  there  one  single  fact  in  the  annals  of  medicine  which 
proves  that  hemlock  is  of  the  slightest  use  in  such  convulsions  and  spasms 
as  strychnine  produces. 

I should  weary  you  by  further  quotations  from  a book,  which,  excellent 
as  it  is  in  many  respects,  is  replete  with  similar  statements.  Look  at  any 
other  work  on  the  same  subject,  and  you  will  find  the  like  kind  of  asser- 
tions equally  at  variance  with  the  present  state  of  our  knowledge.*  But 
if  objections,  such  as  we  have  ventured  to  offer,  can  be  made  to  carefully 
prepared  works  on  therapeutics,  by  gentlemen  who  have  made  that  sub- 
ject a careful  study,  what  confidence  can  be  placed  in  the  assertion  of 
practitioners  generally,  or  of  hopeful  young  men  entering  into  the  pro- 
fession. Only  read  the  accounts  of  distinguished  medical  men,  teachers, 
and  hospital  practitioners,  men  of  large  experience,  as  to  the  effects  of 
bloodletting  and  other  remedies,  and  then  compare  them  with  what  you 

* For  example — nothing  can  be  more  opposed  to  the  present  state  of  our  know- 
ledge and  to  the  numerous  facts  contained  in  this  work,  than  the  following  sentences 
which  meet  us  in  the  first  few  pages  of  a work  published  in  1860,  by  another  distin- 
guished author  on  Therapeutics,  Dr.  Stille : — “ It  is  not  pretended  that  any  human 
resources  can  secure  the  arrest  of  tubercle”  (p.  41).  “Depletion  everywhere  modi- 
fies, at  least,  the  forming  stage  of  inflammation ; mercury  everywhere  acts  upon  its 
products  ” (p.  48).  “ Depletion  is  held  to  be  the  capital  remedy  for  pneumonia,  and 

experience  has  for  centuries  appeared  to  agree  with  reason  in  sanctioning  this  prac- 
tice” (p.  49). 


CURATIVE  ACTION  OF  REMEDIES. 


335 


have  seen  with  your  own  eyes  of  the  successful  treatment  of  inflamma- 
tions m the  clinical  wards.  Andral  tells  us  that  “ the  experience  of  ages 
has  taught  us  to  be  more  prodigal  in  the  taking  of  blood  in  pneumonia, 
than  in  any  other  disease  ; that  there  is  no  period  of  the  disease,  no  con- 
dition of  the  pulse,  no  apparent  debility  of  system,  no  age,  which  forbids 
its  practice.”  Alison  no  less  emphatically  says  : “No  proposition  in 
medical  science  is  more  certain,  and  certainly  none  more  practically  im- 
portant than  that  which  regards  the  power  of  large  and  repeated  blood- 
letting to  arrest  the  progress  of  inflammation  in  its  early  stage.”  “ In 
pneumonia,  the  utmost  confidence  may  be  placed  in  general  bleeding, 
which  should  always  be  large  and  almost  always  repeated.”  Now,  the 
proposition  which  my  experience  has  demonstrated  in  the  clinical  wards 
of  the  Royal  Infirmary,  is  the  very  converse  to  this,  and  that  is,  that 
the  rate  of  mortality  in  inflammations,  and  especially  in  pneumonia  is 
large,  just  in  proportion  to  the  amount  of  bloodletting  and  of  other 
antiphlogistic  remedies  employed.  So  powerful  and  so  persistent,  how- 
ever, have  been  the  doctrines  of  the  past,  that  notwithstanding  the  facts, 
which  I made  public  in  1857  as  to  my  results  in  the  treatment  of 
pneumonia,  and  notwithstanding  the  fact  that  an  antiphlogistic  practice 
in  this  country  is  almost  universally  abandoned,  every  systematic  and 
compiled  work  on  medicine  up  to  this  date  (1861)  still  recommends  for 
that  disease  bloodletting,  to  be  followed  by  the  administration  of  anti- 
mony and  calomel. 

Looking  therefore  at  the  discrepancy  which  exists  between  systematic 
teachings  and  writings  on  the  one  hand,  and  the  actual  practice  in  our 
hospital  wards  and  in  private  on  the  other,  as  to  the  employment  of  the 
materia  medica  in  disease — regarding  also  the  differences  of  opinion 
which  exist  among  practitioners  of  the  highest  respectability  and  expe- 
rience, it  will  be  admitted  to  be  a difficult  task  to  determine  what  posi- 
tive knowledge  we  possess  of  the  value  of  drugs.  Still,  I think  the  time 
has  arrived  for  attempting  it,  and,  in  doing  so,  I have  only  to  assure 
you  that  my  views  on  this  subject  are  the  result  of  long  and  anxious 
consideration.  I shall  describe  what  is  known  first  of  their  curative, 
and,  secondly,  of  their  physiological  action. 

First,  then,  are  there  any  drugs  or  medical  preparations  whose  effects 
are  unquestionably  beneficial  in  particular  diseases  ? I think  there  are, 
as  witnessed  by  the  influence  of — 1,  Quinine  in  ague  ; 2,  Pitch  ointment 
in  psoriasis  ; 3,  Male  shield-fern  in  tape-worm  ; and  4,  Sulphur  ointment 
in  scabies. 

I think  no  one  who  has  used  these  remedies  in  the  diseases  named 
can  doubt  their  curative  power  as  a matter  of  fact,  however  they  may 
differ  as  to  the  mode  of  their  action.  Of  a similar  unquestionable  char- 
acter are  the  following,  although,  for  the  reasons  previously  stated,  the 
two  first  should  be  placed  among  the  dietetica,  and  the  third  among  the 
hygienica.  They  are — 5,  Cod-liver  oil  in  scrofulous  and  tubercular  dis- 
eases ; 6,  Lemon  juice  in  scurvy ; and  7,  Constant  moisture  in  eczema' 
tons  and  impetiginous  diseases  of  the  skin. 

These  seven  remedies  I put  into  the  first,  and  the  following  in  the 
second  class — 8,  Colchicum  in  acute  gout ; 9,  Iodide  of  potassium  in 
certain  forms  of  periostitis;  10,  Iron  in  chlorosis  and  amenorrhoea; 


336 


GENEKAL  THERAPEUTICS. 


11,  Arsenic  in  scaly  skin  diseases ; 12,  Copaiba  and  cubebs  in  gonorrhoea; 
13,  Nitro-inuriatic  acid  in  oxaluria;  14,  Supertartrate  of  potass  in  Bright’s 
disease,  with  diminished  urine  and  dropsy;  and  15,  Oils  and  fats  in  para’ 
sitic  diseases  of  the  skin. 

These  remedies,  though  not  so  valuable,  must,  I think,  be  admitted 
to  be  also  curative  in  certain  cases,  by  the  majority  of  practitioners. 
As  to  bloodletting  in  inflammation,  mercury  in  syphilis,  and  iodine  in 
scrofula,  I consider  their  \alue,  though  highly  lauded  by  some,  to  be 
more  than  questionable. 

The  fifteen  remedies  named,  therefore,  I consider  to  constitute  all 
the  positive  agents  we  possess  capable  of  curing  diseases  or  morbid  states 
when  they  are  once  fairly  established.  Many  other  drugs  relieve  symp- 
toms— are  palliative  and  most  useful  during  our  treatment  of  disorders 
— but,  I repeat,  as  curative^  I shall  only  be  too  happy  to  hear  of  any  I 
have  omitted. 

But  there  are  other  agents  which,  although  they  do  not  possess  direct 
curative  powers,  remove  pain  and  particular  symptoms,  and  enable  us, 
with  the  assistance  of  the  dietctica  and  hygienica,  indirectly  to  bring 
about  recovery.  Among  these  may  be  cited — Bismuth  and  alkalies  in 
heartburn;  Purgatives  in  constipation  ; Opium,  chalk,  and  astringents 
in  diarrhoea;  Etbers  in  asthmatic  dyspioea;  Naphtha  and  hydrocyanic 
acid  in  dyspeptic  vomiting;  Narcotics  in  local  pain;  Chloroform  in  sus- 
pending sensation  ; Belladonna  and  the  Calabar  Bean  in  certain  diseases 
of  the  eye;  Santonine  in  ascarides;  Counter-irritants,  in  various  kinds 
of  local  pain  ; and  small  Bloodlettings  in  aneurisms,  pulmonary  conges- 
tions, and  hypertrophied  heart.  To  these  may  be  added,  certain  essen- 
tial Oils,  and  Assafoetida,  in  flatulence — Sudorifics  and  Diuretics  to  meet 
peculiar  indications — Nitrate  oi  Silver  locally  in  ulcers,  etc.  etc. 

Such,  then,  are  the  chief  articles  of  the  materia  medical  am  acquainted 
with  that  can  be  shown  to  be  of  direct  therapeutical  value — discovered 
during  the  last  two  or  three  thousand  years  by  the  medical  practitioners 
of  civilized  nations.  To  some  this  result  may  appear  to  be  insignificant, 
but  by  those  who  are  capable  of  appreciating  the  difficulty  of  establish- 
ing the  therapeutical  value  of  medicines,  it  will  be  admitted  that  the  use 
of  these  remedies  has  proved  of  incalculable  benefit  to  mankind. 

In  the  second  place,  let  us  consider  what  is  known  of  the  action  of 
the  materia  medica  on  the  functions  of  the  various  tissues  and  organs 
of  the  body  in  a state  of  health. 

Action  of  Medicines  on  the  Ultimate  Elements  of  the  Tissues. 

Molecular  elements. — We  have  no  drugs,  properly  so  called,  capable 
of  influencing  the  activity  of  the  molecular  element  of  the  body,  unless 
we  include  cod-liver  oil,  which  increases  the  molecular  constituents  of 
the  chyle,  but  which,  for  reasons  previously  stated,  we  class  among  the 
dietetica.  In  one  sense  it  is  true  it  may  with  reason  be  maintained  that 
all  medicines  operate  on  this  element  of  structure.  This,  as  a theory 
of  the  ultimate  action  of  drugs,  will  be  referred  to  subsequently. 

The  cell  elements. — Beyond  what  we  are  acquainted  with,  concern- 
ing the  albuminous,  fatty,  and  mineral  elements,  which  enter  into  the 


PHYSIOLOGICAL  ACTION  OF  REMEDIES. 


337 


structure  of  cells,  we  are  ignorant  of  any  medicinal  substances  known  to 
affect  them  especially. 

The  tubular  elements. — The  nerve  tubes  are  differently  affected  by 
numerous  substances,  which  we  shall  refer  to  under  the  head  of  nervous 
system — and  the  minute  blood  tubes  are  especially  dilated  by  a new  sub- 
stance— the  nitrate  of  amyle — which  Dr.  Richardson  has  shown  experi- 
mentally to  have  this  property. 

Fibrous  elements. — We  have  no  knowledge  of  any  especial  agents 
which  act  upon  the  molecular,  areolar,  or  elastic  fibrous  tissues.  The 
muscular  and  probably  other  contractile  fibres,  generally  are  supposed 
capable  of  being  influenced  by  a class  of  remedies  called  tonics.  But 
when  we  investigate  closely  into  what  this  tonic  property  consists,  we 
find  it  to  be  anything  which  removes  debility.  Hence  it  has  been  ascribed 
to  stimulants,  nutrients,  vegetable  bitters,  and  mineral  salts,  and  great 
discussion  has  arisen  whether  these  operate  through  the  nervous  system 
or  through  the  circulation — whether  they  stimulate  appetite  or  impart 
directly  restorative  qualities  to  the  blood — the  truth  is  we  know  little  or 
nothing  on  these  topics  of  a positive  character,  and  may  rest  assured  that 
nutritive  food  and  proper  exercise  are  the  real  agents  through  which 
strength  is  imparted  to  the  muscular  system. 

Cartilaginous  and  osseous  tissues. — These  textures  have  the  peculiar 
property  of  separating  from  the  blood  and  fixing  large  quantities  of 
mineral  matter,  which,  of  course,  must  enter  the  body  in  the  tood  and 
drink.  Of  any  method  of  increasing  or  modifying  this  peculiar  pro- 
perty we  are  profoundly  ignorant. 

Therapeutists  generally  in  their  writings,  although  certainly  not  de- 
ficient in  all  sorts  of  theories  as  to  the  actions  of  medicines,  have  cultivated 
very  little  a knowledge  of  the  ultimate  composition  or  structure  of  those 
tissues  or  organs  on  which  their  remedies  operate.  This  is  one  of  the 
reasons  why  their  views  give  such  little  satisfaction  to  the  modern  scientific 
inquirer. 

Action  of  Medicines  on  the  Nervous  System. 

Many  articles  of  the  materia  medica  produce  decided  effects  upon  dif- 
ferent parts  of  the  nervous  system,  stimulating  or  perverting  some,  and 
destroying  or  suspending  others.  From  the  circumstance  also  that  these 
effects  have,  to  a great  extent,  been  largely  studied  by  physiologists,  as 
the  result  of  experimental  investigation,  our  knowledge  with  regard  to 
them  is  much  more  precise  than  it  is  with  respect  to  many  other  drugs. 
They  have  been  classified  according  to  their  stimulating,  narcotic,  or  seda- 
tive properties,  understanding  by  stimulant,  what  excites  nervous  func- 
tions, by  narcotic.,  what  first  increases,  then  depresses  it,  and  by  sedative., 
what  depresses  it.  I shall  refer  to  them,  however,  according  as  their 
action  principally  affects  the  brain,  spinal  cord,  or  nerves. 

Cerebral  f unctions. — These  are  influenced  by  opium  and  most  of  the 
pure  narcotics,  which  first  excite  and  then  depress  or  destroy  the  mental 
faculties.  According  to  Flourens,  opium  acts  on  the  cerebral  lobes, 
while  belladonna  operates  on  the  corpora  quadrigemina.  The  first  causes 
contraction,  and  the  last  dilatation  of  the  pupils.  Tea  and  coffee  are 
pure  exciters  of  the  cerebral  functions,  and  cause  sleeplessness.  Alco- 
22 


J38 


GENERAL  THERAPEUTICS. 


holic  drinks^  ether^  chloroform^  and  similar  stimulants,  first  excite  and 
then  suspend  the  mental  faculties,  like  opium.  The  modern  practice 
of  depriving  persons  of  consciousness,  in  order,  for  a time,  to  destroy 
sensation,  has  been  very  much  misunderstood,  in  consequence  of  such 
remedies  having  been  erroneously  and  unscientifically  denominated  an- 
aesthetics. The  fact  is,  they  influence  local  sensibility,  or  the  sense  of 
touch  very  slightly  if  at  all.  Their  action  is  cerebral,  and  in  large  doses 
spinal.  Hence  the  danger  which  occasionally  attends  their  action. 

Spinal  functions. — Strxjchnine  acts  especially  as  an  exciter  of  the 
motor  filaments  of  the  spinal  cord,  causing  tonic  muscular  contractions, 
as  in  tetanus  from  spinal  arachnitis,  or  from  the  irritation  of  a wound. 
Worari  produces  exactly  an  opposite  effect,  causing  paralysis  and  reso- 
lution of  the  same  parts.  Conium  paralyses  the  motor  and  sensitive 
spinal  nerves,  produciug  paraplegia,  commencing  at  the  feet  and  creeping 
’Upwards.  (See  case  of  Duncan  Gow,  p.  460.)  Picrotoxine^  according  to 
Dr.  Mortimer  Glover,  causes  the  animal  to  stagger  backwards,  as  in  the 
experiments  of  Magendie  on  the  Crura  Cerebelli.  Tobacco  is  a powerful 
sedative  and  depresses  all  the  spinal  functions. 

Cerehro- Spinal  functions. — Ilxjdrocxjanic  acid  in  poisonous  doses,  acts 
^conjointly  on  the  cerebrum  and  spinal  cord.  All  the  animals  1 have 
seen  killed  by  this  agent  utter  a scream,  lose  their  consciousness,  and  are 
convulsed.  These  are  the  symptoms  of  epilepsy.  Cold  is  at  first  an 
exciter  of  the  spinal  functions,  and  is  a strong  stimulant  to  diastaltic 
activity,  but,  if  long  continued,  produces  drowsiness  and  stupor. 

Neuro  and  Neuro-Spinal  functions. — These  are  especially  affected  by 
the  action  of  certain  metallic  poisons,  such  as  mercury.,  which  occasions 
irregular  muscular  action  with  weakness,  and  lead,  which  causes  numb- 
ness and  palsy,  most  common  in  the  hands.  On  the  other  hand,  caxi- 
tharides  stimulates  the  contractions  of  the  neck  of  the  urinary  bladder, 
and  secale  cornutum  those  of  the  pregnant  uterus.  Stramonium  acts  as 
a sedative  to  the  nerves  of  the  bronchi.  Aconite  operates  powerfully  in 
paralysing  the  action  of  the  heart,  through  the  cardiac  nerves  of  the 
vagus,  while  antimony  excites  vomiting  by  acting  on  the  gastric  and 
other  branches  of  the  same  nerve.  Belladonna  also  has  a peculiar  local 
influence  in  causing  dilatation  of  the  pupil,  while  the  Calalar  lean  has  the 
opposite  effect,  producing  its  contraction.  The  secretion  of  the  lachrymal 
gland  is  increased  by  the  pungent  emanations  from  onioxi,  garlic,  squill, 
and  mustard. 

Organic  Nerve  Functions. — It  is  now  some  years  since  I put  forth 
the  idea  that  qxiinine,  salieine,  and  the  allied  compounds,  have  a special 
influence  over  the  sympathetic  or  ganglionic  system  of  nerves,  controlling 
and  exciting  their  power,  and  thus  influencing  those  periodical  functions 
connected  with  nutrition,  secretion,  and  growth.  The  experiments  of 
Bernard,  Brown-Sequard,  and  others,  have  now  proved  that  these  are  in- 
timately connected  with  this  part  of  the  nervous  system — irritation  of 
these  nerves  causing  cold  and  pallor,  while  section  or  destruction  of  them 
induces  increased  heat  and  redness,  Pereira  supposed  that  stimulants 
and  sedatives  especially  acted  upon  this  system  of  nerves,  but,  unques- 
tionably, they  also  act  on  the  brain. 

Jt  must  be  further  observed  that,  although  the  primary  action  of 


PHYSIOLOGICAL  ACTION  OF  REMEDIES. 


339 


these  narcotic  medicines  is  such  as  I have  stated,  that  in  large  doses 
their  influence  is  more  extended,  and  their  operation  is  more  diffused 
over  the  nervous  system.  Thus,  chloroform  may  not  only  act  on  the 
brain,  but  on  the  spinal  cord.  It  is  very  probable  also  that  most  of  the 
medicines  which  have  an  unequivocal  action  on  special  organs,  do  so  by 
operating  on  the  nerves  distributed  to  them,  through  the  medium  of  the 
blood. 

Action  of  Medicines  on  the  Respiratory  System. 

Diffusible  stimulants,  more  especially  the  ethers,  have  an  unques- 
tionable effect  in  checking  or  relieving  dyspnoea, which  is  probably  owing 
to  their  action  on  the  heart  and  circulation  generally,  rather  than  on  the 
lungs  specially.  Whether  there  is  such  a medicine  as  a true  expectorant, 
that  is,  one  capable  of  increasing  the  secretion  from  the  bronchial 
mucous  membrane,  is,  in  my  opinion,  quite  uncertain.  Even  Headland 
admits,  that,  on  this  point,  no  investigation  has  been  made  (p.  325). 
That  antimony,  ipecacuanha,  squill,  and  other  drugs  possess  this  property, 
however,  has  been  so  generally  assumed,  that  they  are  constantly  em- 
ployed in  all  cases  of  cough,  with  or  without  expectoration,  and 
lengthened  discussions  have  occurred  as  to  whether  such  remedies  act 
on  the  glands  of  the  mucous  membrane,  or  upon  the  muscular  fibres  of 
the  bronchial  tube.  In  the  meantime,  the  uncertainty  of  their  action  is 
admitted,  and  there  are  no  series  of  observations  extant,  so  far  as  I am 
aware,  which  prove  that  they  act  at  all.  The  lungs  have  been  made  the 
vehicle  for  the  introduction  of  medicines  in  a state  of  vapor  from  ancient 
times,  and  the  discovery  of  the  effects  of  ether  in  producing  insensibility 
to  pain  has  only  served  to  extend  the  practice. 

Action  of  Medicines  on  the  Circulatory  System. 

Numerous  remedies  have  been  employed  for  the  express  purpose  of 
diminishing  and  increasing  the  rapidity  of  the  circulation  and  the  force 
of  the  pulse,  as  well  as  the  quantity  and  quality  of  the  blood.  This  can 
be  done  directly  by  bloodletting  and  starvation  on  the  one  hand,  and  by 
stimulants  and  generous  diet  on  the  other.  Certain  drugs  are  supposed 
to  have  an  especial  action  on  the  nerves  of  the  heart,  more  especially 
aconite  and  digitalis.  Veratrum  viride  has  recently  been  extolled  as 
being  capable  of  diminishing  the  force  of  the  pulse,  which  I have  myself 
seen  it  do,  by  acting  as  a depressing  acrid  poison  to  the  system  generally. 
Other  remedies  are  imagined  to  act  on  the  capillary  circulation  when 
ruptured,  and  to  be  capable  of  arresting  haemorrhage  from  them  ; among 
these  are  acetate  of  lead  and  gallic  acid-  But  how  these  drugs,  intro- 
duced into  the  stomach,  should  produce  this  effect,  has  never  been 
shown,  and  there  are  no  series  of  observations  which  establish  their 
alleged  influence,  although,  as  in  the  case  of  expectorants,  the  assump- 
tion is  generally  acted  upon. 

The  Blood. — All  soluble  remedies  introduced  into  the  economy  are 
absorbed  into  the  blood.  They  may  act  on  the  nerves  or  distinct  parts 
through  it,  but  there  are  some  which  act  upon  the  blood  itself,  adding  to 
or  detracting  from  its  constituents.  The  former  are  restoratives^  the 


340 


GENERAL  THERAPEUTICS.' 


latter  are  named  by  Headland  catalytics.  Among  the  former  we  must 
never  forget  that  aliment  holds  the  first  place,  and  that  it  is  by  restoring 
what  is  deficient,  or  detracting  from  what  is  in  excess  in  the  diet,  that 
many  medicines  operate ; as  when  cod-liver  oil  is  given  in  scrofula,  or 
lemon-juice  in  scurvy.  To  exactly  the  same  principle  I would  refer  the 
operations  of  alkalies  and  acids,  which,  by  forming  new  combinations  in 
the  blood,  serve  to  restore  or  correct  morbid  conditions  of  that  fluid. 
The  same  may  be  said  of  salines  and  of  chalybeates.  It  should  be  ob- 
served, however,  that  several  of  these  remedies  can  only  be  considered 
restorative,  on  being  added  to  the  blood  in  proportion  somewhat  similar 
to  what  exists  in  health ; but  that,  if  introduced  in  excess,  so  far  from 
being  beneficial,  they  are  absolutely  destructive.  In  cholera,  for  instance, 
it  was  shown  by  Dr.  Stevens  that  the  saline  constituents  of  the  blood 
were  greatly  diminished.  They  were,  in  consequence,  dissolved  in  water, 
and  large  quantities  of  the  solution  injected  into  the  veins.  The  efi'ect 
appeared,  at  first,  to  be  miraculous : persons  on  the  point  of  death 
recovering  in  a wonderful  manner.  But  as  excess  of  water  and  saline 
matter  dissolves  the  blood  corpuscles,  all  these  persons,  after  a few 
hours,  again  sank  and  died.  In  their  attempts  to  introduce  chemical 
remedies  and  form  chemical  combinations,  therapeutists  have  too  often 
overlooked  the  fact,  that  in  order  to  act  as  restoratives,  drugs  must 
facilitate  the  addition  of  structural  elements  to  the  economy.  Hitherto, 
however,  very  few  of  the  writers  on  this  subject  have  been  histologists. 

Mercury  has  been  supposed  capable  of  dissolving  the  fibrin  of  the 
blood,  and  thereby  of  favoring  absorption  of  coagulable  lymph.  For 
the  same  reason  it  has  been  considered  antiphlogistic.  These  views  are 
connected  with  the  exploded  theory  of  inflammation  commencing  in  in- 
creased fibrinosis,  and  have  been  shown,  by  modern  experience,  to  be 
altogether  erroneous. 

The  assumption  that  many  diseases  originate  in  the  blood,  has  led  to 
the  employment  of  a variety  of  medicines  called  specifics,  which,  in  the 
opinion  of  some  neutralize  in  that  fluid  the  particular  agency  producing 
the  disease.  There  is  no  theory  which  the  modern  inquirer  should  dis- 
trust so  much  as  this,  or  with  regard  to  which  he  should  demand  more 
rigorous  proof.  The  tendency  of  modern  physiology  and  of  modern  ex- 
perience is  to  show  the  fallacy  of  the  reasoning  on  which  this  doctrine 
has  been  supported.  For  example,  iodine  has  been  supposed  to  be  spe- 
cific in  scrofula,  mercury  in  syphilis,  antimony  in  inflammations,  colchi- 
cum  in  gout,  etc.  etc.  We  now  know  that  scrofula  is  to  be  removed 
best,  not  by  giving  a poison  which  acts  as  a specific  or  alterative,  but  by 
improving  nutrition.  We  shall  subsequently  see  that  syphilis  has  been 
cured,  in  recent  times,  just  in  proportion  as  we  have  ceased  to  give  mer- 
cury. Antimony,  in  contra-stimulant  doses,  is  a fatal  practice  in  acute 
inflammations.  And  if  colchicum  be  useful  in  gout,  it  is  not  by  acting 
as  a catalytic  or  blood-destroyer.  If  by  specific,  again,  be  meant  remedies 
operating  in  an  unknown  manner,  it  is  only  reasonable  to  believe  that,  as 
knowledge  advances,  and  we  obtain  glimpses  of  how  medicines  operate 
physiologically,  the  idea  of  specifics  should  be  banished  from  therapeutics. 

The  Blood  Glands. — We  are  unacquainted  with  any  medicine  which 
has  an  especial  operation  upon  the  lymphatic  system  of  glands,  more  espe- 


PHYSIOLOGICAL  ACTION  OF  REMEDIES. 


341 


cially  as  sanguiferous  organs.  Generous  food,  and  cod-liver  oil,  increase 
the  amount  of  chyle.  Iodine  is  said  to  diminish  the  size  of  the  thyroid, 
when  hypertrophied  in  bronchocele;  and,  according  to  Piorry,  quinine, 
in  large  doses,  almost  immediately  decreases  the  enlarged  spleen  in  in- 
termittent fever.  Further  observations,  however,  are  required  to  estab- 
lish either  supposition. 

Action  of  Medicines  on  (he  Digestive  System. 

In  consequence  of  medicines  being  directly  introduced  into  the 
digestive  tube,  we  have  to  distinguish  two  kinds  of  operations,  viz.,  such 
as  act  locally,  and  such  as  act  secondarily  on  other  parts  of  the  body, 
through  the  medium  of  the  blood. 

Salivary  Glands. — These  glands  are  always  called  into  action  during 
mastication,  and  may  be  excited  by  the  aid  of  sialagogues.  Here  the  in- 
fluence of  mercury  is  unquestionable,  profuse  salivation  being  the  leading 
symptom  of  its  peculiar  action  on  the  economy.  Chewing  tobacco,  pyre- 
thrum,  betel,  and  some  other  irritating  substances  in  the  mouth,  produce 
the  same  effect  locally. 

The  Pharynx  and  (Esophagus  are  said  to  be  rendered  dry,  and  to  be 
spasmodically  contracted  by  belladonna. 

Stomach. — The  reflex  action  of  vomiting  may  be  excited  in  various 
ways — 1st,  By  giddiness  and  vertigo  arising  from  the  motion  of  a ship 
at  sea,  or  of  a swing.  2d,  By  a variety  of  cerebral  diseases.  3d,  By 
the  mental  feeling  of  disgust  or  of  irritation.  4th,  By  certain  peculiar 
irritations,  as  that  of  a gall-stone.  5th,  From  pregnancy.  6th,  By  the 
introduction  of  certain  medicines  called  emetics,  some  of  which  act  in 
this  way  whether  taken  into  the  stomach  or  whether  injected  into  the 
blood,  such  as  antimony.  In  all  these  cases,  therefore,  the  action  is 
owing  to  nervous  irritation,  and  when  produced  by  drugs,  these  apparently 
act  through  the  blood  on  the  vagi  nerves.  Other  emetics,  such  as  sulphate 
of  zinc  or  oxide  of  arsenic,  act  through  their  topical  irritant  properties. 
The  secretion  of  gastric  juice  may  be  increased  by  stimulants,  and  if  in 
excess  be  neutralised  by  antacids,  such  as  bismuth,  magnesia,  and  alkalies. 
It  is  thought  also  that  its  digestible  properties,  which  partly  depend 
upon  its  acidity,  may  be  increased  by  small  doses  of  hydrochloric  acid. 
(See  General  Pathology  and  Treatment  of  Dyspepsia.) 

Liver. — x\lthough  mercury,  taraxacum,  and  some  other  remedies,  are 
generally  supposed  to  have  the  property  of  increasing  the  secretion  of 
this  organ,  it  still  remains  to  be  proved  whether  this  is  the  case  or  not. 
Indeed,  I am  acquainted  with  no  series  of  observations  which  demon- 
strate that  an  increased  flow  of  bile  has  been  unequivocally  produced  by 
any  known  remedy. 

Pancreas. — We  know  of  no  remedy  which  influences  the  functions  of 
this  organ. 

Intestinal  Glands. — All  local  irritations  excite  these  glands  to  an 
increased  action,  and  numerous  purgatives,  especially  the  more  drastic 
ones,  are  supposed  also  to  induce  increased  excretion  from  them.  Others, 
such  as  elaterium,  are  imagined  even  to  cause  separation  of  serum  largely 
from  the  blood-vessels.  We  now  know  that  immediately  below  the 
intestinal  mucous  membrane,  there  is  a rich  layer  of  organic  nerves, 


342 


GENERAL  THERAPEUTICS. 


which  not  only  supply  the  glands,  hut  the  blood-vessels  and  muscular 
layers  also,  and  so  regulate  secretion,  excretion,  and  peristaltic  motion. 
There  is  no  difficulty,  therefore,  in  supposing  theoretically  that  the 
special  action  of  many  purgatives  is  through  the  blood  on  this  portion 
of  the  nervous  system,  although  we  have  still  no  proof  of  it  derived  from 
experiment. 

Intestinal  Tube. — Numerous  remedies  excite  the  peristaltic  action  of 
the  digestive  canal.  They  are  called  purgatives,  and  are  derived  from 
the  animal,  vegetable,  and  mineral  kingdoms.  There  can  be  no  doubt 
that  saliva,  bile,  the  pancreatic  juice,  and  other  fluids  secreted  in  the 
alimentary  canal,  are  natural  stimulants  to  its  proper  action ; and  when 
any  one  of  them  is  deficient,  constipation  is  the  common  result.  Excess 
of  bile,  purges,  mechanical  irritants,  also  excite  intestinal  action,  as  the 
undigested  husks  of  vegetables,  small  seeds,  powdered  tin,  and  so  on. 
Purgative  drugs  may  act  either  locally  or  constitutionally,  sometimes  in 
both  ways.  The  more  acrid,  such  as  gamboge,  may  act  principally  in 
the  one  way ; and  the  more  bland,  such  as  neutral  salts,  more  par- 
ticularly in  the  other.  It  has  been  shown,  however,  that  the  true  pur- 
gatives, like  the  emetics,  when  introduced  into  the  circulation  directly 
through  a vein,  produce  their  peculiar  local  action.  It  has  been  sup- 
posed that  some  of  them,  such  as  rhubarb,  act  more  especially  upon  the 
upper  part  of  the  canal ; and  others,  such  as  aloes,  operate  more  par- 
ticularly on  the  lower  portion  of  it.  Seeing  that  we  have  unquestionably 
drugs  that  operate  on  the  stomach,  and  others  on  the  bowels,  it  may 
easily  be  conceived  that  among  the  numerous  purgatives  which  exist, 
several  of  them  may  act  on  distinct  parts  of  so  lengthy  a tube.  But 
this  has  by  no  means  been  clearly  proved. 

Another  class  of  remedies,  known  as  astringents,  have  the  opposite 
efibct  to  purgatives — some  diminishing  mechanical  irritation,  and  others 
having  a direct  constringing  effect  on  the  muscles  and  blood-vessels. 
Among  the  former  are  demulcents,  antacids,  and  opiates.  Among  the 
latter,  catechu,  kino,  gallic  acid,  and  others  from  the  vegetable ; and 
sulphuric  acid,  alum,  nitrate  of  silver,  iron,  and  others  from  the  mineral 
kingdom.  Introduced  into  the  alimentary  canal,  whether  ’by  the 
stomach  or  rectum,  their  action  is  local.  That  they  ever  operate  on 
distant  parts  through  the  blood  is  doubtful.  One  of  the  most  valuable 
astringents  for  the  stomach  is  ice,  and  for  the  lower  part  of  the  bowel 
cold  water,  used  as  an  injeetion. 

Medicines  used  to  expel  worms  from  the  alimentary  canal  are  called 
anthelmintics,  and  the  influence  of  some  of  these  is  unquestionable.  Some 
act  mechanically,  as  powdered  tin,  and  others  by  their  purgative 
qualities ; while  a third  class  appear  to  exercise  a poisonous  influence 
over  the  parasite.  Of  these  last,  the  most  powerful  is  the  essential  oil 
of  the  male  shield-fern,  which  kills  the  taenia  solium. 

Action  of  Medicines  on  the  Genito-  Urinary  System. 

We  have  no  proof  of  any  direct  aphrodisiac  properties  existing,  in 
drugs.  The  same  may  be  said  with  regard  to  emmenagogues,  or  medicines 
supposed  capable  of  increasing  the  catamenial  discharge.  In  cases  of 


PHYSIOLOGICAL  ACTION  OF  REMEDIES. 


343 


amenorrboea,  clialybeates  and  other  tonic  remedies  are  usually  prescribed, 
but  too  frequently  with  indifferent  success.  Ergot  of  rye  stimulates  tbe 
contractions  of  tbe  uterus  during  labor.  Tbe  secretion  of  tbe  mammary 
gland  is  said  to  be  affected  by  drugs  administered  to  tbe  mother, 
especially  by  acrid  vegetable  purgatives,  and  by  bitters,  such  as  worm- 
wood, and  that  in  this  way  they  operate  on  tbe  infant.  Tbe  existence 
of  any  true  lactagogue  lias  yet  to  be  proved. 

Medicines  which  increase  tbe  flow  of  urine  are  called  Diuretics.  Of 
these,  tbe  most  powerful  are  certain  alcoholic  preparations,  such  as  nitric 
ether  and  gin,  a few  vegetable  substances,  such  as  digitalis  and  squill, 
and  some  salts,  such  as  tbe  supertartrate  and  the  acetate  of  potash. 
The  effect  of  these  remedies  is  unequivocal,  and  their  curative  influence, 
in  certain  cases  of  Bright’s  disease,  has  frequently  been  demonstrated  by 
me  in  tbe  clinical  wards  (see  Bright’s  disease,  case  of  Herdman).  We 
know  of  no  drug  capable  of  checking  the  urinary  secretion.  It  has  been 
said  that  colcliicum  has  a special  action  in  eliminating  urea  from  the 
kidney  (Maclagan),  although  this  has  been  disputed  (Grarrod).  Can- 
tharides  appears  to  influence  more  especially  the  urinary  bladder,  causing 
contractions  in  its  neck  and  strangury.  Camphor  is  said  especially  to 
allay  vesical  irritation,  although  I have  never  seen  it  produce  that  effect. 
Certain  balsams,  especially  that  of  copaiba,  and  the  essential  oil  of  cubebs, 
have  an  unquestionable  influence  in  diminishing  purulent  discharges  from 
the  urethra,  an  effect  probably  owing  to  their  local  action,  as  they  pass 
over  the  mucous  membrane,  dissolved  in  the  urine. 

Action  of  Medicines  on  the  Integumentary  System. 

Remedies  that  increase  the  watery  secretion  from  the  sudoriferous 
glands  are  called  Diaphoretics.  This  effect  is  also  occasioned  by  exer- 
cise, warmth,  and  especially  heated  air — indeed  anything  that  increases 
the  circulation  of  blood  in  the  skin.  It  is  also  a symptom  of  exhaustion, 
however  occasioned,  and  is  therefore  present  in  all  diseases  which 
rapidly  depress  the  system,  as  acute  inflammations,  fevers,  phthisis,  etc. 
The  stronger  a man  the  less  easily  he  sweats  on  exertion.  All  nauseat- 
ing and  depressing  remedies  are  diaphoretic,  such  as  antimony,  ipecacu- 
anha, as  well  as  narcotics,  which  after  excitement  produce  a sedative  in- 
fluence. We  are  ignorant  of  any  medicines  which  increase  the  sebaceous 
secretion  from  the  skin. 

The  skin  may  be  made  the  vehicle  for  introducing  medicines  into  the 
blood — 1st,  By  friction,  as  in  rubbing  with  mercurial  ointment,  when 
salivation  is  occasioned ; 2d,  by  inoculation,  as  in  tbe  artificial  produc- 
tion of  cow  or  small  pox;  3d,  by  abrasion,  as  when  powdered  opium  or 
strychnine  is  sprinkled  over  a blistered  surface ; and  4th,  by  injection, 
as  when  morphia  in  solution  is  injected  into  the  subcutaneous  cellular 
tissue  with  a syringe  and  a finely  pointed  steel  canula ; 5th,  by  vapor. 
Artificial  irritations  of  the  skin,  to  produce  internal  or  distant  effects, 
are  caused  by  what  are  denominated  counter-irritants^  including  stimu- 
lants, frictions,  hot  applications  to  parts,  sinapisms,  blisters,  moxas, 
cauteries,  etc.  etc.  These  all  operate  through  the  nerves  by  reflex  action  : 
some,  like  warm  fomentations,  soothe  irritation ; others,  as  blisters,  create*' 


344 


GENERVL  THERAPEUTICS. 


it  locally,  but  remove  it  from  where  it  was  primarily  seated.  How  this 
is  accomplished  constitutes  one  of  the  most  vexed  questions  in  thera- 
peutics. 

Where  there  is  breach  of  surface  in  the  skin,  eruptions  or  ulcers, 
various  applications  are  made  to  it,  constituting  special  treatments  in 
medical  and  surgical  practice. 

In  the  short  general  account  now  given  of  the  physiological  action  of 
medicines,  my  object  has  been  not  to  make  an  enumeration  of  drugs,  but 
to  point  out  what  influences  can  and  cannot  be  exerted  by  them  over  the 
functions  of  the  animal  economy,  according  to  the  present  state  of  our 
knowledge.  Systematic  writers  on  therapeutics  are  fond  of  grouping 
remedies  together  according  to  their  presumed  qualities,  eithe.r  as  modi- 
fying function  in  health,  or  restoring  health  during  disease,  constituting 
what  have  been  called  the  physiological  and  therapeutical  arrangements 
of  drugs.  Great  confusion  has  resulted  from  both  systems,  because,  as 
we  have  seen  from  the  previous  inquiry,  our  positive  knowledge  of  either 
is  very  limited.  It  follows  that  they  deal  largely  in  assumption  and 
loose  analogies.  One  drug  is  often  made  to  play  many  parts,  and  often 
possesses  the  most  contradictory  qualities.  WKat  we  require  is  exact 
knowledge  with  regard  to  them,  and  this  can  only  be  arrived  at  by  de- 
termining in  the  first  place  their  simplest  uses.  Even  here,  as  we  have 
seen,  there  is  yet  much  to  learn.  Let  us  next  inquire  the  mode  in  which 
they  act  on  the  animal  economy. 

General  Theory  of  the  Action  of  Remedies. 

Drugs  may  act  topically  on  the  parts  to  which  they  are  applied ; on 
distant  parts  by  reflex  action  through  the  nerves,  and  by  selective 
affinity  between  the  tissues  and  the  blood. 

Great  discussion  has  taken  place  as  to  whether  certain  medicines 
operate  directly  on  the  nerves  or  through  the  blood.  The  fact  that  the 
entire  circulation  is  accomplished  in  about  half  a minute  (Hering, 
Blake)  is  quite  sufficient  to  account  for  the  rapidity  of  the  most  active 
drugs,  even  of  poisonous  doses  of  hydrocyanic  acid ; whilst  it  has  been 
proved  that  medicines  which  act  strongly  on  the  nerves,  when  they  are 
taken  into  the  stomach,  such  as  worari,  have  no  efi'ect  when  applied  to 
the  nerves  themselves  (Kolliker).  Indeed,  it  has  been  shewn  that  some 
remedies  when  applied  directly  act  on  muscles,  others  on  nerves,  and  a 
third  class  on  both  (Kiihne),  In  the  living  body,  however,  activity  of  the 
circulation  is  necessary  for  the  operation  of  remedies,  and  we  observe  that 
whenever  it  is  too  languid  from  exhaustion  they  fail  to  operate.  It  is  fur- 
ther to  be  observed  that  by  whatever  channel  a drug  with  characteristic 
properties  is  introduced  into  the  system — whether  by  the  stomach  or  the 
rectum,  by  the  skin  or  the  lungs — the  effect  is  exactly  the  same  as  if  it 
was  introduced  into  the  blood  itself.  It  follows  that  the  active  pro- 
perties of  drugs  are  first  absorbed  into  the  blood  (Magendie),  and  then 
act  upon  difi'erent  tissues,  exerting  or  diminishing  their  functions,  in 
consequence  of  a property  of  attraction  and  selection  exerted  by  the 
molecules  of  the  tissues  themselves.  In  this  respect  drugs  act  in  the 


GENERAL  THEORY  OF  THE  ACTION  OF  REMEDIES 


345 


same  way  that  articles  of  diet  do.  In  virtue  of  vital  powers,  whereby  one 
tissue  attracts  and  selects  from  the  blood  fat,  another  albumen,  and  a third 
mineral  matter — or  one  gland  attracts  the  materials  out  of  which  it 
forms  bile,  while  another  attracts  the  substance  which  it  forms  into  urea — 
so  does  this  tissue  attract  and  select  from  the  blood  the  peculiar  property 
of  one  drug,  and  another  tissue  that  of  a different  one.  This  is  the  only 
explanation  that  can  be  offered  of  why  ipecacuanha  acts  as  an  emetic 
and  aloes  as  a purgative;  why  opium  acts  on  the  brain,  causing  sleep ; and 
strychnine  on  the  spinal  cord,  causing  spasm  ; why  mercury  stimulates 
the  salivary,  and  supertartrate  of  potash  the  renal  glands.  This  theory 
accounts  also  for  the  degrees  and  varieties  of  disordered  function  pro- 
duced by  different  drugs  of  the  same  class.  The  existence  of  such 
properties  in  drugs,  or,  more  strictly  speaking,  in  the  living  tissues  to 
which  through  the  blood  parts  of  these  drugs  are  carried  in  solution, 
are  ultimate  facts  in  the  science  of  therapeutics.  At  the  same  time  it 
may  be  understood  that  in  a few  cases  impressions  made  upon  the 
extremities  of  sensitive  nerves  act  according  to  the  laws  of  reflex  action, 
as  when  counter-irritants  relieve  internal  pain,  or  when  sternutatories 
induce  sneezing.  The  study  of  these  various  facts  must  ever  furnish  the 
proof  that  all  exact  explanation  and  knowledge  of  the  action  of  drugs 
must  spring  from  physiological  investigation. 

It  has  been  very  generally  supposed  that  if  one  drug  exalts  action 
and  another  depresses  it,  the  eflects  produced  by  the  first  may  be 
counteracted  by  the  second.  But  this  does  not  always  follow.  For 
example,  strychnine  evidently  excites  the  motor  nerves  to  action,  and 
worari  as  certainly  paralyses  them.  As  medicines,  however,  the  one  has 
no  counteracting  effect  to  the  influence  of  the  other.  Poison  an  animal 
first  with  strychnine  and  then  with  worari ; so  far  from  health  resulting, 
the  death  of  the  animal  is  rendered  doubly  certain.  Experiment  and 
experience  are  here  both  opposed  to  a theory  which  lies  at  the  basis  of 
much  of  our  practice.  I have  given  strychnine  in  numerous  cases,  and 
in  all  forms  of  paraplegia,  and  have  yet  to  find  a single  instance  in  which 
any  benefit  resulted  from  its  administration.  Again,  in  delirium  tremens 
there  is  great  wakefulness;  it  might  be  supposed  that  giving  opium, 
which  causes  somnolence,  would  cure  the  former  symptom ; yet  I have 
frequently  satisfied  myself  that  so  far  from  doing  so  it  exasperates  and 
prolongs  the  malady.  Exactly  on  the  same  principle  strong  coffee  and 
tea  have  been  given  to  cause  wakefulness  in  cases  of  poisoning  by  opium, 
but  in  no  one  instance  have  they  been  shown  ever  to  produce  the  desired 
effect.  The  reason  of  all  this  appears  to  be  very  obvious.  Each  drug 
has  an  af&nity  for  certain  parts  of  the  nervous  texture.  The  ultimate 
tubes  or  especial  centres  acted  upon  by  strychnine,  are  not  those  which 
are  influenced  by  worari.  Neither  is  the  nervous  matter  affected  by 
alcohol  or  opium  that  which  is  impressed  by  coffee  or  tea. 

Another  very  general  idea  prevails,  viz.,  that  a medicine  decidedly 
curative,  such  as  quinine  in  intermittent  fever,  is  also  prophylactic,  and 
will  keep  off  the  disease.  It  is  difficult  to  understand  how  this  can  be 
true  in  theory  ; and  in  practice,  though  largely  acted  on,  we  are  as  yet 
destitute  of  any  demonstrative  facts  in  its  support. 

It  is  now  recognised  that  medicines  derived  from  the  organic  world 


346 


GENERAL  THERAPEUTICS. 


owe  tlieir  peculiar  action  to  certain  principles  whicli  they  contain,  and 
which  the  chemist  can  abstract  from  them.  Thus  from  Peruvian  bark  is 
extracted  quinine;  from  opium,  morphia  ; from  nux  vomica,  strychnine  ; 
from  belladonna,  atropine,  and  so  on ; and  experiment  has  demonstrated 
that  the  peculiar  properties  of  the  drugs  are  not  only  possessed  by,  but 
intensified  and  concentrated  in  these  preparations.  The  art  of  phar- 
macy therefore  has  greatly  advanced  of  late  years,  and  placed  in  the 
hands  of  physicians  medicines  capable  of  acting  with  far  greater  power 
and  certainty  than  formerly. 

The  notion  that  disease  is  a something  which,  having  got  in,  requires 
to  be  driven  out  of  the  system — is  an  enemy  that  we  must  attack,  lay 
siege  to,  and  conquer — is  one  that  largely  prevails  in  the  works  of  thera- 
peutists.— “ The  intestinal  canal  is,  in  the  great  majority  of  cases,  the 
battlefield  where  the  issue  of  the  most  important  disorders  is  decided.” — 
(Hufeland.)  “ We  must  introduce  the  only  medicine  of  which  we  are 
thoroughly  convinced  that  it  possesses  the  power  of  efficiently  striving 
with  the  enemy  who,  by  subtle  means,  has  now  efiFected  an  entrance  within 
our  stronghold.” — (Headland.)  “ The  whole  of  life  is  a perpetual  struggle 
with  an  enemy  to  whom  we  must  at  last  succumb.” — (Stille.)  These 
expressions,  however  metaphorical,  indicate  the  kind  of  operation  sought 
to  be  carried  out  in  treating  disease.  The  active  practitioner,  like  the 
victorious  general,  is  more  intent  on  driving  out  the  enemy,  than  in 
securing  the  safety  of  the  fortress,  which  during  the  operations  of  both 
is  too  often  greatly  damaged,  and  not  unfrequently  levelled  to  the 
ground.  But  the  truth  is,  in  many  cases  what  we  call  disease,  instead 
of  being  an  enemy  is  our  best  friend.  It  should  be  regarded  as  the 
natural  and  necessary  result  of  those  injuries  to  which  the  animal  econ- 
omy is  necessarily  exposed.  It  is  the  effort  made  by  nature  to  elimi- 
nate from,  or  reconcile  the  frame  with,  those  noxious  causes  which 
have  influenced  it.  If  it  cannot  do  this,  the  vital  force  is  exhausted. 
Our  great  object,  therefore,  should  be,  not  to  suppress,  but  to  favor 
the  natural  operations  of  diseases,  and  conduct  them  to  a favorable 
termination.  If  a sword  is  thrust  into  the  flesh,  should  we  suppress 
the  pain,  heat,  redness,  and  swelling  which  result?  No;  for  they  are 
the  evidence  of  those  healthful  changes,  which,  properly  managed,  will 
heal  the  wound.  If  the  lung  be  inflamed,  should  we  seek  to  check 
the  dyspnoea,  arrest  the  fever,  and  weaken  the  pulse  ? Again  I say 
no.  They  are  the  proofs  that  the  constitution  is  actively  at  work  in  re- 
pairing the  injury,  and  preparing  the  way  for  recovery.  Neither  can  it 
be  correctly  supposed  that  life  is  a constant  struggle  with  death.  On 
the  contrary,  death  is  the  natural  termination  of  life ; and  so  far  from 
being  an  evil,  can  only  be  so  considered,  when  it  is  induced  by  violent 
or  unnatural  means. 

Another  circumstance  should  not  be  overlooked,  and  that  is  the 
correctness  of  the  observation  made  at  the  commencement  of  this  century 
by  Bichat,  viz. — that  the  science  of  therapeutics  has  not  been,  as  is 
alleged,  founded  on  rigid  observation  and  experience,  but  on  “ the  pre- 
vailing theories  in  physic.”  Thus  it  is  that  when  the  theory  of  inflam- 
mation regarded  fulness  of  the  blood-vessels  as  the  essence  of  that 
disease,  the  practice  which  resulted  was  of  course  blood-letting.  So 


TRUE  FOUNDATIONS  FOR  MEDICAL  PRACTICE. 


347 


long  as  a full  and  rapid  pulse  was  imagined  an  injurious  symptom,  its 
reduction  by  antiplilogistics  was  thought  to  be  a matter  of  necessity. . 
It  is  strange  that  the  persons  who  delighted  to  call  themselves  practical 
men,  never  perceived  that  their  practice  was  a most  fatal  one.  Now 
the  theory  is  changed,  and  the  practice  is  changed  with  it ; and  the  proof 
that  the  last  theory  is  superior  to  the  former  one,  is  that  the  mortality 
from  cases  of  acute  inflammations  is  greatly  diminished.  It  follows 
that  the  true  method  of  advancing  our  knowledge  of  how  to  treat  disease 
for  the  future,  is  not  blindly  to  go  on  repeating  the  routine  practice  of 
our  forefathers,  but  to  improve  our  theory  of  morbid  processes,  and  then 
re-investigate,  with  all  the  aids  of  modem  science,  the  effects  of  remedies. 
This  leads  me  to  the  last  general  proposition  we  have  to  discuss. 

PHYSIOLOGY  AND  PATHOLOGY  THE  TRUE  FOUNDA- 
TIONS  FOR  MEDICAL  PRACTICE. 

When  we  investigate  closely  into  what  is  actually  known  of  our  the- 
rapeutical means,  divided  into  alimenta,  hygienica,  and  materia  medica, 
it  will  be  seen  that  we  have  few  exact  details  founded  on  scientific  re- 
search. What  we  require  is,  that  such  details  must  be  first  arrived  at, 
and  then  applied  in  accordance  with  pathological  laws.  These  point  out 
that  all  treatment  must  be  general  and  special — general  as  regards  the 
nature  of  the  disease,  special  as  regards  its  seat.  The  great  problem  in 
conducting  any  given  case  is  to  carry  out  both  indications,  .so  that  one 
does  not  interfere  with  the  other.  If,  for  example,  the  object  be  to 
favor  the  removal  of  inflammation  or  tubercle  from  the  lung,  the 
means  requisite  for  that  end  must  not  be  put  aside  or  counteracted  by 
a desire  of  alleviating  pain,  breathlessness,  or  expectoration.  Indeed, 
one  point  of  great  importance,  and  which  clinical  observation  has  in 
recent  times  made  manifest,  is,  that  general  and  local  symptoms  fre- 
quently bear  no  relation  whatever  to  the  fatality  of  the  lesion.  Thus, 
an  extensive  acute  inflammation  of  the  lungs,  a febricula,  or  an  impacted 
gall-stone,  may  cause  the  most  violent  .symptoms  and  perturbation  of 
the  economy,  and  yet  spontaneously  terminate  in  recovery  in  a few 
days ; while  a phthisis,  a pleurisy  with  effusion,  or  even  a pneumothorax, 
which  may  permanently  destroy  the  action  of  a lung,  may  come  on 
imperceptibly,  and  cause  only  trifling  functional  symptoms.  To  the 
pathologist,  therefore,  such  symptoms  are  no  longer  the  same  guides 
to  treatment  as  they  used  to  be.  They  do  not  so  much  excite  his 
regard  as  the  structural  or  chemical  lesions  which  produce  them,  for  he 
knows  that  the  former  will  disappear  if  the  latter  are  removed.  It 
need  not,  therefore,  excite  surprise  that  as  our  knowledge  of  pathology 
has  advanced,  and  our  means  of  diagnosis  have  improved,  we  direct 
our  attention  more  to  morbid  alterations  and  less  to  the  temporary 
effects.  In  this  way  it  has  gradually  become  manifest  that  so  far  from 
doing  good  by  attempts  to  relieve  symptoms,  we  too  often  do  harm  to 
the  disease.  If,  for  instance,  impaired  digestion  cause  headache  and 
sleeplessness,  the  relief  of  these  symptoms  by  morphia  is  anything  but 
beneficial,  inasmuch  as  it  depresses  the  nervous  system  and  diminishes 


348 


GENEEAL  THERAPEUTICS. 


the  appetite,  and  so  increases  the  real  disease.  For  the  same  reason,  of 
what  advantage  can  sedatives  and  cough  mixtures  he  in  phthisis  ? 
The  true  indication  for  treatment  is  to  strengthen  the  appetite,  increase 
the  nutrition,  and  invigorate  the  frame.  Medicines  which  only  tempo- 
rarily lull  irritation,  create  nausea,  destroy  appetite,  and  favor  diapho- 
resis, however  they  may  relieve  symptoms,  can  never  arrest  the 
disease. 

An  observation  of  the  mode  in  which  the  various  sciences  are  evolved 
will  show  that  their  progress  has  been  more  or  less  influenced  by  that 
of  collateral  branches  of  knowledge,  and  especially  by  the  invention  of 
ingenious  instruments,  the  use  of  which  has  led  to  the  discovery  of  new 
facts.  Let  us  consider  for  a moment  how  the  rude  art  of  navigation 
possessed  by  the  ancients  was  improved  by  the  invention  of  the  mariner’s 
compass ; how  astronomy  is  dependent  on  mathematics,  and  on  the  tele- 
scope ; how  natural  philosophy,  by  inventing  steam-engines  and  electrical 
instruments,  has  added  to  all  the  comforts  of  life,  and  so  on.  It  would 
be  as  absurd  to  reproach  the  ancients  with  ignorance  of  navigation,  or 
of  railways,  because  they  were  unacquainted  with  the  mariner’s  compass 
and  with  the  power  of  steam,  as  it  is  to  charge  medical  men  with  igno- 
rance of  therapeutics,  until  physiology  and  pathology  are  so  advanced, 
that  diagnosis  and  the  action  of  medicines  are  better  understood.  Now 
I am  anxious  to  impress  upon  you  that  this  is  not  to  be  done  by  the 
method  hitherto  pursued  by  the  profession.  Most  young  men  on  entering 
practice  endeavor  to  impress  upon  their  memory,  by  repeated  trials,  the 
methods  and  formulas  of  their  predecessors.  This  has  been  done  so 
often  that  little  more  can  be  expected  from  such  a system.  On  the  other 
hand,  the  more  we  consider  the  flood  of  light  which  has  been  poured 
upon  our  art  by  the  physiological  discoveries  of  Harvey,  C.  Bell,  Magen- 
die,  Marshall  Hall,  Schleiden,  Schwann,  and  others,  the  more  it  must 
become  apparent  that  the  true  way  of  cultivating  medicine  is  by  prose- 
cuting researches  in  physiology  and  pathology. 

This  conclusion  in  no  way  invalidates  the  necessity  of  observing 
the  effects  of  medicines  at  the  bed-side.  It  only  points  out  that  the 
reason  we  have  made  so  little  progress  in  therapeutics  of  late  years,  is 
in  consequence  of  the  imperfect  condition  of  the  sciences  necessary  to 
its  evolution.  Some,  it  is  true,  may  argue  that  many  of  our  triumphs  in 
practical  medicine  have  no  such  scientific  foundation.  But  of  these  I 
would  remark,  that  although  the  mere  remedy  may  have  been  acciden- 
tally applied  in  the  first  instance,  still  the  cause,  diagnosis,  and  course  of 
the  disease  were  pretty  well  known,  and  that  from  these  the  pathology 
could  be  correctly  inferred.  For  example,  in  ague  and  scurvy,  the 
diagnosis  is  easy.  The  causes — malaria  in  the  one  case,  and  imperfect 
diet  in  the  other ; and  the  pathology — a morbid  state  of  the  blood — were 
known.  The  progress  of  these  diseases  was  also  recognised  to  go  on 
from  bad  to  worse  so  long  as  the  cause  continued.  Then  it  was  ascer- 
tained that  Peruvian  bark  and  lemon-juice  removed  these  morbid  condi- 
tions. Why  the  one  should  be  removed  by  the  first  remedy,  and  the 
other  by  the  second,  has  still  to  be  discovered.  All  I contend  for  is, 
that  therapeutical  trials  cannot  be  expected  to  be  useful,  unless  they  be 
preceded — 1st,  by  an  accurate  diagnosis  of  the  disease ; 2d,  by  a know- 


TRUE  FOUNDATIONS  FOE  MEDICAL  PRACIICE. 


349 


ledge  of  its  pathology ; and  3d,  by  an  acquaintance  with  its  natural 
progress. 

Not  long  ago  a young  American  physician  brought  under  my  notice 
a tincture  of  the  veratrum  viride,  which  he  maintained  possessed  the 
power  of  diminishing  the  force  of  the  pulse,  and  said  that  on  this  account 
it  was  a most  valuable  medicine  in  fevers,  inflammations,  and  other 
diseases  where  the  pulse  was  excited.  But  pathology  indicates  that  so 
far  from  lowering  the  pulse  in  these  disorders,  what  is  required  is  in 
truth  to  support  it,  for  the  reasons  I have  formerly  mentioned.  Indeed, 
I cannot  conceive  any  circumstances  in  which  such  a remedy,  even  if  it 
possessed  the  virtues  ascribed  to  it,  can  be  useful.  But  it  so  happens 
that  several  years  ago  Dr.  Norwood,  of  Nashville,  in  the  United  States, 
was  good  enough  to  send  me  a bottle  of  the  tincture,  which  I tried  in 
several  cases  of  fever  in  the  inflrmary.  In  every  instance  the  medicine 
caused  violent  vomiting,  pain  in  the  stomach,  weak  pulse,  and  symptoms 
of  collapse,  and  had  to  be  discontinued ; but  in  no  one  instance  did  it 
shorten  the  disease  or  improve  the  symptoms — quite  the  contrary.  Yet 
this  remedy  is  once  more  recommended  to  us  on  the  ground  of  subduing, 
not  a disease,  but  a symptom,  although  everything  we  know  of  pathology 
and  the  natural  history  of  fevers  and  inflammations  is  entirely  opposed 
to  its  employment. 

In  the  same  manner  hosts  of  new  drugs,  or  new  preparations  of  old 
ones,  are  constantly  extolled  and  recommended  on  the  most  insufiScient 
data,  few  seeming  to  think  it  necessary  to  make  experiments,  careful 
observations,  or  deductions,  but  appealing  only  to  a very  limited  expe- 
rience. But  we  have  previously  seen,  even  where  experience  has 
been  universal  and  unanimous — as  in  the  case  of  bloodletting  in  inflam- 
mations— what  mischief  and  error  have  arisen  from  unacquaiutance  with 
physiology  and  pathology. 

As  another  example,  let  us  for  a moment  consider  the  contradictory 
opinions  that  prevail  with  regard  to  a medicine  which,  perhaps,  has  been 
more  extensively  tried  than  any  other : I allude  to  mercury.  I need 
not  cite  the  extravagant  praises  which  it  has  received  from  its  partisans. 
It  will  suffice  to  say,  that  one  of  the  most  accomplished  professors  of 
materia  medica  in  these  times  tells  us  that,  physiologically,  it  is  “ a cor- 
rosiv^e,  irritant,  errhine,  cathartic,  and  astringent ; a stimulant,  diuretic, 
diaphoretic,  cholagogue,  and  emmenagogue  ; and  an  excitor  of  that  pecu- 
liar state  of  the  constitution  denominated  mercurial  action,  of  which 
salivation  is  one  of  the  chief  local  signs.  Therapeutically,”  he  says,  “ it 
is  antiphlogistic,  alterative,  sedative  or  contra-stimulant,  deobstruent, 
antisyphilitic,  and  anthelmintic.” — (Christison.)  A drug  possessed  of 
such  wonderfully  extensive  and  varied  powers  should  certainly  by  this 
time  have  had  its  virtues  universally  recognised ; yet  the  fact  is,  that 
with  the  exception  of  its  action  as  a sialagogue  and  a cathartic,  there  is 
scarcely  one  other  of  its  supposed  virtues  that  is  not  disputed. 

Is  mercury  a cholagogue  ? We  have  no  proof  whatever  that  it 
increases  the  secretion  of  bile ; and  the  only  experimental  investigation 
with  which  I am  acquainted — viz.,  that  of  Dr.  Scott,  who  gave  calomel 
to  dogs,  and  then  collected  the  bile  through  a fistulous  opening  made 
into  the  biliary  duct — found  it  in  three  days  to  diminish  the  quantity  of 


350 


GENERAL  THERAPEUTICS. 


that  fluid. ^ Is  it  an  antisyphilitic  ? In  recent  times  it  is  admitted  that 
syphilis  has  diminished  in  intensity  just  in  proportion  as  the  use  of  mer- 
cury has  declined  ; and  the  gigantic  experiments  made  on  entire  garrison 
regiments  in  France,  Germany,  and  Sweden,  prove  that  the  non-mercurial 
treatment  of  syphilis  is  far  superior  to  the  mercurial  in  every  respect. 
Is  it  antiphlogistic  ? All  that  we  know  of  modern  practice  negatives 
the  idea.  Does  it  cause  absorption  of  lymph  or  the  coagulated  exuda- 
tion ? The  clinical  observations  of  Professor  John  Taylor,  of  London, 
in  pericarditis,  and  of  Dr.  Williams,  of  Boston,  United  States,  in  iritis, 
are  opposed  to  such  a supposition. 

Then  as  to  its  mode  of  administration  what  dififerences  exist ! Some 
give  it  in  large,  others  in  small  doses — some  in  acute,  others  in  chronic 
diseases  of  the  same  kind.  Some  argue  that  it  should  precede,  others 
follow  venesection.  Some  combine  calomel  with  blue-pill  to  intensify 
its  action  ; others  with  opium  for  the  same  reason.  Its  applications  are 
so  numerous  and  contradictory,  that  the  question  may  well  be,  not  for 
what  diseases  is  it  useful,  but  rather  which  has  not  been  represented  to 
be  benefited  by  this  drug  ? In  the  meantime,  it  is  admitted  on  all  hands, 
that  it  arrests  the  appetite,  checks  nutrition,  excites  a peculiar  fever  and 
erethism,  produces  a coppery  taste  in  the  mouth,  furred  tongue,  and  sali- 
vation ; and  the  pathologist  may  well  inquire  how  a poison  operating  in 
such  a way  can  have  any  curative  tendency  whatever. 

Now,  why  all  this  uncertainty  as  to  the  ther^fpeutic  action  of  drugs? 
My  answer  is — In  consequence  of  our  ignorance  of  an  exact  diagnosis 
and  of  a true  pathology.  Many  persons  think  that  the  science  of  thera- 
peutics is  to  be  advanced  by  trying  the  effects  of  drugs  on  animals,  by 
testing  them  in  healthy  persons — by  clinical  observations,  by  records  of 
cases,  and  so  on  ; but  whatever  amount  of  knowledge  may  be  thus 
arrived  at,  it  can  never  be  advantageous  for  medical  treatment,  until,  as 
I have  endeavored  to  show,  we  are  first  capable  of  recognising  with 
exactitude  the  disease  we  investigate,  and  secondly,  know  its  nature  and 
natural  progress. 

These  steps  must  be  preliminary  to  all  advance  in  therapeutics,  and 
that  they  have  not  hitherto  been  made  so,  is  at  once  the  explanation  of 
past  failure,  and  the  indication  for  future  success.  The  true  promoters 
of  therapeutics,  consequently,  are  not  those  men  who  pass  their  lives  in 
treating  patients  as  well  as  they  can  from  the  results  of  pre-existing  or 
present  knowledge ; they  are  not  those  who  are  constantly  arranging 
the  well-known  opinions  and  assertions  of  former  writers  as  to  the 
efiects  of  past  treatment ; but  they  are  those  who  direct  all  their  ener- 
gies to  improving  diagnosis,  advancing  physiology  and  pathology,  and 
re-testing  the  action  of  doubtful  remedies  with  all  the  advantage  de- 
rived from  our  advanced  knowledge.  This  conviction  must  force  itself 
on  the  minds  of  all  who  seriously  consider  the  subject,  and,  in  truth,  it 
is  the  one  which  renders  every  earnest  and  truthful  student  amongst  us 
a physiological  pathologist.  The  result  is  already  obvious.  We  are 
gradually  sweeping  away  the  errors  of  empiricism,  slowly  clearing  the 
ground  for  the  erection  of  a more  simple  and  solid  temple  of  knowledge. 
This  accomplished,  we  hope  to  accumulate,  by  laborious  toil  and  research, 

* Beale’s  Archives  of  Medicine,  vol.  i.,  p.  209. 


TRUE  FOUNDATIONS  FOR  MEDICAL  PRACTICE. 


351 


materials  for  its  foundation, — a work  to  which  I think  we  are  gradually 
approaching, — in  the  hope  that,  by  patience  and  perseverance,  a day. 
will  arrive  when  Medicine  will  be  generally  allowed  to  have  approxi- 
mated towards,  if  it  do  not  actually  reach,  the  character  of  an  exact 
science.  The  true  principles,  therefore,  which  should  guide  our  efforts 
to  advance  therapeutics  are — 

1.  That  an  empirical  treatment  derived  from  blind  authority,  and 
an  expectant  treatment  originating  in  an  equally  blind  faith  in  nature, 
are  both  wrong. 

2.  That  a knowledge  of  physiology  and  pathology  is  the  real  found- 
ation and  necessary  introduction  to  a correct  study  of  therapeutics. 

3.  That  a true  experience  can  only  have  for  its  proper  aim  the  deter- 
mination of  how  far  the  laws  evolved  during  the  advance  of  these 
sciences  (physiology  and  pathology)  can  be  made  available  for  the  cure 
of  disease. 

In  concluding  this  part  of  our  lectures,  I have  only  to  express  my 
conviction  that  any  uncertainties  as  to  the  future  existence  of  a scien- 
tific Medicine  can  only  be  removed  by  working  out  in  all  its  details  the 
Molecular  Theory  of  Organization.  The  histogenetic  and  histolytic  trans- 
formations of  the  tissues,  the  various  metamorphoses  they  undergo  in  the 
exercise  of  the  nutritive  and  nervous  functions,  as  well  as  the  correla- 
tion and  conservation  of  the  dynamical,  chemical,  and  vital  forces  of  the 
economy,  are  the  points  now  being  determined  by  the  physiologist.  We 
are  still  waiting  for  the  solution,  by  the  organic  chemist,  of  several 
inquiries  necessary  for  our  onward  progress.  But  these  accomplished, 
as  it  is  hoped  they  soon  will  be,  it  must  be  recognised  that  all  action 
and  all  function  must  be  essentially  dependent  on  the  formation  and 
existence  of  the  molecular  constituents  of  the  frame.  Then,  also,  it  will  be 
seen  that  the  agents  which  operate  upon  it,  either  from  without  or  within, 
must  be  capable  of  being  so  prepared  as  to  act  on  these  minute  particles, 
and  it  will  be  made  apparent  that  one  law  will  blend  into  a harmonious 
whole  the  kindred  sciences  of  physiology,  pathology,  and  therapeutics. 
In  the  meantime  it  follows  from  all  that  has  preceded,  that  many  of  the 
principles  which  have  hitherto  guided  us  in  the  treatment  of  disease 
must  be  considerably  modified.  That  medical  practice  has  undergone  a 
great  revolution  during  the  last  twenty  years,  is  a fact  already  so  well 
established,  that  it  can  be  no  longer  denied.  Firmly  believing  that 
many  of  the  changes  which  have  been  effected  are  permanent  improve- 
ments in  our  art,  and  may  be  traced  to  the  advance  in  the  sciences  on 
which  that  art  is  based,  it  will  be  our  especial  object  in  the  succeeding 
pages  to  point  out  in  what  way  more  perfect  principles  have  led  to  a 
better  practice.  Amid  the  multiplicity  of  conflicting  statements,  and 
the  clashing  of  opposing  systems,  it  will  be  our  honest  desire  to  sepa- 
rate what  is  known  from  what  is  unknown,  and  lay  down  such  rules 
for  treatment  as  both  science  and  experience  may  alike  confirm. 


SECTION  IV. 


DISEASES  OF  THE  NEKVOUS  SYSTEM. 

The  diagnosis  of  nervous  disorders  is  dependent  on  a kind  of  knowledge 
altogether  different  from  that  appertaining  to  the  consideration  of 
cutaneous,  pulmonary,  or  cardiac  affections.  In  these  last,  as  we  shall 
see,  a direct  appeal  to  the  senses  enables  us  to  arrive  at  conclusions  with 
tolerably  accuracy.  An  arbitrary  classification  of  skin  diseases  once 
established,  with  clear  definitions,  we  have  only  to  apply  these  to  the 
appearances  observed  to  ascertain  the  disorder.  Once  master  the  prac- 
tical difficulty  of  distinguishing  with  exactitude  moist  from  dry  rales — 
whether  a murmur  replace  the  first  or  second  sound  of  the  heart,  and 
what  is  its  position,  and  we  possess  a key  which,  with  the  aid  of  per- 
cussion, will  frequently  enable  us  to  ai  rive  at  the  certain  diagnosis  of 
pulmonary  and  cardiac  .affections.  But  with  regard  to  nervous  diseases, 
no  such  exactitude  is  attainable  in  the  present  state  of  the  science  or  art 
of  medicine.  The  encephalon  is  an  aggregation  of  various  parts,  more 
or  less  connected  together,  the  functions  of  which  are  by  no  means 
determined.  In  health  these  act  in  harmony,  but  in  disease  they  are  so 
irregularly  disordered  that  while  the  action  of  one  is  excited,  that  of 
another  may  be  perverted  or  annihilated.  Then,  again,  we  frequently 
observe  that  some  of  the  most  fatal  nervous  diseases,  such  as  hydro- 
phobia, leave  after  death  no  lesion  detectable  by  the  most  careful 
histological  examination,  whilst  on  other  occasions  tumors  and  extensive 
destruction  of  the  cerebral  mass  may  exist,  without  producing  any 
symptoms  whatever.  And  yet,  notwithstanding  the  obvious  difficulties 
which  oppose  themselves  to  exactitude  of  diagnosis  of  nervous  diseases, 
careful  observation,  conjoined  with  a knowledge  of  physiology  and  patho- 
logy, will  enable  us  to  approximate  closely  towards,  if  not  actually  to 
reach,  a correct  opinion  in  the  great  majority  of  cases. 

The  same  circumstances  render  a pathological  classification  of  nervous 
diseases  impossible.  Thus  any  one  special  lesion  may  produce  the  most 
remarkably  different  effects,  according  as  it  occurs  rapidly  or  slowly ; as 
it  is  single  or  multiple ; as  it  is  small  or  great  in  amount ; as  its 
nature  is  simple  or  compound ; or  as  it  affects  different  parts  of  the 
nervous  mass.  Thus  the  compound  functional  character  of  the  brain 
alone,  if  disordered,  may  give  rise  to  increase,  perversion,  or  loss  of 
three  functions,  viz.,  intelligence,  sensation,  and  motion,  each  as  different 
in  its  modes  of  manifestation  and  effects,  as  are  the  important  functions 
of  digestion,  respiration,  and  secretion.  Neither  can  we  satisfactorily 
arrange  nervous  diseases  in  accordance  with  the  symptoms  which  may  be 


CEREBRAL  AND  SPINAL  SOFTENINGS. 


353 


present,  as  these  are  so  various  and  so  complicated  in  different  cases. 
This,  however,  is  the  method  which  has  stamped  its  features  on  medical 
literature  since  the  days  of  Hippocrates,  and  from  which,  ia  consequence, 
without  anything  more  certain  to  offer,  it  is  in  the  present  state  of 
medical  science  impossible  to  escape.  What  we,  however,  strenuously 
contend  for,  is  the  inconsistency  in  our  nomenclature  of  applying  to 
morbid  lesions  the  same  names  as  have  long  been  recognised  in  a 
different  sense  as  indicating  groups  of  symptoms.  Apoplexy,  for 
instance,  is  not  necessarily  hemorrhage  into  the  brain,  nor  does  every 
hemorrhage  produce  apoplexy.  If,  then,  we  use  a mixed  classification 
which  seems  to  be  the  best  now  open  to  us,  that  is,  one  partly  anatomi- 
cal, founded  on  altered  structures,  and  partly  physiological,  founded  on 
altered  functions  (that  is,  symptoms) — let  us  define  accurately  in  all 
instances  what  we  mean  by  the  names  employed.  Thus  we  can  use  the 
terms  congestion,  softening,  and  suppuration  of,  or  exudation,  effusion, 
and  hemorrhage  into  the  brain  and  spinal  cord,  as  we  do  when  these 
lesions  affect  any  other  organs.  But  we  should  understand  by  apoplexy y, 
loss  of  consciousness  and  voluntary  motion,  beginning  at  the  brain ; by 
epilepsy^  paroxysmal  loss  of  consciousness  with  convulsion;  by  spa^rriy 
increased  tonic ; and  by  convulsion,  increased  clonic  contractions  of  the 
muscles;  and  \>j paralysis,  loss  of  motor,  or  sensitive  power  of  a part, 
etc.  If  we  employ  morbid  lesions  to  designate  the  disease,  we  regard 
groups  of  symptoms  as  their  effects.  But  if  we  use  groups  of  symptoms 
to  denominate  the  disease,  then,  however  well  we  may  observe  these,  we 
are  often  incapable  of  determining  what  are  the  structural  changes  on 
which  they  immediately  depend. 

The  key  to  the  diagnosis  of  nervous  diseases  will  be  found  in  the 
general  sketch  we  have  given  of  the  function  of  innervation  (p.  137),, 
and  especially  in  the  pathological  laws  which  regulate  diseased  action  of 
the  nervous  system ; and  to  these  we  refer  the  reader  (p.  148).  The- 
morbid  anatomy  of  the  nervous  system  will  be  found  treated  of  in 
various  parts  of  the  work."^  But  there  is  one  predominant  lesion, 
which  has  lately  had  much  light  thro\Vn  upon  it  histologically,  and 
which  is  so  important  in  a diagnostic  point  of  view,  that  we  propose 
allluding  to  it,  before  entering  on  the  consideration  of  individual  nervous 
diseases. 


ON  THE  PATHOLOGY  OF  CEREBRAL  AND  SPINAL  SOFT- 
ENINGS, AND  ON  THE  NECESSITY  OF  EMPLOYING 
THE  MICROSCOPE  TO  ASCERTAIN  THEIR  NATURE. 

The  nature  of  cerebral  and  spinal  softening  has  been  much  disputed. 
Some  attribute  it  entirely  to  chronic  or  acute  inflammation ; others, 
while  they  acknowledge  that  softening  is  undoubtedly  thus  produced,  are 
also  of  opinion  that  it  may  occasionally  depend  upon  other  causes. 

* Congestion  of  the  cerebral  vessels,  pp.  148  to  151,  Exudative  softenings,  pp. 
16Y,  168.  Albuminous  degeneration,  p.  248,  Pigmentary  degeneration,  p.  263. 
Mineral  degeneration,  p.  271. 

23 


354 


DISEASES  OF  THE  NEEVOUS  SYSTEM. 


Thus  softening  has  been  considered  a lesion  8ui  generis^  similar  to  what 
occurs  in  ataxic  fever  (Recaniier),  to  gangrena  senilis  (Rostan,  Aber- 
comby),  to  obliteration  of  the  arteries  (Bright,  Carswell),  or  to  a dimi- 
nution of  nutrition  (Delaberge,  Monneret).  It  has  also  been  referred  to 
post-mortem  maceration  (Carswell,  Paterson  of  Leith),  and  is  undoubt- 
edly often  produced  by  mechanical  violence  after  death.  The  difficulty 
hitherto  has  been  how  to  distinguish  with  precision  one  kind  of  soften- 
ing from  another. 

From  a careful  analysis  of  numerous  cases  of  cerebral  softenings,  I 
have  arrived  at  the  conclusion  that  they  may  originate  in  six  ways. 
1st,  From  exudation  which  is  infiltrated  among  the  elementary  nervous 
structures ; 2d,  from  a mechanical  breaking  up  of  these  structures  by 
hemorrhagic  extravasations,  whether  in  large  masses  or  infiltrated  in 
small  isolated  points ; 3d,  from  fatty  degeneration  of  the  nerve  cells, 
independent  of  exudation ; 4th,  from  the  mere  imbibition  of  serum 

which  loosens  the  connection  between 
the  nerve  tubes  and  cells ; 5th,  from 
mechanical  violence  in  exposing  the 
nervous  centres ; and  6th,  from  putre- 
faction. 

1st,  Exudative  or  inflammatory 
softening  always  contains  granules 
and  granule  cells,  which  are  nume- 
rous according  to  the  degree  of  soften- 
ing. The  granules  are  for  the  most 
part  seen  coating  the  vessels  (Figs. 
148,  334,  and  335),  and  the  cells 
also  may  occasionally  be  seen  there  in 
various  stages  of  development  (Fig. 
150).  In  the  demonstrations  that 
are  made  under  the  microscope,  they 
the  tubes  (Fig.  401),  which,  accord- 
ing to  the  severity  and  extent  of  the  lesion,  are  easily  separated  from  one 
another,  or  broken  up  in  a variety  of  ways.  When  recent,  the  serum 


are  frequently  seen  diffused  among 


which  accompanies  the  exudation  is  infiltrated  into  the  nervous  substance. 


Fig.  401,  Structure  of  inflammatory  exudative  softening  of  the  lumbar  portion  of 
the  spinal  cord,  showing  granule  cells  infiltrated  among  the  nerve-tubes  in  a para- 
plegic individual. — ( Wedl.) 

Fig.  402.  Structure  of  a tubercular  exudation  in  the  cerebellum,  composed  of 
granules  and  tubercle  corpuscles,  with  a few  fragments  of  nerve-tubes. 

Fig.  403.  Structure  of  the  softened  cerebellum,  immediately  external  to  the  same 
tubercular  mass,  containing  a larger  number  of  fragments  of  the  nerve-tubes,  with 
numerous  granular  corpuscles.  260  diam. 


CEREBRAL  AND  SPINAL  SOFTENINGS. 


355 


and  may  assist  occasionally  in  producing  softening,  although  for  the. 
most  part  it  is  rapidly  absorbed.  In  chronic  cases  this  form  of  soften- 
ing may  be  regarded  in  one  sense  as  a fatty  degeneration,  although, 
when  speaking  of  this  last  lesion,  I have  stated  my  reasons  for  consider- 
ing it  as  a transformation  of  the  exudation,  and  not  of  the  nervous  sub- 
stance. (See  p.  257.)  Simple,  tubercular,  and  cancerous  exudations, 
alike  cause  cerebral  or  spinal  softenings,  as  shown  by  the  presence  of 
the  characters  peculiar  to  each.  Tubercular  masses  in  the  brain  are 
generally  surrounded  by  a layer  of  cerebral  substance  exhibiting  all  the 
character.s  of  this  form  of  softening  (Fig.  403).  Cancerous  exudation 
into  the  brain  is  very  rare  (Fig.  302). 

2f/,  Re  norrhajic  softeninj. — When  blood  is  extravasated  with  force 
into  the  cerebral  structure,  it  breaks  up  the  nerve-tubes  of  the  part  and 
coagulates.  The  coagulum  then  forms 
a solid  mass,  whilst  the  serum,  more 
or  less  tinged  with  coloring  matter,  is 
infiltrated  to  a greater  or  less  distance 
and  absorbed.  Under  such  circum- 
stances, the  softened  nervous  tissue  sur- 
rounding the  clot  presents  fragments 


r- o o'" 


peculiar  tendency  to  form  circular, 
oval,  or  irregularly-formed  globules, 
with  double  outlines,  as  iu  Fig.  404. 

There  are  none  of  the  granule  cells  so 
character isticof  an  inflammatory  soften- 
ing, although  they  may  appear  later,  as 

the  result  of  exudation  from  the  cere-  Fig.  404. 

bral  vessels  surrounding  the  clot.  In  such  cases  the  greatest  variation 
in  the  appearance  of  the  nerve-tubes  is  observable,  from  a slight  dimi- 
nution in  their  natural  firmness  and  consistence,  which  renders  them 
easily  separable,  or  causes  varicosities  or  swellings  in  them  to  be  readily 
produced  on  pressure,  up  to  a condition  when  they  exhibit  nothing  but 
fragments  and  separate  globules,  as  in  Fig.  404. 

The  colored  cerebral  softenings  which  are  subsequently  produced  as 
a result  of  hemorrhage  are  owdng  to  the  transformations  which  go  on  in 
the  coagulum  itself.  They  assume  a bright  orange,  brick  red,  yellow, 
fawn,  or  dirty  brown  color,  and  under  the  microscope  are  found  to 
consist  of  hematine  in  various  forms  and  tints.  Thus  the  whole  may  be 
granular,  or  mingled  with  crystals  of  hematoidine  or  melanine ; and  the 
granules,  granular  masses,  and  celloid  degenerations,  may  present  numer- 
ous shades  of  orange,  red,  brown,  black,  etc.  etc.  (See  Pigmentary 
Degeneration,  p.  262,  et  seq.) 

3c?,  True  fatty  softening. — This  lesion,  that  is,  a primary  fatty 


Fig.  404.  Structure  of  the  softened  cerebral  substance,  surrounding  a recent  clot 
of  blood,  showing  the  appearance  assumed  by  the  nerve-tubes  when  broken  up,  and 
softened  by  imbibition  with  serum. — See  Apoplexy,  case  of  Pitbladdo.  250  diam. 


35G 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


degeneration  independent  of  exudation  or  hemorrhage,  is  one  of  the 

existence  of  which  I was  for  a long  time 
very  doubtful.  Careful  investigation,  how- 
ever,has  satisfied  me, that  it  does  occasionally, 
though  rarely,  present  itself,  apparently  as  a 
consequence  of  obstruction  of  arteries.  In 
this  case  the  vessels  are  not  coated  necessarily 
with  granular  exudation,  but  the  nerve-cells 
undergo  the  fatty  degeneration  primarily  and 
are  enlarged.  The  walls  of  many  of  them 
also  are  dissolved,  leaving  triangular  or  cres- 
centic-shaped granular  masses  between  the 
nerve-tubes.  This  alteration  is  accompanied 
with  diminution  of  the  cerebral  density,  and 
the  nerve-tubes  are  also  easily  separated  and 
broken  up,  though  not  so  readily,  as  in  the  last  form  of  softening  noticed. 

4^/?,  Serous  or  dropsical  softening. — This  kind  of  softening  is  due  to 
imbibition  of  the  serum,  which  is  effused  into  the  ventricles  in  cases  of 
hydrocephalus  and  other  diseases.  Hence  it  is  only  found  in  the  neigh- 
borhood of  such  effusions,  and  most  commonly  in  the  central  portions 
of  the  brain,  as  in  the  white  matter  of  the  septum  lucidum,  fornix,  etc. 
It  is  the  white  softening  of  morbid  anatomists,  and  consists  structurally 
of  nothing  but  the  oedematous  normal  elements  of  the  parts,  without  any 
of  the  changes  peculiar  to  the  exudative,  hemorrhagic,  or  true  fatty 
softenings.  The  observations  of  Dr.  Robert  Paterson  of  Leith  tend  to 
show  that  the  brain  substance  is  very  porous,  and  that  if  a slice  of  it  is 
placed  in  water,  it  readily  imbibed  a considerable  quantity,  becoming  at 
the  same  time  more  soft.  Whether  such  softening  ever  occurs  in  the 
living  body  is  very  doubtful ; it  is  most  probably  a post-mortem  change. 
Sometimes  serum  is  found  to  a considerable  extent  in  the  ventricles, 
without  softening  of  the  surrounding  parts.  The  fluid  apparently  in 
such  cases  has  not  passed  through  the  lining  membrane  of  the  ventricles. 
At  other  times  this  has  occurred,  and  the  softening  so  occasioned  is  found 
to  be  greatest  near  the  central  parts,  and  to  diminish  according  to  the 
distance  from  them.  The  causes  which  produce,  and  at  others  impede, 
post-mortem  imbibition  are  unknown. 

5/^7^,  Mechanical  softening. — I have  frequently  seen  softenings  occa- 
sioned in  the  brain,  and  more  frequently  still  in  the  spinal  cord,  through 
crushing  the  nervous  texture,  after  death,  in  various  ways.  Thus  the 
saw  or  chisel  may  occasion  mechanical  softenings  in  the  superficial  parts 
of  the  brain,  when  the  calvarium  is  being  removed  by  inexperienced  or 
unskilful  operators.  In  France,  where  the  hammer  is  used  for  this  pur- 
pose, it  is  a frequent  cause  of  superficial  softenings.  The  spinal  cord  is 
especially  liable  to  be  injured,  by  slipping  of  the  chisel  or  lever  used  in 
elevating  the  posterior  spinous  processes  of  the  vertebra.  Portions  of 
soft  nervous  tissue,  such  as  the  corpus  striatum,  have  frequently  had  their 

Fig.  405.  Structure  of  the  softened  pons  varolii,  in  a case  where  the  basilar  artery 
was  obstructed,  showing  true  fatty  degeneration  of  the  nerve-cells,  among  somewhat 
softened  and  broken  up  nerve-tubes.  See  Cerebral  Hemorrhage,  case  of  Alexander 
Walker.  50  diam. 


CEREBRAL  AND  SPINAL  SOFTENINGS. 


357 


text  are  reduced  to  a pulpy  consistence  by  mere  handling,  or  by  constant 
application  of  the  finger  simply  to  ascertain  whether  it  be  softened  or  no» 
I have  seen  softenings  exactly  resembling  such  as  may  be  occasioned  by 
disease,  produced  in  all  these  ways,  and  thus  give  rise  to  most  erroneous 
conclusions.  They  are  only  to  be  distinguished  by  a microscopical  ex- 
amination, and  by  a careful  consideration  of  the  symptoms  observed 
during  life,  and  of  the  causes  which  probably  may  have  produced  them 
after-d3ath. 

G^A,  Putrefactive  softening. — This  may  occur  in  warm  weather,  from 
the  body  having  been  examined  long  after  death,  or  from  accidental 
causes.  Hence  the  necessity  of  always  stating  the  number  of  hours  after 
death  that  the  examination  is  made.  Such  softenings  are  always  diffused 
through  considerable  masses  of  cerebral  texture,  and  may  be  recognised 
by  this  cirGimstance  combined  with  an  absence  of  all  the  signs  which 
distinguish  the  other  forms. 

Of  these  SIX  kinds  of  softening  found  in  the  body  after  death,  only 
the  first  three  occur  in  the  living  subject,  and  give  rise  to  symptoms,  and 
of  these  three,  the  pure  fatty  degeneration,  though  frequently  associated 
with  the  others,  has  been  so  seldom  noticed,  that  we  are  to  a great  extent 
unacquainted  with  its  symptoms  as  a special  lesion.  As  regards  the  last 
t’lree,  they  have  been  frequently  confounded  by  morbid  anatomists  with 
the  others,  and  all  attributed  to  one  cause.  I diink  we  are  now  enabled 
to  distiuguish  accurately  such  as  are  the  result  of  exudation  from  such 
as  are  not. 

From  a careful  analysis  of  32  cases  of  softening  of  the  nervous 
centres,  which  I published  in  1842-43,*  it  was  shown  that  different 
symptoms  were  connected  with  exudative  or  inflammatory,  from  those 
which  occurred  in  non-inflamniatory  softening.  In  24  of  these  cases  in 
which  cerebral  softening  was  observed,  granular  corpuscles  were  present 
in  18,  whilst  in  G no  traces  of  these  bodies  could  be  found.  On  analys- 
ing the  symptoms  of  the  24  cases,  a marked  difference  was  found  be- 
tween those  resulting  from  the  two  lesions.  Thus,  in  the  cases  where 
onlg  inflammatory  softening  was  present,  well-marked  symptoms  invari- 
ably existed,  such  a loss  of  consciousness,  preceded  or  followed  by  dul- 
uess  of  intellect,  contraction  and  rigidity  of  the  extremities,  or  paralysis. 
On  the  other  hand,  in  the  six  cases  of  non-inflammatory  softening,  there 
was  no  paralysis  or  contraction,  and  no  dulness  or  disturbance  of  the 
intellect.  Again,  in  the  four  cases  where  l a lesions  were  present, 
symptoms  were  always  observed  in  the  side  of  the  body  opposite  to  the 
seat  of  the  inflammatory  softening,  but  none  existed  in  the  opposite  side 
in  the  noninflammatory.  An  analysis  of  these  24  cases,  therefore,  leads 
me  to  the  conclusion,  that  the  two  kinds  of  softening  I have  endeavored 
to  establish  are  alike  distinguishable,  by  their  intimate  structure,  and  by 
the  sympto  ns  accompanying  them  during  life. 

Now  all  practical  men  agree  in  considering  it  a matter  of  extreme 
difficulty  to  reconcile,  with  any  certainty,  the  morbid  appearances  found 
in  the  brain,  with  the  symptoms  observed  during  life.  The  future 
microscopic  examination  of  the  softening  may  serve  to  prevent  much  of 
the  error  that  has  hitherto  been  committed.  For  instance,  softening  of 

* Edinburgh  Medical  and  Surgical  Journal,  Nos.  163,  155,  and  157. 


358 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


the  fornix,  septum  lucidum,  and  central  parts  of  the  brain,  may  exist  in 
two  cases.  To  the  naked  eye  they  may  be  in  every  respect  identical, 
and  yet  the  microscope  enables  us  to  determine  that  the  one  contains 
granular  corpuscles,  whilst,  in  the  other,  not  one  of  these  bodies  is  to  be 
found.  It  becomes  evident,  then,  that  previous  to  this  distinction  having- 
been  made,  two  different  lesions  were  confounded  together ; and  that  a 
different  train  of  symptoms  should,  under  such  circumstances,  be  occa- 
sioned, is  only  to  be  expected.  Again,  it  has  frequently  excited  surprise 
that,  notwithstanding  the  existence  of  well-marked  symptoms  of  soften- 
ing, nothing  was  to  be  discovered  after  death.  Now  I have  demonstrated 
in  several  instances  that,  although  to  the  naked  sight  no  morbid  lesion 
was  apparent,  still  portions  of  brain  might  contain  the  same  granular- 
corpuscles  as  are  to  be  seen  in  more  apparent  lesions ; and  that  by  con- 
sidering such  p-arts  diseased,  all  the  symptoms  might  be  explained  ac- 
cording to  the  pathological  laws  I have  previously  referred  to  (p.  148, 
et  seq.)  By  excluding  these  sources  of  error,  therefore,  and  by  distin- 
guishing the  lesion  dependent  on  inflammation  from  others  which  simulate 
it,  we  shall  be  enabled  to  obtain  more  exact  data  for  future  investigations. 
From  the  observations  recorded,  however,  the  two  following  propositions 
may,  I think,  be  established.  1st,  That  pathologists  have  often  con- 
founded softening  dependent  on  disease  during  life,  with  softening  occa- 
sioned by  post-mortem  changes  or  mechanical  violence.  2d,  That  not- 
withstanding the  most  anxious  search,  and  the  existence  during  life  of 
the  most  decided  symptoms  of  softening,  the  organic  disease,  though  really 
present,  has  frequently  escaped  observation. 

Proposition  1. — That  pathologists  have  often  confounded  softening 
dependent  on  disease  during  life^  with  softening  occasioned  hy  post' 
mortem  changes^  or  mechanical  violence. 

With  respect  to  this  proposition  it  may  be  observed  that,  in  many 
cases  where  no  symptoms  were  present  during  life,  extensive  softening 
of  the  brain  has  been  found  after  death.  This  is  a well-known  fact,  and 
is  one  which  tends  in  no  small  degree  to  throw  confusion  on  the  pathology 
of  nervous  diseases.  Thus,  in  one  case  of  a series  I published  in  1843,^ 
there  was  extensive  softening  of  the  central  portion  of  the  brain,  corpora 
striata,  and  optic  thalami,  which,  however,  contained  no  granular 
corpuscles.  The  symptoms  attending  these  lesions  were  sudden  insensi- 
bility and  convulsions,  which  evidently  depended  on  a capillary  apoplexy 
that  was  also  present.  No  paralysis  or  contraction  existed.  Four  other 
cases  were  recorded,  with  more  or  less  softening  of  the  brain,  without 
head  symptoms,  and  without  granular  corpuscles  in  the  softened  portions. 

Now  in  all  these  five  cases  there  was  an  extensive  softening,  the 
nature  of  which  it  was  impossible  for  any  one  to  distinguish  positively, 
by  unaided  sight.  In  none  of  them  did  granular  corpuscles  exist,  and 
in  none  did  those  symptoms  occur  which  are  peculiar  to  softenings  pro- 
duced during  life. 

In  addition  to  these  five  cases  there  were  four  others,  where,  conjoined 

* Pathological  and  Histological  Researches  on  Inflammation  of  the  Nervous  Centres. 
By  the  Author.  Edinburgh,  1843. 


CEKEBKAL  AXD  SPIXAL  SOFTENINGS. 


359 


with  an  exudative  softening  producing  particular  symptoms,  there  was 
also  a softening,  occasioning  no  symptoms  whatever,  and  containing  no 
granule  cells.  The  circumstances  attendant  on  these  nine  cases,  there- 
fore, must  convince  us  that  softenings  produced  mechanically,  or  by 
post-mortem  changes,  have  frequently  been  mistaken  for  those  occurring 
during  life,  and  must  necessarily  he  so^  so  long  as  unaided  sight  is  made 
the  sole  means  of  forming  a judgment  'with  respect  to  their  nature. 

A perusal  of  these  cases  must  satisfy  any  one  that  pathologists  have 
hitherto  been  confounding  two  distinct  lesions,  viz.,  a softening  dependent 
on  \itil  changes,  and  a softening  dependent  on  mechanical  or  other 
causes. 


PnoPosiTioN  2, — That  notwithstanding  the  most  anxmis  search.,  and  the 
existence  during  life  of  the  most  decided  symptoms  of  softening,  the 
organic  disease,  though  really  present,  has  freguently  escaped  obser- 
vation. 

In  the  series  of  cases  alluded  to  there  are  several  which  serve  to 
establish  tnis  proposition,  of  which  T may  more  especially  refer  to  two. 

Case  1,  a man  had  paralysis,  with  complete  resolution  of  the  limbs 
on  the  right  side,  and  intense  rigidity  of  those  on  the  left.  Death 
occurred  in  six  hours.  On  dissection,  a large  coagulum  of  blood  was 
discovered  in  the  left  hemisphere,  thus  explaining  the  paralysis  on  the 
right  side.  In  the  right  hemisphere  an  old  apoplectic  cyst  was  found, 
and  a number  of  small  cavities,  described  by  Dr.  Sims  as  chronic 
softening  undergoing  a cure.  Here,  then,  there  was  nothing  acute, 
nothing  to  explain  the  intense  rigidity.  A microscopic  examination 
demonstrated  that  these  cavities  contained  numerous  granular  cor- 
puscles and  granules,  thus  proving  the  existence  of  structural  changes  in 
the  right  lobe  of  the  brain,  and  explaining  the  rigidity  on  the  left  side 
of  the  body. 

Case  2 was  that  of  a man  who  entered  the  infirmary  under  Dr. 
Paterson,  in  1842.  All  the  symptoms  of  acute  softening  were  present; 
paralysis  of  the  left  side,  including  rigidity  and  contraction  of  the  left 
arm,  dulness  of  intellect,  and  tonic  spasms  of  the  muscles  of  the  mouth 
and  neck.  The  right  side  was  also  affected  in  a slight  degree.  As 
the  case  excited  considerable  interest,  great  care  was  taken  in  examin- 
ing the  brain  after  death.  When  the  lateral  ventricles  were  opened, 
it  became  a question  whether  the  right  corpus  striatum  was  softened. 
Several  persons  applied  their  fingers  and  endeavored  to  ascertain  the 
point.  As  the  manual  examination  proceeded,  the  normal  consistence 
of  the  part  diminished,  until  at  length  it  presented  all  the  appearance 
of  pultaceous  softening.  In  this  state  it  was  shewn  to  Dr.  Paterson, 
who  naturally  enough  considered  it  to  be  the  result  of  disease.  I 
differed  from  him  in  opinion,  first,  because  I had  carefully  observed 
the  gradual  increase  of  the  softening  in  the  manner  alluded  to ; and 
secoadly,  because  disease  of  the  corpus  striatum,  in  one  side  of  the 
brain,  could  not  have  explained  the  well-marked  symptoms  which 
existed  on  both  sides  of  the  body.  When  the  pons  varolii  was  bisected, 
Dr.  Peacock,  who  conducted  the  examination,  conceived  it  to  be 


360 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


softened;  others  who  examined  it  could  perceive  no  difference  in  the 
texture;  its  color  and  consistence  were  unchanged.  Keasoning  from 
the  symptoms,  the  lesion  was  very  likely  to  exist.  But  how,  it  was 
argued,  could  a judgment  he  formed;  we  ought  to  reason  from  facts, 
not  theories  ? Here,  then,  was  an  evident  lesion  of  the  corpus  striatum, 
which  explained  nothing,  and  a problematical  lesion  of  the  pons  varolii, 
which,  however,  did  it  exist,  would  satisfactorily  account  for  the  symp- 
toms. In  this  state  of  uncertainty  the  microscope  was  sent  for,  and  I 
demonstrated  and  made  evident  to  Drs.  Paterson,  Peacock,  and  all 
the  students  present,  that  the  corpus  striatum  contained  no  granular 
corpuscles,  whilst  in  the  pons  varolii  they  were  very  abundant.  I 
have  endeavored  to  describe  what  took  place  on  this  occasion,  from 
which  it  must  be  evident  that  had  not  the  microscope  been  appealed 
to,  the  right  corpus  striatum  would  have  been  pronounced  softened, 
whilst  the  real  lesion  in  the  pons  varolii  might  have  escaped  observa- 
tion. Under  such  circumstances  this  case  would  have  added  another  to 
the  inexplicable  observations  with  which  the  records  of  nervous  diseases 
abound. 

Wliat  renders  these  cases,  and  several  others  I could  relate,  so 
remarkable  and  satisfactory  is,  that  they  are  not  instances  where  the 
dissection  was  performed  in  a hurried  manner,  and  by  incompetent 
persons.  On  the  contrary,  from  the  particular  symptoms  connected 
with  them  during  life,  the  post-mortem  examination  was  in  all  con- 
ducted with  extreme  care.  The  physician  who  had  charge  of  the  case 
was  present.  The  examinations  were  witnessed  or  conducted  by  my- 
self, in  the  presence  of  clerks  and  numerous  students,  and  I may  say 
that  we  were  all  in  doubt  until  the  microscope  cleared  up  tlie  difficulty. 
These  cases,  therefore,  sufficiently  demonstrate  that  the  naked  siyht  is 
positively  unable  to  detect  lesions,  even  although  they  are  directly  indi- 
cated by  the  symptoms,  and  carefully  looked  for  by  experienced  morbid 
anatomists. 

If,  then,  the  two  propositions  formerly  stated  have  been  satisfac- 
torily proved,  and  it  is  agreed  that  pathologists  have  been  confounding 
vital  with  post-mortem  softening,  and  overlooking  the  former,  although 
undoubtedly  present,  it  must  be  evident  that  many  of  the  contradic- 
tions which  have  apparently  existed  in  connection  with  the  pathology 
of  nervous  diseases  may  be  accounted  for.  It  must  also  be  clear  that 
no  confidence  can  be  placed  in  the  analysis  of  cases,  however  nume- 
rous, when  the  sources  of  error  now  indicated  have  not  been  carefully 
excluded. 


ACUTE  HYDBOCEPHALUS. 

Case  1."^ — Acute  Hydrocephalus — Recovery, 

History, — Janet  Reid,  aet,  12 — admitted  June  12th  1850.  About  three  weeks 
ago  she  fell  down  and  struck  the  back  of  her  head  violently,  but  soon  recovered,  and 
remained  well  until  two  days  ago,  when  febrile  symptoms,  with  headache,  occurred. 
The  following  morning  these  continued,  and  vomiting  came  on,  with  great  restless- 
ness, and  crying  at  night. 


* Reported  by  Mr.  E.  S.  Wason,  Clinical  Clerk. 


ACUTE  HYDROCEPHALUS. 


361 


Symptoms  on  Admission, — On  admission  she  is  very  drowsy,  and  starts  occa- 
sionally in  her  sleep.  When  roused  she  is  fretful  and  irritable,  and  complains  of 
headache.  The  pupils  are  dilated,  but  contractile  on  exposure  to  a strong  light ; 
pulse  104,  of  good  strength  ; skin  hot ; tongue  covered  with  a white  fur,  and  dry ; 
no  appetite ; great  thirst ; bowels  not  open  for  two  days.  Urine,  sp.  gr.  1030,  with 
phosphatic  deposits.  U Calomd^  gr.  iij  ; Fwlv.  Scammon.  gr.  v.,  Fiant  Fnlv.  tales 
duo.  Sumat  tcmcm  statiin.,  et  alterumpost  Koras  tres. — Applicent.  hinodines^  iv.  capiti. 

Progress  of  the  Case. — June  IZth. — Leeches  bled  well.  Took  both  powders, 
and  had  an  injection,  which  brought  away  one  stool  of  a dark  greenish  color.  Still 
complains  of  pains  in  the  head,  and  general  uneasiness  when  moved.  But  tliere  has 
been  no  more  vomiting,  and  there  is  no  intolerance  of  light.  Pupils  natural ; pulse 
120,  rather  sharp  ; skin  still  hot  and  dry  ; continues  drowsy,  and  fretful  when  moved  ; 
tongue  white  and  moist. — Sumat  Ext.  Senuce,  3 U,  aqua.,  et  repetatur  post  Koras 
quatuor  si  opus  sit.  June  \ otK. — No  headache  and  not  so  drowsy.  June  ‘I'ld. — Since 
last  report  has  been  gradually  improving  ; the  febrile  symptoms  have  ceased,  and  she 
was  dismissed  quite  well. 

Case  2.* — Acute  Hydrocephalus  in  a Scrofulous  Child — Recovery. 

History. — John  MhUilay,  aet.  9,  son  of  a servant — admitted  July  5,  1855. 
This  boy  is  of  a scrofulous  constitution,  and  was  admitted  into  the  Surgical 
Hospital,  June  22d,  for  a scrofulous  sore  on  the  left  ankle.  Three  days  afterwards 
he  was  attacked  with  scarlatina,  which  ran  a mild  course,  and  from  which  he  was 
convalescent  on  the  29th,  June  30^/q  however,  he  complained  of  not  having  slept, 
vomited  several  times,  and  was  very  restless.  July  Is^,  he  refused  to  eat  anything, 
and  in  the  course  of  the  day  screamed  violently  several  times.  There  was  also 
cephalalgia,  drowsiness,  photophobia,  and  great  irritation  when  roused.  In  this 
condition  he  remained  until  admitted  into  the  Medical  Clinical  ward,  the  tendency 
to  constipation  having  been  counteracted  by  the  administration  of  purgatives  twice. 

Symptoms  on  Admission. — On  admission,  the  face  is  pinched,  and  expressive 
of  great  irritability.  He  cries  fretfully  when  touched  or  disturbed.  The  eyes  are 
spasmodically  closed,  and  he  resists  all  attempts  to  open  them  ; but  when  this  is 
done,  both  pupils  are  seen  to  be  dilated,  and  not  movable  on  exposure  to  the  light. 
On  being  left  quiet,  he  turns  away  from  the  light,  and  relapses  into  a doze, 
interrupted  by  occasional  moanings.  Pulse  slow  and  feeble,  difficult  to  count  from 
resistance  of  the  child ; skin  and  head  of  natural  temperature.  There  is  still  a 
scrofulous  ulcer  on  the  left  ankle,  discharging  pus  of  an  offensive  odor.  Tongue 
furred ; refuses  food ; bowels  constipated ; has  no  cough  or  pulmonary  symptoms, 
and  has  never  had  strabismus,  grinding  of  teeth,  convulsion,  or  paralysis. — To  have 
beef  tea.,  milk.,  and  nutrients.,  witK  § iij  of  sKerry  wine  daily.  Pulv.  Jalap,  gr.  v. ; 
Hydrarg.  Chlorid.  gr.  ij  ; ft.  pulv.  Kora  somni  sumendm. 

Progress  op  the  Case. — July  — At  seven  a.m.  passed  a copious,  dark, 

offensive  stool.  Has  been  persuaded  to  take  a little  milk,  but  refuses  other  nourish- 
ment. Still  fretful  and  irrritable,  but  the  nurse  says  he  did  not  scream  or  toss  about 
so  much  during  the  night.  Pulse  64,  weak.  Otherwise  the  same.  July  1 1 tJi. — 
Since  last  report  the  general  irritability  has  somewhat  diminished,  and  last  night 
he  slept  well.  Has  gradually  been  induced  to  take  more  nourishment.  Does  not 
scream  now,  but  moans  occasionally,  and  tosses  about  until  exhaustion  produces 

sleep.  Now  and  then  he  puts  his  hand  to  the  forehead,  and  says  he  feels  pain 

there.  His  sight  is  occasionally  dim,  but  at  other  times  he  sees  well.  Cannot 

sustain  any  train  of  thought  or  conversation  long  Still  constipation,  which  is 

relieved  every  third  day  with  the  powder  of  calomel  and  jalap.  July  20tK. — There 
has  been  gradual  improvement  on  the  whole,  although  much  variation  from  day  to 
day.  Some  nights  are  more  restless  than  others,  with  occasional  screaming.  He 
still  puts  his  hand  to  the  head,  which  is  sometimes,  he  says,' “ sore.”  The  pulse 
has  varied  from  60  to  80.  The  appetite  has  improved,  and  he  takes  more  nourish- 
ment. Sight  and  memory  more  perfect.  August  3c?. — Has  been  occasionally 
screaming  a good  deal  at  night,  but  is  now  much  better,  and  walks  about  on 
crutches,  the  scrofulous  sore  on  the  ankle  being  no  better.  August  SiK. — It  having 
been  stated  that  he  was  affected  with  worms,  he  has  taken  some  doses  of  the  etherial 
extract  of  the  Male  Shield  Fern,  followed  by  purgatives.  These  have  produced 

* Reported  by  Mr.  Robert  Byers,  Clinical  Clerk. 


362 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


several  stools,  but  no  worms.  His  appetite  and  general  health  have  now  been  greatly 
restored.  There  is  no  pain  in  the  head,  or  restlessness  at  night,  and  he  was  sent  back 
to  the  surgical  wards  to  have  his  ulcer  treated. 

Commentary. — In  the  two  preceding  cases  we  have  good  examples 
of  that  congestive  and  irritative  state  of  the  brain,  which  occurring  in 
children  has  been  regarded  as  indicative  of  acute  hydrocephalus. 
Whether  in  either  of  them  the  disease  had  proceeded  to  actual  effusion, 
it  is  of  course  difficult  to  determine,  although  the  pain  in  the  head  and 
restlessness  passing  into  somnolence  render  this  probable.  In  the  first 
case,  where  the  child  was  tolerably  healthy,  febrile  phenomena  with  ex- 
citement were  more  pronounced  than  in  the  second  scrofulous  case,  in 
which  exhaustion  was  evident  from  the  first.  Hence  why  a few  leeches 
and  laxatives  constituted  the  treatment  in  the  girl  Reid,  although,  it  will 
be  observed,  that  their  employment  produced  no  marked  improvement 
in  the  symptoms,  the  pulse  on  the  following  day  being  120,  sharp,  the 
skin  hot  and  dry,  with  a continuance  of  the  drowsiness.  Notwithstand- 
ing, no  further  antiphlogistic  remedies  were  persisted  in,  and  two  days 
subsequently  the  patient  became  convalescent.  In  the  second  case  an 
opposite  plan  of  treatment  was  practised  from  the  first.  Here  the  pulse 
was  slow  and  feeble,  the  symptoms  were  indicative  of  exhaustion,  and 
this  child  not  only  had  a scrofulous  sore,  but  had  recently  recovered  from 
an  attack  of  scarlatina.  Nutrients  with  wine,  therefore,  were  persever- 
ingly  pressed  upon  the  patient,  notwithstanding  the  deficient  appetite 
and  nausea,  with  the  effect  of  ultimately  establishing  a recovery. 

Case  III.'^ — Acute  Hydrocephalus — Phthisis  Pulmonalis—  Death — 
Effusion  into  the  Lateral  Ventricles — Eon-lnjlcmmatory  sojtening 
of  the  central  parts  of  the  Brain — Meningitis  at  the  base  of  Cra- 
nium— General  Tuberculosis. 

History. — Mary  Ann  Flynn,  set.  6 — admitted  June  26,  1845.  She  is  an  intelli- 
gent child,  of  scrofulous  and  cachectic  appearance,  and  greatly  emaciated.  From  her 
own  statement  she  had  influenza  a year  ago,  and  has  had  a cough  ever  since. 
Her  diet  has  always  been  very  poor,  chiefly  consisting  of  potatoes  without  any  milk 
or  animal  food.  Latterly  she  has  experienced  pain  in  the  head,  has  been  feverish  and 
restless  at  night,  and  yesterday  she  vomited  several  times. 

Symptoms  on  Admission. — On  admission  she  complains  of  headache,  pain  in  the 
back,  great  thirst,  nausea,  and  cough.  The  pain  in  the  head  is  felt  over  the  fore- 
head, sometimes  extending  to  the  entire  head ; is  constant  but  not  severe  at 
present.  She  has  also  slight  pains  in  the  back,  not  increased  on  pressure.  Her 
intellectual  powers  are  for  her  age  unusually  good  ; pupils  and  eyeballs  natural ; 
never  had  fits  or  other  derangement  of  the  nervous  system.  She  has  no  appetite, 
refuses  all  food,  but  constantly  desires  drink ; tongue  covered  with  a whitish  fur ; 
mouth  dry.  She  has  not  vomited  since  admission,  but  complains  of  distressii  g 
nausea;  abdomen  feels  natural;  had  diarrhoea  of  light  yellow  fluid  stools  two  da}s 
ago,  which  has  now  ceased ; has  frequent  prolonged  cough,  not  accompanied  by 
much  expectoration.  On  percussing  the  chest,  there  is  comparative  dulness  under 
the  right  clavicle,  and  on  auscultation  over  this  part,  a loud  moist  rattle  accom- 
panies the  inspiration,  extending  down  to  the  third  rib.  Here  also  there  is  broncl.o- 
phony.  Similar  signs  exist  on  the  right  side  posteriorly,  at  the  apex  of  lung,  and 
over  the  rest  of  the  chest  there  is  great  harshness  with  inspiration,  and  prolonged 
expiration  with  occasional  sibilation.  Respirations  are  26  in  the  minute ; pulse 
150,  small  and  somewhat  hard;  heart  sounds  rapid,  but  normal  in  character;  skin 
hot,  covered  with  perspiration ; head  unusually  warm. — Applicent.  hirudines  iv. 
temporihus — llaheat  Vini  Ipecac.  ^ ss. 


Reported  by  Mr.  D.  P.  Morris,  Clinical  Clerk. 


ACUTE  HYDROCEPHALUS. 


363 


Progress  of  the  Case. — June  I'lth. — The  emetic  operated  powerfully ; nausea 
removed  ; headache  diminished ; otherwise  the  same.  July  2d. — Since  the  28th 
there  has  been  frequent  vomiting,  for  which  naphtha,  hydrocyanic  acid,  and  other- 
remedies,  have  been  given  without  benefit.  Little  food  has  been  taken.  Loud 
gurgling  audible  under  right  clavicle  ; constant  cough,  with  purulent  expectoration. 
The  surface  is  pale,  and  she  cannot  be  spoken  to  or  touched  without  causing  cries 
and  moaning.  Bowels  open ; stools  natural.  There  has  been  occasional  diarrhoea, 
which  has  been  checked  by  chalk  mixture.  Constant  pains  in  the  head,  with 
great  restlessness  at  night.  Pupils  slightly  dilated ; pulse  lUO,  of  good  strength. 
Abradalur  Capillitium  et  Applicet.  Emp.  Lyttm.  Milk  diet  with  beef  tea  and  wine 
in  small  quantities.  July  1th. — Has  continued  much  the  same  since  last  report, 
the  vomiting  being  considerably  less  frequent  however.  Last  night  it  is  reported 
she  was  comatose,  and  could  not  be  roused,  and  that  convergent  strabismus  of  the 
left  eye  was  undoubtedly  present.  To-day  she  is  lying  on  the  right  side,  the  knees 
drawn  up  to  the  abdomen  ; the  face  pale  ; surface  cool ; respiration  easy.  She  does 
not  answer  questions  or  protrude  her  tongue  when  desired,  although  her  eyes  and 
look  are  intelligent.  No  paralysis.  Metallic  resonance  when  she  speaks  or  cries 
under  right  clavicle.  Pulse  104,  of  good  strength.  Habeat  Calomel,  gr.  ij,  tertid 
qudque  hord.  July  \2th. — There  has  been  alternate  looseness  and  constipation  of 
the  bowels,  the  stools  being  of  a spinach  color.  Sometimes  better,  at  others  com- 
plaining of  great  pain  in  the  head.  The  expression  of  countenance  is  now  worn 
and  haggard,  with  evident  anxiety  ; eye  and  mind  still  peculiarly,  and  even  painfully 
intelligent.  No  convulsion  or  paralysis,  but  great  restlessness  occasionally  at  night. 
At  other  times  she  sleeps  well.  Pulse  is  more  frequent  and  weak,  generally  about 
160  a minute.  Omit.  Pulv.  Calomel.  Habeat  Vini,  §ij,  secundd  qudque  hord. 
July  15<;A.— Has  been  gradually  sinking  since  last  report.  Pulse  180,  feeble.  Still 
intelligent,  and  answers  questions.  Died  at  five  p.m.,  from  exhaustion,  without  pre- 
vious coma,  strabismus,  convulsions,  rigidity,  or  paralysis. 

Sectio  Cadaveris. — Forty-three  hours  after  death. 

Body  greatly  emaciated. 

Head. — On  removing  the  dura  mater  from  the  superior  surface  of  the  hemi- 
spheres, the  arachnoid  covering  them  was  found  unusually  dry,  and  the  pia  mater 
somewhat  pale.  On  stripping  the  membranes  from  the  convolutions,  and  holding 
them  up  before  the  light,  they  could  be  seen  to  be  sprinkled  at  irregular  distances 
with  minute  white  hard  points,  having  the  appearance  of  tubercle,  deposited  in  the 
sub-arachnoid  tissue.  The  glandulte  Pacchioni  could  easily  be  distinguished  from 
them  by  their  situation,  softer  consistence,  and  larger  size.  On  removing  slices 
from  the  hemispheres,  fluctuation  of  fluid  in  the  ventricles  could  readily  be  felt 
below.  A puncture  was  cautiously  made  in  the  roof  of  the  left  lateral  ventricle,  and 
^iiiss  of  colorless  serum  were  removed  with  a pipette.  On  declining  the  head 
towards  the  left  side,  more  fluid  was  removed,  which  had  evidently  passed  from 
the  right  ventricle  into  the  left  through  the  foramen  of  Monro.  This  last  portion 
was  turbid,  and  contained  small  floating  fragments  of  lymph.  On  opening  the 
right  ventricle  it  was  collapsed.  The  foramen  of  Monro  was  the  size  of  a large  pea. 
The  fornix,  internal  walls  of  the  ventricle  and  cerebral  portions  in  the  neighbor- 
hood of  the  ventricles  were  of  pulpy  consistence,  but  of  their  normal  color.  On 
removing  the  brain  from  the  cranium,  the  pons  varolii,  medulla  oblongata,  and 
corpora  albicantia,  were  seen  to  be  covered  with  a layer  of  pale  gelatinous  lymph, 
one-eighth  of  an  inch  in  thickness.  This  layer  only  extended  to  the  medulla 
oblongata  inferiorly,  where  it  passed  through  the  foramen  magnum,  as  was  proved 
by  careful  examination  of  the  spinal  cord,  which  was  healthy  throughout.  The 
third  and  fourth  ventricles  of  the  brain  were  enlarged,  and  distended  with  serum. 
The  left  lateral  ventricle  was  also  enlarged,  especially  its  posterior  and  inferior 
cornua.  The  enlargement  of  the  right  lateral  ventricle  was  confined  principally  to 
the  anterior  cornu. 

Chest. — Pleurae  on  right  side  sprinkled  with  miliary  tubercle,  situated  below 
the  serous  surface.  Both  lungs  studded  throughout  with  hard  miliary  tubercle,  of 
a grey  color ; in  some  places,  however,  it  was  yellow  and  soft.  The  intervening 
pulmonary  tissue  was  of  a bright  red  color,  engorged,  but  pervious  to  air.  In  the 
superior  lobe  of  right  lung  the  tubercles  were  closely  aggregated  together,  and  con- 
tained numerous  anfractuous  cavities  varying  in  size.  Some  were  lined  by  a distinct 


364 


DISEASES  OF  THE  NEKVOUS  SYSTEM. 


membrane,  and  all  were  filled  with  scrofulous  pus.  Heart  and  vessels  healthy.  The 
bronchial  glands  enlarged  from  infiltration  of  yellow  cheesy  tubercle,  mixed  with 
pigmentary  deposit. 

Abdomen. — Liver  of  natural  size.  Gall-ducts  and  gall-bladder  distended  with 
fluid  gx’cen  bile.  Kidneys  healthy  in  size  and  general  structure,  but  the  cortical 
substance  sprinkled  over  with  minute  grains  of  tubercle.  Stomach  healthy.  The 
ilium  was  the  seat  of  tubercular  ulceration  throughout,  situated  principally  in  the 
aggregate  glands.  Large  intestines  healthy.  Mesenteric  and  lumbar  glands  for  the 
most  part  enlai-ged  in  consequence  of  tubercular  infiltration.  Spleen  throughout 
studded  with  yellow  cheesy  tubercle  in  granules  varying  in  size  from  a pin’s  head  to 
that  of  a pea.  Peritoneum  here  and  there  dotted  over  with  hard  miliary  tubercle, 
deposited,  however,  below  the  serous  membrane. 

Microscopic  Examination.— The  pale  gelatinous  lymph  at  the  base  of  the  brain 
was  principally  composed  of  molecular  matter,  in  which  a few  granule  cells  might 
here  and  there  be  detected.  The  turbid  fluid  at  the  floor  of  the  ventricles  contained 
epithelium  cells,  some  of  which  were  undergoing  the  fatty  degeneration.  The  white 
cerebral  softening  contained  no  granules  nor  granule  cells.  The  hard  grey  and  soft 
yellow  tubercles  in  various  parts  of  the  body  were  carefully  examined,  and  were  found 
to  present  their  usual  characters  (Figs.  157,  161). 

Commentary. — Tliis  is  a well-characterised  case  of  acute  hydrocephalus 
in  a child  also  affected  with  general  tuberculosis.  From  the  first  it  was 
certain  that  it  would  be  fatal,  for  in  addition  to  the  cerebral  lesion  we 
had  to  do  with  an  advanced  phthisical  condition.  The  appearances  after 
death  are  strictly  in  accordance  with  all  the  symptoms  which  were  care- 
fully observed  during  life.  Her  mind  throughout  was  unaffected,  except 
when  occasional  drowsiness  or  coma  prevailed,  and  the  circumference  of 
the  hemisjThere  was  normal,  while  the  lesions  observed  were  confined  to 
the  ventricles  and  base  of  the  cerebrum.  Then  there  was  no  paralysis  or 
convulsion,  and  the  softening  of  the  central  parts  was  proved  to  be  serous. 
The  pain,  irritation,  stupor,  and  other  symptoms,  are  readily  explicable 
by  the  tubercular  meningitis  and  gradual  distension  of  the  ventricles 
with  fluid.  Tlie  treatment  was  nutritive,  and  in  obedience  to  the  prac- 
tice of  twenty  years  ago,  an  emetic,  a few  leeches  on  the  head,  and  small 
doses  of  calomel  were  given.  They  were  of  no  benefit,  and  need  never 
be  employed. 

The  nature  of  acute  hydrocephalus  has  been  keenly  disputed,  and, 
whether  it  be  inflammatory  or  non-inflammatory,  and  should  be  treated 
with  antiphlogistics  or  nutrients,  will  be  found  to  be  discussed  at  great 
length  in  systematic  works  and  numerous  monographs. The  fact  is, 
that  the  group  of  symptoms  indicating  the  occurrence  of  water  in  the 
brain  is  altogether  insufiicient  to  prove  the  existence  of  this  morbid  pro- 
duct in  acute  cases.  What  we  observe  are  symptoms  of  excitement, 
gradually  passing  into  those  of  depression,  occasionally  accompanied  with 
paroxysms  of  pain,  restlessness,  and  screaming,  alternating  with  drowsi- 
ness, exhaustion,  and  coma.  The  sesymptoms  are  common  to  various 
lesions  of  the  brain,  and  may  be  the  result  of  mere  congestion,  or  of  this 
state  terminating  in  effusion  and  frequently  in  exudation.  Hence  why 
sometimes  after  death  we  find  no  lesion  whatever ; at  others  more  or 
less  distension  of  the  ventricles  with  serum,  and  very  commonly  in 
addition  exudation  at  the  base  of  the  cranium.  In  every  case  the  symp- 
toms are  referable  not  so  much  to  the  one  or  the  other  of  these  lesions, 
as  to  something  which  they  all  have  in  common,  and  this  undoubtedly  is 

* See  the  author’s  article  on  Hydrocephalus,  iu  the  Library  of  Medicine,  vol.  ii. 
London,  1840. 


ACUTE  HYDROCEPHALUS. 


365 


more  or  less  pressure  on  various  portions  of  the  brain,  causing  first  irri- 
tation and  then  perversion  of  function,  or  so  operating  as  to  excite  some 
parts  and  to  depress  others.  In  the  great  majority  of  cases  the  fluid  dis- 
tending the  ventricles  is  more  allied  to  the  dropsies  than  to  the  exuda- 
tions. Nay,  even  when  lymph  is  thrown  out  at  the  base  of  the  brain, 
the  amount  of  serum  in  the  ventricles  is  altogether  disproportioned  to  the 
quantity  of  coagulated  fibrin  deposited.  Hence  I am  disposed  to  think 
that,  even  when  evidence  of  so-called  inflammation  does  exist,  as  in  Case  ' 
III.,  still  the  fluid  which  distends  the  ventricles  is  owing  to  a mechanical 
obstruction  of  the  vessels,  causing  dropsical  effusion.  As  to  the  central 
white  softening  so  commonly  found  in  hydrocephalic  cases,  it  is,  in  the 
vast  majority  of  instances,  a post-mortem  appearance,  caused  by  mechani- 
cal imbibition  of  the  serum  into  the  porous  substance  of  the  white  tubular 
structure  of  the  brain.  I have  seen  this  softening  most  extensive  in  cases 
where,  immediately  before  death,  the  transmitting  functions  of  the  white 
central  parts  were  perfect ; and  the  fact  that  no  relation  exists  between 
the  symptoms  during  life  and  such  softening  after  death  has  been  noticed 
by  numerous  observers. 

In  a special  work  on  this  subject  (London  : 1843),  Dr.  Risdon 
Bennett,  looking  to  the  scrofulous  character  of  the  children  usually 
affected  with  this  disease,  refers  its  nature  to  “ vital  changes  in  the 
brain,  chiefly  in  the  central  white  parts,  of  the  character  probably  of 
tubercular  degeneration, — and  that  softening,  effusion  into  the  ventricles, 
and  meningitis,  are  all  consequences  of  antecedent  alterations  of  nutri- 
tion ” — Pp.  148-49).  This  view,  which  contains  the  general  truth,  may, 

I think,  now  be  more  specifically  stated  as  follows : — All  circumstances, 
including  scrofula,  which  weaken  the  general  nutrition  of  the  economy, 
tend  to  occasion  languor  and  obstruction  of  the  cerebral  circulation. 
This  defective  nutrition  is,  in  young  children,  especially  liable  to  occasion 
congestions  within  the  cranium,  causing  effusions  and  exudations,  either 
simple  or  tubercular,  and  as  a mechanical  result  of  such  effusion,  those 
softenings  so  frequently  found  after  death.  Such  appears  to  me  the  true 
pathology  of  acute  hydrocephalus,  including  the  “ hydrocephaloid  dis- 
ease ” of  Dr.  Marshall  Hall. 

In  the  treatment  of  this  disease  much  stress  has  been  laid  by  prac- 
titioners on  the  question,  as  to  whether  in  any  given  case  the  symptoms 
are  or  are  not  dependent  on  inflammation,  and  if  so,  what  may  be  the 
character,  seat,  and  stage  of  the  inflammation.  If  the  disease  be  inflam- 
matory, blood-letting,  with  antiphlogistics  and  calomel,  has  been  enjoined.  • 
When,  on  the  other  hand,  it  arises  from  diarrhcea,  or  after  exhaustive 
diseases,  an  opposite  line  of  treatment  has  been  the  rule.  The  profession 
cannot  be  too  grateful  to  Dr.  Marshall  Hall  for  clearly  pointing  out  how 
all  the  symptoms  of  hydrocephalus  frequently  arise  in  children  after  long- 
continued  diarrhoea,  febrile  eruptions,  or  other  exhaustive  causes,  and 
how  they  may  frequently  be  restored  under  such  circumstances  by  nu- 
trients and  stimulants.  But  it  may  now  be  asked  whether,  in  fact,  we 
possess  the  means  of  clearly  distinguishing  the  inflammatory  from  the 
non-inflammatory  forms,  and  whether,  if  we  did,  we  are  justified  in  treat- 
ing the  former  by  antiphlogistic  remedies  ? 

In  reply  to  these  questions,  I would  observe,  in  the  first  place,  that 
all  authors  are  agreed  as  to  the  difficulty  of  separating  acute  hydrocephalus 


366 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


from  remittent  fever,  and  no  one,  so  far  as  I am  aware,  has  ever  pretended 
that  he  coiild  point  out  with  exactitude  the  symptoms  which  distinguish 
cases  in  which  there  are,  and  those  in  which  there  are  not,  exudations  of 
lymph  within  the  cranium.  After  the  most  careful  examination  of  many 
cases,  both  during  life  and  after  death,  I feel  satisfied  that,  conjoined 
with  exactly  the  same  train  of  symptoms,  we  may  sometimes  find  only 
effusion  of  serum  in  the  ventricles,  with  white  softening,  and  at  others 
more  or  less  meningitis  of  the  base.  Again,  I also  feel  satisfied  that 
this  meningitis,  as  proved  after  death  by  the  existence  of  layers  of  lymph, 
so  far  from  indicating  a so-called  sthenic  constitution  in  children,  much 
more  frequently  occurs  in  scrofulous  and  weak  children.  Of  this.  Case 
III.  is  an  example,  where  with  phthisis  and  general  tuberculosis,  there 
was  found  conjoined  with  etfusion  into  the  ventricles,  inflammatory  ex- 
udation at  the  base  of  the  cranium.  The  distinctions,  therefore,  hitherto 
so  much  dwelt  upon,  of  two  distinct  forms — an  inflammatory  and  a non- 
inflammatory— as  guides  of  treatment,  have  no  real  existence,  and  are 
opposed  to  all  positive  research,  as  well  as  to  a large  experience  in  the 
observation  and  treatment  of  individual  cases.  When,  in  addition,  it  is 
considered  that  all  the  symptoms  of  acute  hydrocephalus  are  referable  to 
more  or  less  pressure  on  different  parts  of  the  brain ; that  this  pressure 
may  be  occasioned  by  congestion,  effusion,  or  exudation  ; and  that  we 
have  no  means  of  determining  which  or  how  much  of  each  is  present  in 
any  individual  case,  it  must,  I think,  be  certain  that  it  is  impossible  in 
the  vast  majority  of  cases,  and  highly  doubtful  in  all,  to  determine  the 
existence  of  meningitis  or  cerebritis  as  a concomitant  of  acute  hydro- 
cephalus. Lastly,  the  symptoms  of  the  “ hydrocephaloid  disease,”  so 
well  described  by  Dr.  Marshall  Hall,  in  which  all  the  phenomena  of 
hydrocephalus  occur,  and  which  are  only  distinguishable  by  the  circum- 
stance that  they  originate  from  exhaustive  causes,  should  alone  make  us 
pause  before  we  have  recourse  to  a lowering  system  of  practice. 

But  supposing  we  had  the  power  to  detect  in  any  given  case  the 
occurrence  of  active  exudation  going  on  within  the  cranium,  should  we 
even  then  be  justified  in  having  recourse  to  blood-lettirg,  general  or 
local  ? The  considerations  we  have  previously  entered  into  (p.  268,  et 
seq.) — first,  as  to  the  incompetency  of  this  remedy  (and  of  antiphlogistics 
generally  ) to  meet  the  end  in  view  ; and,  secondly,  as  to  the  fact  that  we 
can  only  reach  the  circulation  within  the  cranium  by  influencing  the 
force  of  the  heart  (p.  148,^^  seq.) — are  sufficient  answers  to  this  question. 
It  follows,  then,  that  the  uncertainty  of  diagnosis,  as  well  as  the  evil  ef- 
fects likely  to  result  from  a lowering  practice  in  these  cases  which  almost 
always  occur  in  weak  children,  are  not  only  opposed  to  it,  but  perhaps 
sufficiently  explain  the  acknowledged  great  mortality  of  the  disease.  For 
the  like  reasons  the  use  of  calomel  to  cause  absorption  of  matters,  whose 
existence  we  have  no  means  of  detecting,  appears  equally  unreasonable, 
even  supposing  it  had  been  proved  to  possess  an  absorbing  power,  which 
it  certainly  has  not. 

On  the  other  hand,  the  two  first  eases  we  have  recorded  are  examples 
of  what  may  be  done  by  an  opposite  plan  of  treatment  in  acute  hydro- 
cephalus, and  in  the  third  case,  we  believe  the  practice  followed  to  have 
been  the  only  warrantable  one  in  the  desperate  and  necessary  fatal  cir- 
cumstances. It  bore  reference  to  improving  the  general  constitution  and 


CEREBRAL  MENINGITIS. 


367 


nutritive  powers  of  the  patient,  which  in  all  cases  connected  with  a 
scrofulous  habit  are  the  indications  to  be  more  or  less  energetically  fol- 
lowed according  to  the  severity  and  duration  of  the  disease.  The  calo- 
mel given  as  an  alterative  utterly  failed. 

CEREBRAL  MENINGITIS. 

Case  I Y.* General  Acute  Meningitis  supervening  on  Pleuro- Pneumonia, 

History. — David  Murray,  set.  43,  a coal-heaver — admitted  January  18,  1854. 
He  has  been  an  intemperate  man,  and  a week  previous  to  admission  was  seen  by 
one  of  the  pupils  to  be  atfected  by  delirium  tremens.  He  now  says,  that  on  the  13th 
(which  was  the  first  day  of  thaw  after  frost  and  snow)  he  was  much  exposed  to  the 
weather  while  at  work,  but  felt  no  ill  efiects  until  the  morning  of  the  15th  at  four 
o’clock,  when  he  awoke  very  sick,  and  vomited  several  times.  He  kept  his  bed, 
feeling  feverish,  and  in  the  afternoon  began  to  cough.  On  the  morning  of  the  16th 
he  experienced  a sharp  pain  in  the  right  chest,  about  three  inches  below  the  nipple, 
which  was  increased  by  coughing  and  inspiring  deeply,  and  prevented  his  lying  on 
that  side.  Has  had  no  rigor  nor  headache. 

Symptoms  on  Admission. — On  admission,  respiration  is  impeded  by  interrupted 
inspirations  which  give  pain.  Over  the  lower  half  of  the  right  lung  posteriorly, 
there  is  marked  dulness  on  percussion,  loud  crepitation  on  insjiiration,  and  broncho- 
phony. The  sputa  are  scanty,  consisting  of  gelatinous  matter,  with  rusty  brown 
patches.  No  dyspnoea.  Pulse  120,  strong  and  full ; skin  hot  and  dry ; tongue 
dry,  furred,  and  fissured  ; great  thirst ; no  appetite  ; bowels  open,  lias  no  headache 
at  present,  but  says  he  is  restless  at  night,  and  sleeps  badly.  Other  functions 
normal.  To  have  one-third  of  a grain  of  tartrate  of  antimony  in  solution  every  two 
hours. 

Progress  of  the  Case. — Tanuaru  Tld. — Since /last  report  the  pneumonia  has 
followed  its  usual  course. — (See  Pneumonia.)  On  the  20th  crepitation  had  dis- 
appeared, but  has  returned  to-day.  Yesterday  evening  was  ordered  a diuretic 
draught,  containing  Sp.  AEdier.  Nit.  3 j.  The  pulse  130,  weak,  and  at  the  visit  his 
replies  to  questions  were  a little  confused.  January  23(7. — Yesterday  afternoon  he 
was  observed  to  mutter  incoherently,  but  remained  quiet  until  eight  p.m.,  when  he 
became  violently  delirious.  He  had  a very  wild  and  fierce  expression  of  eye  and 
countenance,  insisted  on  getting  up,  would  npt  be  controlled,  and  struggled  violently 
with  those  who  endeavored  to  restrain  him.  He  spoke  little,  but  made  incoherent 
noises.  The  pupils  were  much  dilated  ; the  pulse  very  rapid  and  weak.  The  head 
was  shaved.,  and  constant  cold  applied.  Prostration,  however,  coming  on,  wine  and 
stimulants  were  given  freely.  He  continued  now  and  then  to  struggle  violently ; 
strabismus  was  apparent  latterly.  Died  exhausted  at  five  o’clock  a.m.  this  morning. 

Sectio  Cadaveris. — Thirty-one  hours  after  death. 

Body  greatly  emaciated. 

Head. — On  removing  the  skull-cap,  the  dura  mater  presented  a uniform  yellowish 
tint,  dependent  on  a recent  exudation  below  it.  On  removal,  the  subarachnoid 
tissue  was  infiltrated  with  a soft  exudation,  which  covered  the  entire  surfiice  of  both 
hemispheres,  and  of  the  cerebellum.  It  was  as  abundant  at  the  base  as  on  the  supe- 
rior surface  of  the  brain.  On  cutting  into  the  cerebral  substance,  it  was  observed 
that  the  yellow  exudation  accompanied  the  inflexions  of  the  pia  mater  between  the 
convolutions.  The  lateral  ventricles  contained  § iss  of  turbid  serum.  The  lining 
walls  of  the  ventricles  were  a little  congested ; the  choroid  plexuses  healthy.  The 
septum  lucidum  rather  soft,  but  the  other  portions  of  the  brain  normal. 

Thorax. — Three  lower  fourths  of  the  right  lung  presented  the  characters  of  grey 
hepatization  posteriorly.  The  anterior  surfaces  were  healthy.  The  pleune  covering 
this  lung  were  partially  adherent,  with  some  shreds  of  recent  lymph.  Other  thoracic 
organs  healthy. 

Abdomen. — The  liver  enlarged,  weighing  6 lbs.  4 oz.,  of  pale  color,  and  soft.  The 
spleen  also  soft  and  pulpy.  Other  abdominal  organs  healthy. 

Microscopic  Examination. — The  exudation  poured  out  in  the  subarachnoid 

* Reported  by  Mr.  Robert  Bird,  Clinical  Clerk. 


368 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


cavity  had  everywhere  undergone  the  transformation  into  pus.  The  turbid  fluid  in 
the  lateral  ventricles  also  contained  some  pus,  with  a few  epithelial  cells.  The 
cerebral  tissue  was  healthy.  The  liver  cells  contained  an  unusual  amount  of  fatty 
granules.  The  pneumonic  portion  of  the  right  lung  was  infiltrated  with  fluid  mole- 
cular matter  and  pus  corpuscles,  most  of  which  were  more  or  less  collapsed,  and  all 
of  them  very  granular.  The  whole  evidently  in  a state  of  disintegration. 

Commentary. — In  this  man,  who  was  intemperate,  and  laboring 
under  pneumonia,  whicli  was  progressing  favorably,  there  supervened 
at  noon  on  the  seventh  day  of  the  disease  a little  confusion  in  his  ideas, 
which  in  the  course  of  the  afternoon  passed  into  violent  delirium,  caus- 
ing strabismus  and  dilated  pupils.  At  night  he  became  comatose,  and 
died  at  five  o’clock  next  morning.  At  the  commencement  of  the  pneu- 
monia he  had  vomited,  a symptom  perhaps  referable  in  him  to  cerebral 
irritation,  a condition  which  the  febrile  state  he  was  subsequently  thrown 
into,  however,  did  not  appear  to  augment  in  any  unusual  degree.  On 
examining  the  head  after  death,  the  subarachnoid  cavity  and  involutions 
of  the  pia  mater  over  the  whole  surface  of  the  brain  were  loaded  with 
purulent  matter,  and  | iss  of  turbid  serum  was  effused  into  the  lateral 
ventricles.  This,  therefore,  was  an  instance  of  very  rapid  death  from 
meningitis,  a result  partly  attributable  to  his  previous  intemperate  habits, 
and  partly  to  the  circumstance  that  the  disease  appeared  at  a time  when 
he  was  already  much  exhausted  by  the  pneumonic  attack.  In  this,  as  in 
Case  III.,  it  is  observable  that  the  occurrence  of  extensive  exudation  is 
in  no  way  incompatible  with  depression  of  the  bodily  powers,  a fact  alto- 
gether opposed  to  tliG  supposed  connection  between  inflammation  and  a 
sthenic  state  of  the  constitution.  In  fact,  the  extent  as  well  as  the 
fatality  of  the  cerebral  disease  is  probably  to  be  attributed  to  the  ex- 
haustion of  the  vital  powers  at  the  time  of  its  occurrence. 

The  pneumonia  went  through  its  usual  progress,  and  on  the  day  when 
the  meningitis  commenced,  the  returning  crepitation  was  audible.  On 
examination  after  death,  the  whole  pulmonary  exudation  was  found 
softened  and  converted  into  pus,  which  was  already  undergoing  rapid 
disintegration.  (See  Pneumonia.) 


Case  V.* — Acute  Meningitis  at  the  Base  of  Brain — Serous  Effusion  into 
the  Ventricles.,  with  white  softening  of  cerebral  substance — Phthisis. 

History. — Helen  Walker,  ast.  21,  a servant — admitted  July  4,  1853.  8he  has 
for  some  years  been  subject  to  cough  and  dyspnoea,  but  says  she  never  had  any  serious 
illne.ss  until  eleven  days  ago.  She  then  experienced  rigor,  pain  in  the  head,  thirst, 
and  other  febrile  symptoms.  The  headache  has  been  variable  in  intensity,  being 
sometimes  slight,  at  others  very  severe. 

Symptoms  on  Admission. — On  admission,  she  appears  to  be  very  weak  and 
languid.  Complains  of  severe  frontal  headache  which  is  increased  towards  night. 
The  eyes  are  dull  and  heavy ; pupils  unaffected.  No  muscae  volitantes,  tinnitus 
aurium,  or  vertigo.  Is  quite  conscious,  but  has  a tendency  to  stupor.  The  febrile 
symptoms  have  now  for  the  most  part  disappeared.  No  thinst  ; appetite  impaired  ; 
tongue  furred ; pulse  84,  .soft.  On  examination  of  the  chest,  all  the  signs  of  phthisis, 
with  cavities  in  both  lungs,  were  detected.  The  other  functions  are  normal,  ^he 
requested  to  have  an  emetic,  which  had  previously  relieved  her,  and  one  of  ipecacu- 
anha and  sul|)hate  of  zinc  was  given. 

Progress  of  the  Case. — July  oth. — The  emetic  has  not  produced  the  same 


* Reported  by  Mr.  G.  C.  Pirrie,  Clinical  Clerk. 


CEREBRAL  MENINGITIS. 


3C9 


relief  as  formerly.  Headache  continues.  In  other  respects  the  same.  Six  leeches 
to  he  applied  to  the  temples.  July  6<A.— Last  night  wandering  of  the  mind,  with  . 
slight  delirium.  To-day,  great  depression,  and  stupor.  As  the  bowels  have  not 
been  relieved,  to  have  a drop  of  croton  oil,  on  sugar,  to  be  followed  by  an  enema,  if 
necessary.  Head  to  be  shaved^  and  cold  applied.  Beef  tea  ayid  nutrients.  July  1th. 
— Last  night  great  incoherence  of  mind,  with  raving.  To-day  at  visit,  still  mutter- 
ing.  Eyes  are  heavy ; pupils  contracted ; tongue  moist  and  white.  Takes  no 
no'urishment ; bowels  open;  pulse  120,  regular,  but  weak.  July  Uh.—^o  change. 
Coma  coming  on.  A blister  to  be  applied  to  the  occiput.  July  9th. — Coma,  with 
occasional  low  muttering  delirium  ; picking  at  the  bed-clothes ; pulse  almost  imper- 
ceptible. Died  on  the  morning  of  the  10  th. 

Sectio  Cadaveris. — Thirty-six  hours  after  death. 

Body  thin  but  not  much  emaciated. 

Head. — The  arachnoid  surfaces  were  very  dry.  The  lateral  ventricles  contained 
about  § of  slightly  turbid  serum.  The  walls  of  the  ventricles  and  central  white 
portions  of  the  brain  in  their  neighborhood  were  pultaceous,  and  easily  broke  down 
under  a stream  of  water,  presenting  a rough  surface,  and  on  section  a ragged  edge, 
but  retaining  their  natural  color.  At  the  base  of  the  brain,  the  crura  cerebri  are 
surrounded  with  soft  yehow  exudation,  which  is  situated  in  the  subaraclmoid  cavity, 
and  extends  to  the  thalami  optici,  and  slightly  into  the  locus  perforatus  posticus. 
No  tubercle  can  be  seen  in  the  meninges,  and  about  § ij  of  serum  were  collected  in. 
occipital  depressions  after  removal  of  the  brain. 

Chest. — Both  lungs  were  infiltrated  with  tubercle,  especially  the  upper  lobes. 
A cavity  the  size  of  a hazel-nut  at  the  summit  of  left  lung,  and  there  were  several  in 
the  upper  lobe  of  right  lung,  communicating  with  one  anotlier. 

Abdomen. — Abdominal  organs  healthy. 

Microscopic  Examination. — In  the  slightly  turbid  fluid  of  the  ventricles  were 
several  epithelial  cells  from  the  choroid  plexuses,  undergoing  the  fatty  degeneration. 
The  pultaceous  white  softening  surrounding  the  ventricles  contained  no  granule  c^’lls 
or  masses,  and  consisted  of  the  tubes,  easily  broken  down  between  glasses,  presenting 
numerous  large  varicosities,  circles  with  double  lines,  etc.  (Fig.  404)^.  The  exudation 
at  the  base  was  chiefly  molecular,  with  here  and  there  traces  of  pus. 

Commentary. — This  case  is  in  many  respects  like  those  formerly 
given  under  the  head  of  acute  hydrocephalus,  and  serves  to  illustrate  the 
occurrence  of  acute  meningitis  with  serous  effusion,  in  a phthisical  and 
exhausted  subject.  In  this,  as  in  the  instances  referred  to,  the  leeches^ 
applied  to  the  temples,  with  a view  of  relieving  the  headache,  were  of  no 
benefit  whatever,  even  temporarily.  The  day  after  their  application  all 
the  symptoms  and  weakness  were  more  pronounced  ; in  other  words,  the 
disease  proceeded  onwards  towards  the  fatal  termination.  The  structure 
of  the  exudation  at  the  base  of  the  cranium,  and  the  incipient  fatty  de- 
generation in  the  serum  of  the  ventricle.5,  indicate  that  these  lesions  were 
of  much  longer  standing  than  might  have  been  supposed  from  a consid- 
eration merely  of  the  symptoms  of  the  case. 

Case  VI. — Acute  Meningitis  at  the  base  of  the  Brain — Effusion  of 

Serum  into  the  Lateral  Ventricles — Effete  Tubercle  in  the  Pons 

Varolii  and  Lungs. 

History. — John  Robertson,  aet.  35,  a discharged  soldier — admitted  June  25, 
1850.  He  has  been  of  intemperate  habits,  and  latterly,  owing  to  poverty,  has  had 
a very  poor  diet,  and  been  insufficiently  clothed.  On  the  13th  he  first  experienced 
headache  and  febrile  symptoms.  On  the  21st  there  was  vomiting,  with  cough  and 
expectoration,  and  on  the  23d  great  restlessness  and  delirium  at  night.  These  symp- 
toms have  continued  ever  since. 

Symptoms  on  Admission. — On  admission  he  is  in  a state  of  great  prostration. 
He  lies  quietly  on  his  back,  frequently  talking  incoherently,  but  is  easily  roused 


24 


Reported  by  Mr.  David  Christison,  Clinical  Clerk. 


370 


DISEASES  OE  THE  NERVOUS  SYSTEM. 


when  spoken  to,  and  then  answers  questions  sensibly.  Countenance  pale-,  eyes 
suffused ; pupils  rather  contracted.  He  has  no  pain  anywhere.  His  hands  and 
arms  are  in  a constant  state  of  tremor,  the  former  engaged  in  clutching  the  bed- 
clothes. Evacuations  normal,  not  involuntary ; tongue  white  and  dry  ; deglutition 
difficult ; chest  everywhere  resonant ; expiration  prolonged  and  harsh';  little  (;ouo-h 
at  present,  and  no  expectoration  ; pulse  64,  feeble.  Has  been  treated  before  adnns- 
sion  with  calomel  and  antimonials.  To  have  | iij  of  whisky  daily  with  nutrients. 
3 Sp.  jEtlur.  ML  3 ss  ; Mist.  Scillce,  I iiiss  ; Aquee,  I jss.  M ISumat  ? ss  quavtd 
qadque  hard.  Head  to  be  shaved  and  a blister  applied. 

pROGRi  ss  OF  THE  Case. — .June  26^/t. — Passed  a restless  night,  with  considerable 
delirium.  To  day  is  no  better.  Moist  rales  audible  at  the  base  of  lungs  posteriorly. 
Weakness  increasing.  To  have  nutrients.  June  21th. — Has  refused  all  kinds  of 
food  and  drink.  Coma  is  now  coming  on.  The  extremities  are  cold ; face  livid ; 
respiration  laborious ; pulse  60,  can  scarcely  be  felt.  The  urine  has  been  drawn  off 
by  catheter,  and  is  quite  normal.  Bowels  not  open  for  two  day's.  3 Ammon.  Carb. 
gr  xviii.  ; Mist.  Comph.  § iv  ; Solve.  Sumat  § ss  quartd  pidque  hord.  June  28^/i. 
— Became  gradually  weaker,  and  expired  at  four  o’clock  this  mo.'ning. 

Sectio  Cadaveris. — Twenty-four  hours  after  death. 

Body  somewhat  emaciated. 

Head. — The  convolutions  on  the  surface  of  the  cerebral  hemispheres  were  some- 
what flattened,  but  not  preternaturally  dry.  The  substance  of  the  brain  was  normal. 
The  lateral  ventricles  distended  with  turbid  serum,  slightly  tinged  with  blood,  to  the 
extent  of  § ij.  Central  substance  of  brain  healthy.  The  subarachnoid  tissue  at  the 
base  everywhere  infiltrated  with  recent  coagulated  lymph.  In  the  substance  of  the 
pons  varolii  was  a tubercular  mass,  the  size  of  a pea,  firm  externally,  soft  towards  the 
centre,  and  surrounded  by  a zone  of  congested  vessels.  The  membranes  covering  the 
hemispheres,  and  other  portions  of  the  brain,  healthy. 

Thorax. — Heart  healthy.  Pleurae  on  both  sides  adherent  by  chronic  bands  of 
lymph,  especially  at  the  apices  of  the  lungs.  Here  both  lungs  w ere  indurated  and 
puckered,  and  contained  several  cretaceous  and  calcareous  concretions.  Their  an- 
terior margins  were  emphysematous,  and  the  posterior  and  inferior  portions 
engorged,  and  the  bronchi  more  or  less  filled  with  purulent  mucus.  Here  and 
there,  scattered  throughout  the  inferior  portions  of  both  lungs  were  masses  of  old 
tubercle  converted  into  calcareous  matter,  and  varying  in  size  from  a barley-corn  to 
that  of  a cherry-stone. 

Abdomen. — Abdominal  organs  healthy. 

Microscopic  Examination. — The  turbid  serum  in  the  lateral  ventricles  con- 
tained numerous  granule  cells,  and  a few  blood  corpuscles.  The  lymph  at  the  base 
of  the  brain  was  molecular,  wdth  here  and  there  masses  of  pus  corjiuscles  in  a state  of 
disintegration.  The  cerebral  substance  around  the  tubercular  mass  in  the  pons 
varolii  was  healthy. 

Commentary. — In  tins  case  prostration  was  so  marked  that  stimu- 
lants and  nutrients  were  given  on  liis  admission,  but  without  the  effect  of 
overcoming  his  exhaustion.  It  is  to  be  observed,  that  although  formerly 
of  a tuberculous  constitution,  which  had  left  traces  of  its  existence, 
both  in  the  brain  and  lungs,  he  had  overcome  this  to  such  a degree  that 
on  exposure  once  again  to  exhausting  causes,  a simple  or  inflammatory 
rather  than  a tubercular  exudation  was  the  result.  The  structure  of  the 
exudation  at  the  base  of  the  cranium,  and  the  granule  cells  in  the  serous 
fluid  of  the  ventricles,  indicated  that  the  lesion  was  already  somewhat 
chronic.  In  this,  as  well  as  the  preceding  case,  it  appears  to  me  that 
the  original  lieadaclio  and  fever  indicated  the  period  of  congestion  and 
exudation,  that  vomiting  pointed  to  commencing,  and  stupor  to  more 
intense  pressure  from  the  subsequent  effusion. 

The  seat  of  meningitis  is  the  so-called  subarachnoid  cavity,  in  which 
there  is  a quantity  of  loose  areolar  tissue,  richly  furnished  with  blood- 
vc_sels.  It  generally  results  that  the  exudation  poured  into  this  cavity. 


CEREBRAL  MENINGITIS. 


371 


instead  of  undergoing  the  transformation  into  fibres,  which  usually  occurs 
on  serous  surfaces,  follows  the  law  which  regulates  its  passage  into  pus. 
Hence  I have  ascertained  that  what  is  generally  called  a recent  layer  of 
coagulable  lymph,  covering  the  convolutions  in  meningitis,  is,  in  point  of 
fact,  a layer  of  pus.  That  the  exudation  should  not  readily  be  poured 
out  into  the  cavity  of  the  arachnoid  is  explicable  by  the  circumstance, 
that  the  solid  and  unyielding  walls  of  the  cranium  would  oppose  any 
tendency  to  the  enlargement  of  that  space.  Indeed,  the  greater  the 
amount  of  exudation  or  etfusion,  especially  in  the  deeper  parts  of  the 
brain,  the  more  would  the  two  layers  of  the  arachnoid  be  compressed 
together,  and  hence  arises  the  dryness  of  this  membrane  in  meningitis 
with  effusion  into  the  ventricles. 

The  exudation  in  acute  meningitis  will  be  found  to  consist  princi- 
pally of  pus  corpuscles,  presenting  an  unusually  molecular  character,  and 
associated  with  numerous  loose  molecules  and  granules.  In  the  chronic 
forms  the  pus  corpuscles  are  seen  to  be  broken  down,  and  the  whole  is 
reduced  to  an  amorphous  granular  mass,  more  or  less  mingled  with  fat 
granules.  The  blood-vessels,  also,  which  enter  into  this  mass  may  fre- 
quently be  seen  undergoing  the  fatty  degeneration.  When  the  ventricles 
are  the  seats  of  exudation,  there  are  generally  in  the  fluid  epithelial  cells 
of  a globular  form,  which  present  various  appearances  according  as  they 
are  swollen  through  endosmose,  or  have  undergone  the  fatty  degeneration 
and  become  granular  cells.  I have  also  noticed  a great  variety  of  changes 
in  the  villi  of  the  choroid  plexus  under  such  circumstances.  Occasion- 
ally their  epithelial  coating  is  much  increased  in  thickness,  and  at  other 
times  is  raised  up  in  the  form  of  small  bullm,  being  probably  the  inci- 
pient stage  of  simple  cystic  formation.  They  frequently  also  contain  a 
greater  or  less  number  of  the  amyloid  bodies  represented  Fig.  392,  the 
connection  of  which  with  active  disease  in  the  ventricles,  however,  has 
not  yet  been  demonstrated. 

As  to  the  diagnosis,  notwithstanding  the  efforts  which  have  been  made 
to  distinguish  meningitis  of  the  convolutions  from  that  of  the  base,  or 
cither  of  these  from  a simple  effusion  into  the  ventricles,  I have  in  vain 
sought  for  any  precise  symptoms  which  could  be  relied  on  as  indicative 
of  the  situation  of  the  disease.  Pain  in  the  head,  vomiting,  drowsiness, 
and  coma,  causing  slow  and  subsequently  rapid  pulse,  succeeded  by  more 
or  less  jactitation  and  convulsion  before  death,  are  the  leading  symptoms. 
The  gradual  mode  of  invasion,  and  the  succession  of  these  symptoms  to 
one  another,  are  also  characteristic,  and  differ  from  those  which  attend 
sudden  attacks  caused  by  hemorrhage,  and  the  slow  progress  of  chronic 
cerebritis.  They  are  all  the  results  evidently  of  general  pressure  on  the 
brain,  and  hence  why  mere  effusion  cannot  be  distinguished  from  menin- 
gitis. The  febrile  state  attending  meningitis  cannot  be  depended  on  as 
a source  of  distinction,  and  the  other  symptoms  are  pretty  much  the 
same. 

Hitherto  the  treatment  of  meningitis,  whether  real  or  supposed,  has 
been  antiphlogistic,  but  it  is  impossible  to  say  that  any  benefit  has  ever 
been  effected  by  the  practice.  The  early  stage  of  the  disease  is  generally 
overlooked,  the  vomiting  and  pain  in  the  head,  so  long  as  the  patient 
retains  his  consciousness,  seldom  leading  to  a suspicion  of  meningitis. 
It  is  only  when  exudation  or  effusion  has  been  poured  out  in  such  quan- 


372 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


tity  as  to  cause  drowsiness  and  stupor  that  our  suspicions  are  awakened, 
and  thus  it  is  very  difficult  to  understand  how  bleeding  or  purging  could 
facilitate  its  absorption.  Besides,  we  have  seen  that  the  tendency  of 
such  exudation  is  to  pass  into  pus ; hence  the  treatment  which  favors 
the  transformation  of  cell  growth,  as  previously  explained  (Section  III. 
p.  275,  et  seq.)^  must  be  the  most  effectual.  For  this  purpose  time  is 
required,  and  the  vital  strength,  instead  of  being  lowered,  should  be  sup- 
ported. It  becomes,  however,  in  actual  practice  very  difficult  to  carry 
out  these  indications.  The  drowsiness  and  coma  greatly  interfere  with 
the  means  we  possess  of  nourishing  the  patient,  because  aliment  cannot 
be  introduced  in  sufficient  quantity,  whilst  the  depression  of  the  nervous 
force  so  disorders  the  whole  glandular  system  as  to  occasion  a profound 
alteration  of  the  nutritive  functions.  Under  such  circumstances  the 
mucous  membranes  become  deranged,  the  tongue  and  throat  parched,  the 
stomach  contracted,  the  bowels  constipated,  and  it  often  has  appeared  to 
me  that  under  such  circumstances  patients  literally  die  of  exhaustion 
from  want  of  food.  The  tissues  become  deteriorated,  while  the  absence 
of  volition  and  sensation,  as  in  cases  of  fever,  favors  the  sloughing  pro- 
cess over  the  dependent  parts  of  the  body,  which  are  continuously  pressed 
upon.  All  these  changes  are  remarkably  well  seen  in  those  cases  of  the 
disease  which  occur  without  any  complication,  and  when  the  tissue  of  the 
brain  itself  is  free  from  organic  lesion.  In  such  instances  a man  is  de- 
prived of  his  intellectual  faculties  merely  ; he  is  reduced  to  the  condition 
of  an  animal  which  has  lost  its  cerebral  lobes ; but  the  man  cannot  be 
kept  alive  in  consequence  of  the  pressure  on  the  encephalon  deranging 
the  nutritive  functions,  whereas  a bird,  after  the  experiment,  may  be  fed 
and  retain  its  vitality  for  months.  Still  the  duty  of  the  medical  prac- 
titioner is  to  support  the  economy  as  much  as  possible — to  give  nutrients 
with  moderate  stimulants — to  foresee  the  possibility  of  sloughs  forming 
on  the  back  and  nates,  and  do  all  in  his  power  to  prevent  them — to  un- 
load the  bowels  and  bladder  from  time  to  time  artificially,  and  thus,  as 
far  as  possible,  counteract  their  torpid  action — and  in  this  way  endeavor 
to  gain  time,  which  will  enable  the  exudation  to  pass  through  its  natural 
transformations,  and  ultimately  to  be  absorbed. 

It  has  always  appeared  to  me  that  the  collection  of  mere  serous 
fluid,  whether  in  the  ventricles  or  over  the  surface  of  the  brain,  either 
with  or  without  exudation,  is  consecutive  on  obstruction  of  the  vessels, 
and  is  therefore  more  allied  to  the  dropsies  than  to  the  inflammations. 
Thus,  when  lymph  is  poured  into  the  subarachnoid  tissue  at  the  base, 
it  compresses  the  vessels  leading  to  the  choroid  plexuses  and  lining 
membrane  of  the  ventricles,  and  so  induces  effusion  ; and  consequently 
effusion  follows,  and  does  not  precede  the  exudation.  It  is  the  collec- 
tion of  serum  which  does  the  mischief,  presses  on  the  brain,  and  causes 
the  somnolence  and  coma.  If  so,  the  occurrence  of  these  symptoms 
should  be  regarded  as  secondary  instead  of  as  primary,  and  as  analo- 
gous to  the  ascites  or  anasarca  following  hepatic  or  renal  disease.* 

* This  view  was  singularly  confirmed  by  a case  which  entered  my  clinical  ward 
during  the  summer  of  1857.  It  was  that  of  George  M‘Leod,  mt.  25,  a policeman,  of 
sound  constitution.  A month  before  admission  he  experienced  headache,  which  grad- 
ually increased  iu  intensity.  Nine  days  before  admission  vomiting  came  on,  which  was 


CEREBRAL  MENINGITIS. 


373 


I have  occasionally  seen  in  the  ventricles  of  the  brain  what  may  be 
called  a desquamative  meningitis,  occasioned  by  the  same  minute 
changes  which  cause  the  corresponding  disorder  in  the  kidneys.  These 
pathological  considerations  are,  it  appears  to  me,  wholly  opposed  to  the 
idea  of  blood-letting  and  antiphlogistics  being  beneficial  after  exudation 
and  effusion  has  occurred. 

Case  VII."^ — Chronic  Meningitis — Serous  effusion  into  the  Ventricles — 
Tubercular  mass  in  left  loloe  of  the  Cerebellum — Cretaceous  tubercle 
in  the  lungs,  with  fibrous  cicatrix. 

H ST  )UY. — James  Scott,  aet.  30,  a writer’s  clerk — admitted  October  29,  1S49. 
The  only  account  that  can  be  obtained  of  him  is  that  he  was  seized  with  vomiting 
about  a week  ago,  and  has  been  ill  ever  since. 

Symptoms  os  Admission  — On  admission  he  seems  to  be  laboring  under-  mental 
oppression.  Tiiere  is  a considerable  deafness  and  confusion  of  ideas,  so  that  he  can- 
not answer  questions  He  does  not  complain  of,  nor  does  he  appear  to  suffer  pain. 
The  eyes  are  somewhat  suffused.  Tongue  covered  with  a moist  fur.  Skin  hot  and 
dry.  Pulse  70,  full.  Drinks  freely  when  water  is  given  him.  Xo  paralysis  can  be 
detected.  Otlier  functions  normal.  Head  to  be  shaved,  and  cold  applied.  A saline 
mixture. 

Progress  op  the  Case. — October  30. — In  the  same  state,  the  bowels  have  been 
freely  moved.  Some  headache,  with  wandering  of  ideas.  §viij  of  blood  to  be  re- 
moved by  cupping  from  the  neck.  October  31. — Xo  relief  from  loss  of  blood.  Stupor 
more  pronounced,  with  slight  twitchings  in  the  face  and  hands.  At  the  visit,  coma  is 
complete.  To  have  a turpentine  injection.^  but  he  expired  about  1 p.m. 

Sectio  Cadaveris. — Twenty-four  hours  after  death. 

Body  robust  and  well  formed. 

Head. — On  removing  the  calvarium  the  cerebral  meninges  were  unusually  dry, 
and  the  convolutions  somewhat  flattened.  The  lateral  ventricles  were  much  dis- 
tended, and  contained  § ij  of  clear  fluid.  Cerebral  substance  firm  and  normal.  The 
left  lobe  of  the  cerebellum  was  firmly  adherent  to  the  dura  mater  covering  it.  On 
being  cut  through,  there  was  found  a hardened  mass  embedded  in  it,  the  size  of  a 
pigeon’s  egg,  resting  inferior! y on  a thin  stratum  of  the  softened  cerebellar  structure, 
about  one-eighth  of  an  inch  in  thickness,  and  of  a reddish  hue.  It  was  of  yellowish 
color  and  cheesy  consistence,  most  dense  in  the  centre.  Other  portions  of  the  brain 
healthy. 

Chest. — The  pleurae  at  the  apices  of  both  lungs  were  coherent  by  chronic  bands 
of  lymph.  Immediately  below  the  adhesions  on  both  sides  were  several  cretaceous 

frequently  repeated  after  taking  food.  On  admission  he  was  drowsy,  and  rapidly 
became  comatose,  the  pulse  60,  respirations  slow.  During  the  subsequent  nine  days 
he  was  two  or  three  times  less  soporous,  and  on  one  occasion  even  answered  questions 
confusedly.  Latterly  the  pulse  became  rapid,  and  he  died  without  convulsion  or 
paralysis.  A post-mortem  examination  showed  the  presence  of  a firm,  chronic  exu- 
dation, upwards  of  one-eighth  of  an  inch  thick  at  the  base,  surrounding  the  basilar 
and  carotid  arteries  and  infiltrated  through  the  subarachnoid  cavity,  so  as  to  sur- 
round the  pons  varolii.  The  ventricles  contained  § ij  of  clear  serum.  The  indura- 
tion, on  microscopic  examination,  was  shown  to  be  chronic,  and  with  its  contained 
vessels  commencing  to  undergo  the  fatty  degeneration.  The  serum  contained  nothing 
but  a few  epithelial  cells.  In  this  case  cupping,  leeches,  ice  applied  to  the  shaven 
scalp,  and  counter-irritants,  were  of  no  benefit  whatever,  and  the  only  thing  that 
appeared  to  do  good  was  unloading  the  bowels  by  means  of  enemata ; latterly,  brandy 
and  beef-tea  were  administered.  I am  of  opinion  that  the  exudation  at  the  base  was 
poured  out  long  before  he  entered  the  house,  but  that  the  subsequent  effusion  into  the 
ventricles,  producing  pressure  on  the  brain,  and  causing  the  coma,  came  on  after  his 
admission. 


Reported  by  Mr.  Alexander  Christison,  Clinical  Clerk. 


374 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


enc}^sted  masses,  about  the  size  of  peas,  surrounded  by  dark,  indurated  pulmonary 
tissue.  On  the  external  surface  of  the  apex  of  the  left  lung  was  a dense  fibrous 
cicatrix,  three-fourths  of  an  inch  long.  The  bronchial  glands  were  enlarged,  and 
infiltrated  with  chronic  tubercle  mostly  cretaceous.  Other  thoracic  organs  healthy. 

Abdomen. — Abdominal  organs,  with  the  exception  of  the  scrotum,  which  con- 
tained some  chronic  fistulie,  healthy. 

Microscopic  Examination. — The  centre  and  circumference  of  the  tubercular 
mass  closely  resembled  the  figures  represented  (Figs.  402,  403) ; but  the  external 
softened  cerebral  substance  contained  a larger  number  of  granular  cells.  The  serous 
fluid  in  the  ventricles  only  contained  a few  epithelial  cells. 

Commentary. — In  this  case,  the  meninges  covering  the  left  cerebellum 
were  thickened  and  adherent  to  the  dura  mater;  and  below  them  was 
found  a tubercular  mass  the  size  of  a pigeon’s  egg.  How  long  this 
lesion  had  existed  it  is  impossible  to  say,  but  its  presence,  by  compress- 
ing the  vessels  at  the  base  of  the  cranium,  was  well  calculated  to  render 
any  temporary  congestion  more  liable  to  terminate  in  effusion.  This, 
whatever  the  exciting  cause,  was  what  I presume  must  have  occurred, 
producing  dropsy  of  the  ventricles,  with  the  usual  symptoms  of  pressure 
on  the  brain,  and  proving  fatal.  The  case  corroborates  also  the  view 
that  such  etfusions  are  rather  the  result  of  pre-existing  lesions,  than  a 
direct  consequence  of  inflammation. 

Case  — Chronic  Cerebral  Meningitis — Indnration  surrounded  by 

softening  of  a gyortion  of  the  Left  Cerebral  Hemisphere. 

History. — Mrs.  Swan,  a3t,  35,  wife  of  a coach-builder,  admitted  December  8,  1850. 
She  had  always  enjoyed  good  health  up  to  four  years  ago.^  when,  having  contracted 
syphilis,  and  having  taken  a large  quantity  of  mercury,  she  began  to  complain  of 
headache,  indigestion,  occasional  vomiting,  constipation,  and  drowsiness.  About 
six  months  ago,  she  had  a fit,  from  which  she  recovered  in  the  course  of  half  an  hour. 
She  suffered  from  similar  attacks  afterwards,  at  intervals  of  from  two  to  three  weeks. 
Those  attacks  were  ushered  in  by  severe  headache,  tinnitus  aurium,  vertigo,  and  dim- 
ness of  vision,  and  they  were  followed  by  great  muscular  debility.  During  the 
paroxysms,  which  lasted  for  various  lengths  of  time,  she  was  insensible  ; there  were 
frothing  at  the  mouth  and  twitchings  of  the  muscles  of  the  limbs,  especially  of  the 
right  arm.  The  last  occurred  two  months  since.  Four  weeks  ago,  she  experi- 
enced, without  any  accompanying  fit  or  insensibility,  a twitching  of  the  muscles  of  the 
right  arm,  together  with  a feeling  of  numbness  in  the  fingers  of  the  right  hand. 
She  subsequently  experienced  less  power  in  the  right  arm,  and  some  numbness  in  the 
right  leg. 

Symptoms  on  Admission. — On  admission,  she  appears  debilitated  and  consider- 
ably emaciated.  There  is  great  mental  confusion,  and  she  often  wanders.  She  com- 
plains of  intense  pain  in  the  head.  There  is,  however,  no  flushing  of  the  face  nor 
congestion  of  the  eyes,  and  no  delirium.  There  is  difficulty  and  slowness  of  articula- 
tion. The  right  side  of  the  face  is  slightly  paralysed.  The  tongue,  when  protruded, 
is  slightly  turned  to  the  right  side.  There  is  no  diminution  of  sensibility.  The 
power  of  motion  in  the  right  arm  is  diminished  ; she  cannot  close  the  hand,  or 
hold  anything  firmly.  Sensibility  is  unimpaired.  The  right  leg  is  not  affected  with 
any  diminution  of  muscular  power,  though  there  is  a feeling  of  dragging  when  the 
limb  is  moved.  The  pulse  is  regular  and  of  good  strength  ; no  cough  ; complains  of 
loss  of  a])petite ; tongue  moist,  white ; no  vomiting  nor  sickness.  Bowels  consti- 
pated ; menstruation  is  irregular,  and  the  discharge  scanty  ; menstruated  last,  six 
weeks  ago.  Urine  muddy,  of  1023  sp.  gr.  : becomes  clear  on  heating. 

Progress  op  the  Case. — From  this  period  until  the  4th  of  January  1851,  she 
remained  pretty  much  in  the  same  condition,  on  some  days  the  confusion  of  intellect 
and  difficulty  of  speech  being  somewhat  less  than  on  others.  The  treatment  con- 
sisted of  the  occasional  application  of  leeches,  and  latterly  of  a blister  to  the  nape  of 
the  neck,  and  purgatives.  On  the  day  mentioned,  however,  she  was  found  comatose — 


* Reported  by  Mr.  Henry  Thom,  Clinical  Clerk. 


CEREBRAL  MENINGITIS. 


375 


did  not  answer  questions,  though  she  seemed  to  know  that  she  was  addressed — pupils 
moderately  dilated — respiration  stertorous.  There  was  slight  twitching  of  the 
muscles  of  the  right  side  of  the  face.  The  right  arm  was  rigidly  flexed,  and  offered 
great  resistance  when  an  effort  was  made  to  extend  it.  January  5.  — To-day  appears 
better.  No  stupor.  Expression  not  so  drowsy.  No  stertorous  breathing.  Has 
spoken  a little.  Has  no  sickness  or  vomiting.  There  are  still  occasional  twitchings 
of  the  muscles  of  the  right  side  of  face.  Right  arm  not  so  rigidly  flexed.  Ordered 
a purgative  enema  immediately.  January  6. — Has  again  relapsed  into  a state  of  coma. 
Breathing  easy.  Twitching  of  the  muscles  of  the  right  side  of  the  face,  of  the  right 
arm,  and  occasionally  of  the  right  leg,  have  again  presented  themselves,  Pulse 
rather  full,  and  slow.  Bowels  freely  opened  by  the  enema.  Sensibility  in  affected 
parts  still  unimpaired.  January  V. — Continues  in  much  the  same  condition.  Does 
not  seem  con.scious  when  spoken  to.  Sensibility  still  unimpaired.  Pulse  frequent, 
and  smaller  than  yesterday.  Increased  rigidity  of  the  right  arm  and  leg,  with  occa- 
sional twitchings.  January  8. — Pulse  frequent,  and  very  small.  Breathing  not 
stertorous.  Lies  on  the  left  side ; and  the  muscles  of  the  neck  are  so  rigid  that  the 
head  is  quite  immovable.  Apparently  sensible,  though  she  can  neither  hear,  speak, 
nor  protrude  the  tongue,  Twitchings  still  occasionally  occur  in  the  light  side  of  free, 
right  arm,  and  right  leg.  Right  arm  rigidly  contracted.  Died  early  on  the  morning 
of  the  9 th. 

Sectio  Cadaveris. — Thirty  hours  after  death. 

Rigor  mortis  well  marked. 

He.vd. — There  were  strong  adhesions  between  the  calvarium  and  dura  mater  over 
the  vertex,  at  which  place  the  latter  membrane  was  considerably  thickened.  The 
arachnoid  membrane  covering  the  posterior  half  of  the  left  cerebral  hemisphere  was 
thickened,  dense,  and  opaque,  closely  adhering  to  the  pia  mater  below.  The  thi(;ken- 
ing  and  adhesion  existed  to  its  greatest  extent  over  a space  about  the  size  of  half-a- 
crown,  situated  about  two  inches  external  to  the  falx,  and  at  the  anterior  portion  of 
the  middle  third  of  the  hemisphere.  Here  the  arachnoid  membrane,  united  with  the 
pia  mater,  was  one-eighth  of  an  inch  thick  ; and  the  dense  layer  being  carefully  dis- 
sected off,  exposed  a discolored  spot  in  the  cerebral  convolutions  measuring  an  inch 
and  a half  from  before  backwards,  and  one  inch  transversely.  The  centre  of  this  spot 
was  indurated  to  the  feel,  whilst  its  circumference  was  soft  and  pulpy.  In  the  centi’e 
there  was  observed  a hard  deposit,  the  size  of  a pea,  of  a bright  yellow  color,  sur- 
rounded by  a purple  areola,  passing  into  a pink  color,  and  disappearing  gradually 
towards  the  margin  of  the  spot  alluded  to.  On  making  sections  through  this  diseased 
portion,  the  discoloration  was  found  to  extend  inwards  and  occupy  a space  about  the 
size  of  a walnut.  It  contained  embedded  in  its  substance  five  other  indurated  mas,ses, 
varying  in  size  from  a millet-seed  to  that  of  a pea,  and  similar  to  the  one  formerly 
noticed.  The  boundaries  of  this  diseased  mass  internally  presented  the  same  color 
and  consistence  as  were  noticed  on  the  surface,  with  the  exception,  perhaps,  that 
the  disappearance  of  color  was  more  gradual  internally,  and  passed  into  a pulpy 
white  softening  of  the  cerebral  hemisphere,  which  extended  from  it  in  a straight 
line,  until  it  terminated  in  the  external  portion  of  the  left  optic  thalamus.  The 
two  lateral  ventricles  contained  each  about  half  a drachm  of  slightly  sanguinolent 
fluid ; and,  in  the  left  one,  a vesicle  the  size  of  a pea,  containing  amber-colored 
matter,  sprang  from  the  choroid  plexus.  Other  portions  of  the  encephalon  were 
healthy. 

Guest. — Heart  healthy.  Valves  normal.  No  adhesion  of  the  pleurae.  The 
bronchi,  when  cut,  poured  out  a sero-sanguinolent  fluid.  Left  lung  throughout  spongy 
and  crepitant,  with  much  pigmentary  matter  scattered  through  it.  Right  lung  was 
non-crepitant  and  engorged  posteriorly  and  inferiorly,  presenting  a mottled  appearance 
when  cut,  from  a number  of  minute  granulations  scattered  throughout.  All  the  other 
viscera  were  quite  healthy. 

Microscopic  Examination. — The  yellow  indurated  masses  described  as  scattered 
throughout  the  diseased  portion  of  the  left  cerebral  hemisphere  consisted  of  a dense 
aggregation  of  molecules  and  granules,  without  tubercle,  pus,  or  any  kind  of  corpuscle. 
The  cerebral  structure  surrounding  these  masses  was  loaded  with  innumerable  granule 
cells  and  masses,  which  existed  throughout  the  whole  discolored  portion  of  the  brain, 
but  became  less  and  less  numerous  in  the  internal  white  softening  as  it  approached  the 
left  optic  thalamus.  Indeed  the  most  internal  portion  of  the  white  softening  near  the 
optic  thalamus  contained  none  of  them. 


376 


DISEASES  or  THE  NERVOUS  SYSTEM. 


Commentary. — This  woman,  when  she  first  came  under  my  notice, 
presented,  in  a very  characteristic  form,  the  general  aspect  and  symp- 
toms of  softening  of  the  brain.  The  dulness  and  confusion  of  intellect, 
without  loss  of  volition  and  sensation — the  weakness  of  the  right  side 
of  the  body,  and  contraction  of  the  right  arm — latterly  the  rigidity  of 
this  extremity  and  the  coma,  could  leave  little  doubt  as  to  the  nature 
of  the  lesion,  and  its  seat  in  the  left  hemisphere.  From  the  account 
received  of  her  history,  which,  however,  was  not  entirely  to  be  de- 
pended on,  it  appeared  that  for  four  years  previously  she  had  been 
subject  to  head  symptoms  and  “fits”  of  an  epileptic  character,  at  all 
events  involving  temporary  loss  of  the  mental  functions  and  convulsive 
movements  of  the  limbs,  especially  on  the  right  side.  This  account  was 
confirmed  by  the  post-mortem  examination,  which  exhibited  chronic 
thickening,  and  adhesion  to  the  brain,  of  the  meninges  on  the  left  side, 
in  addition  to  an  inflammatory  circumscribed  softening,  commencing  in 
the  circumference  of  the  same  hemisphere,  and  extending  inwards  to  the 
optic  thalamus  of  the  same  side.  The  yellow  masses  described  were  evi- 
dently a chronic  form  of  exudation,  and  it  is  very  difiicult  to  determine 
whether  they  originated  or  followed  the  meningitis.  Certainly  they 
occasioned  the  surrounding  discoloration  and  exudation,  which  had  ex- 
tended inwards  to  the  central  portions  of  the  encephalon. 

As  regards  the  connection  of  the  symptoms  with  the  post-mortem 
appearances,  we  can  have  little  diflaculty  in  ascribing  the  commencing 
symptoms  and  “fits”  to  the  meningitis,  which  increasing  in  intensity, 
caused  pressure  on  the  cranial  portion  of  the  cord,  and  occasioned 
the  convulsions.  The  same  lesion,  conjoined  with  the  external  soften- 
ing and  corresponding  change  of  circulation  within  the  cranium,  was 
the  cause  of  the  confusion  of  intellect  and  stupidity  latterly  observed, 
whilst  the  continued  irritation  originating  in  the  local  cerebral  inflam- 
mation, operating  through  the  anterior  portion  of  the  optic  thalamus,  and 
perhaps  a portion  of  the  corpus  striatum,  caused  the  contraction  and 
rigidity  observable  in  the  right  arm.  It  is  of  course  impossible  to 
determine  the  amount  of  pressure  and  its  direction,  which  any  lesion 
may  occasion,  except  from  its  effect.  But  it  seems  to  me  that  this  case 
is  an  illustration  of  the  correctness  of  the  pathological  laws  formerly 
given.  The  first  symptoms  are  those  of  excitation,  and  are  paroxysmal ; 
these  pass  into  more  permanent  symptoms;  and  as  the  organic  disease 
proceeds  from  the  circumference  to  the  centre,  we  observe  the  intelligence 
afiected  most,  motion  secondarily,  and  sensation  not  at  all. 

CEBEBRITIS. 

Case  IX.* — Acute  Cerehritis — Abscesses  in  the  Brain — Old  Tubercle  in 

various  Organs — Chronic  Peritonitis. 

History. — Mary  Melville,  let.  22 — admitted  July  20,  1851.  A girl  of  abandoned 
character,  concerning  whom  no  further  information  could  be  obtained,  than  that  she 
had  been  drinking  to  excess,  and  had  sunk  into  a state  of  stupor,  Irom  which  she 
could  not  be  recovered. 

Symptoms  on  Admission. — On  admission  she  was  insensible,  but  three  hours  after 
being  placed  in  bed,  so  fiir  recovered  consciousness  as  apparently  to  understand  ques- 
tions put  to  her,  although  she  could  not  articulate.  She  cannot  move  the  right  arm, 

* Reported  by  Mr.  D.  0.  Hoile,  Clinical  Clerk. 


CEEEBEITIS. 


377 


although  the  other  limbs  are  moved  freely.  The  eyes  are  suffused ; pupils  and  eye- 
brows contracted;  general  appearance  that  of  prostration.  Pulse  120,  weak;  left 
nand  occasionally  applied  to  the  head,  as  if  pain  was  felt  there ; skin  eool ; breath 
smells  strongly  of  whisky;  breathing  a little  accelerated,  but  no  abnormal_  rales. 
Hear!  to  be  shaved,  and  ice-cold  aj>plications  to  he  conistantly  made.  To  have  3 ss  of 
castor-oil  in  peppermint  water. 

Progress  of  the  Case. — July  21s^. — Was  delirious  during  the  night  and  became 
violent,  raving  incessantly,  and  trying  to  get  out  of  bed,  so  that  it  was  necessary  to 
put  on  the  strait-waistcoat.  Bowels  have  not  been  relieved.  Pulse  130,  weak.  To 
he  cupped  at  the  hack  of  the  neck  to  § viij.  To  have  a turpentine  injection.  July  22c?. 
Still  delirious.  During  the  night  vomited  several  times.  Will  take  no  nourish- 
ment. The  right  arm  is  occasionally  convulsed.  Bowels  have  been  freely  opened. 
In  other  respects  the  same.  A blister  to  be  applied  to  the  sinciput.  Nourishment  to  he 
given  in  small  quantities,  frequently  repeated  with  ^ iv  of  wine.  July  2‘Sd. — Delirium 
not  so  violent  during  the  night,  consisting  of  low  muttering.  At  present  seems  ex- 
hausted. Pulse  126,  small  and  weak.  Vomiting  occurs  now  and  then,  but  not  so 
frequently.  Blister  has  not  risen.  To  continue  nourishment  with  3 vj  wine.  July 
2^th. — Since  last  report  the  violent  symptoms  and  vomiting  have  ceased,  and  she 
appears  to  suffer  no  pain,  although  the  intellect  remains  confused.  She  was  observed 
to  move  the  right  arm,  as  well  as  the  other  limbs  occasionally,  and  took  the  beef 
tea,  and  other  nutrients,  with  wine.  On  the  night  of  the  26th  coma  came  on,  and  on 
the  following  day  she  was  evidently  sinking.  Died  early  on  the  morning  of  the  28th. 

Sectio  Cadaver  is. — Thirty-four  hours  after  death. 

Body  well  formed,  not  emaciated. 

Head. — On  removing  the  skull  cap  and  dura  mater,  the  arachnoid  and  pia  mater 
covering  the  hemispheres  are  seen  to  be  unusually  congested.  About  the  middle  of 
the  right  hemisphere  was  a patch  the  size  of  a sixpence,  of  a dirty  yellow  color, 
which,  on  being  cut  into,  was  found  to  be  the  vault  of  an  abscess,  as  large  as  a wal- 
nut, lined  by  a soft  and  vascular  membrane,  and  containing  one  half  ounce  of  dirty 
greenish  pus.  A similar  abscess  of  nearly  the  same  size  Avas  situated  a little  ante- 
riorly, and  somewhat  deeper,  in  the  anterior  lobe.  A third  abscess,  the  size  of  a 
hen’s  egg,  existed  in  the  centre  of  the  left  hemisphere,  above  the  corpus  callosum,  and 
about  one  quarter  of  an  inch  from  the  surface  of  the  hemisphere.  The  walls  of  these 
abscesses  were  somewhat  indurated,  punctated  with  red  spots,  and  lined  with  a 
fibrinous  matter  about  a quarter  of  an  inch  thick,  which  apparently  had  not  yet 
undergone  the  purulent  transformation.  Other  portions  of  the  brain  healthy. 

Thorax. — In  the  bronchial  glands,  and  at  the  apices  of  both  lungs,  wmre  several 
cretaceous  and  calcareous  tubercles,  surrounded  by  indurated  black  pulmonary  tissue. 
Other  thoracic  organs  healthy. 

Abdomen. — The  peritoneum  covering  the  intestines  presented  here  and  there 
patches  of  highly  vascular  lymph,  studded  with  opaque  granular  lymph  about  the 
size  of  millet  seeds.  The  mesenteric  glands  were  enlarged  and  infiltrated  with  old 
cheesy  tubercles.  The  liver  and  spleen  contained  a few  granular  yellow  deposits. 
The  uterus  was  retroverted,  the  os,  oedematous,  and  the  cavity  of  fundus  filled  with 
a glairy  opaque  yellow  mucus.  Fallopian  tubes  obstructed  by  an  atheromatous  sub- 
stance, resembling  broken  down  and  viscid  pus.  Left  ovary  somewhat  enlarged,  and 
with  its  fellow  covered  with  Graafian  vesicles  in  different  stages  of  development. 
Other  abdominal  organs  healthy. 

Microscopic  Examination. — The  pus  corpuscles  in  the  cerebral  abscesses  more 
delicate  and  clear  than  usual,  displaying  their  nuclei  without  re-agents.  They  were 
also  mingled  with,  and  surrounded  by  celloid  albuminous  deposits.  The  friable 
matter  inside  the  lining  membrane  was  composed  of  minute  molecular  filaments,  and 
numerous  molecules  and  granules.  The  membrane  itself  also  had  a fibrous  basis,  in- 
volving some  nerve  tubes,  but  no  appearance  of  fibre-cells  or  nuclei.  External  to  the 
membrane,  the  cerebral  substance,  to  the  depth  of  about  a line,  was  composed  of  dis- 
integrated nerve-tubes  and  granule  cells  in  great  abundance. 

Case  X. — Actde  Cerehritis — Abscesses  in  the  Brain — Pulmonary  Tubercle 
— Abscess  in  Kidney. 

History. — John  Dods,  pet.  19,  a butcher — entered  the  Clinical  ward  November  9, 
1855.  Has  been  in  weak  health  for  the  last  two  years.  A week  ago  he  was  seized 

^ Reported  by  Mr.  R.  P.  Ritchie,  Clinical  Clerk. 


378 


DISEASES  OF  THE  NEEVOUS  SYSTEM. 


with  pain  in  the  upper  part  of  the  head,  not  preceded  by  shivering,  or  occasioned  by 
any  obvious  cause.  Denies  that  he  had  been  drinking.  Since  then  he  has  felt  hot 
and  feverish,  and  says  he  has  vomited  frequently,  generally  about  half  an  hour  after 
eating.  The  pain  has  continued,  accompanied  with  ringing  in  the  ears,  up  to  the 
present  time. 

Symptoms  on  Admission. — On  admission,  he  complains  of  racking  pains  in  the 
upper  part  of  the  head.  There  is  constant  ringing  in  the  ears  ; the  eyes  are  suffused  • 
face  flushed;  speech  confused,  with  difficulty  in  collecting  his  ideas.  Appetite  he 
declares  to  be  good ; no  great  thirst ; tongue  covered  with  a dirty  yellow  fur,  white 
at  the  edges ; no  pains  in  stomach  ; bowels  regular  ; complains  of  cough,  with’  slight 
mucous  expectoration.  Percussion  everywhere  normal.  On  auscultation,  there  is 
harsh  murmur  with  inspiration  and  prolonged  expiration  at  right  pulmonary  apex  ; 
nowhere  increase  of  vocal  resonance ; pulse  04,  feeble  ; skin  moderately  warm  ; body 
emaciated.  Other  functions  normal.  The  head  to  he  shaved  and  cold  evaporating 
lotions  to  be  constantly  employed. 

Progress  of  the  Case. — November  llth. — Passed  a restless  night,  but  says  the  ce- 
phalalgia is  diminished.  Pulse  still  weak ; has  taken  no  nourishment.  To  have  beef  tea., 
and  3 iij  of  wine.  November  12^/i. — Last  evening  became  very  restless,  and  frequently 
cried  out.  This  morning  at  two  a.  m.  he  screamed  out  violently,  complained  of  pain 
in  his  head,  and  became  incoherent,  but  when  loudly  spoken  to,  gave  rational  answers. 
Both  pupils  were  of  moderate  size,  the  right  slightly  dilated  more  than  the  left,  but  con- 
tracting equally  on  exposure  to  light.  At  four  a.  m.  he  was  seized  with  a general  con- 
vulsion, preceded  by  a scream,  in  which  it  was  observed  that  the  left  superior  extremity 
was  more  rigidly  contracted  than  the  right.  The  right  pupil  now  ^vas  more  dilated  than 
the  left,  and  both  contracted  only  feebly  on  exposure  to  candle  light.  The  convulsion 
lasted  five  minutes,  and  terminated  in  complete  coma,  which  continued  up  to  the  hour 
of  visit.  He  was  then  found  to  be  perfectly  unconscious,  and  could  not  be  roused. 
There  were  occasional  startings  of  the  limbs.  The  left  foot  and  leg  are  insensible  to 
the  action  of  irritants,  which  on  the  right  side,  however,  occasion  slight  movements. 
Respiration  stertorous ; right  pupil  more  dilated  than  the  left;  pulse  120,  full.  To 
be  cupped  at  the  nape  of  the  neck,  and  § viij  of  blood  extracted.  Continue  the  applica- 
tion of  cold  to  the  head.  At  eight  p.  M.,  having  been  cupped,  the  breathing  became 
easier ; but  the  coma  continued,  and  he  died  at  three  a.  m.  on  the  13th. 

Sectio  Cadaveris. — Eighty-one  hours  after  death. 

Body  emaciated. 

Head. — On  removing  the  calvarium,  two  bulging  abscesses  were  seen,  one  occupy- 
ing the  anterior  and  middle  third  of  the  right,  and  the  other  the  posterior  third  of 
the  left  cerebral  hemisphere,  immediately  below  the  dura  mater,  which  was  of  a 
greenish  hue.  On  removing  this  membrane,  the  abscess  on  the  right  side  was  exposed, 
which  was  of  roundish  form,  measuring  three  inches  in  diameter.  On  the  left  side  the 
abscess  was  not  quite  so  large,  measuring  two  and  a half  inches  in  diameter.  On 
cutting  through  these  abscesses,  they  were  seen  to  be  embedded  in  the  cerebral  lobes, 
above  the  corpus  callosum.  They  consisted  of  several  excavations,  varying  in  size 
from  a pea  to  that  of  a hazel  nut,  all  communicating  with  one  another,  and  filled  with 
greenish  pus.  Their  margins  presented  a smooth,  abrupt  border,  which  was  consid- 
erably indurated  to  the  depth  of  one-eighth  of  an  inch,  with  points  of  blood  here  and 
there  scattered  through  it.  The  ventricles  and  all  other  parts  of  the  brain  were  healthy. 

Thorax. — In  the  apex  of  right  lung  were  about  half  a dozen  miliary  tubercles, 
and  the  pleura3  over  these  were  firmly  united  by  dense  chronic  adhesions.  The  ante- 
rior surface  of  the  left  lung  slightly  emphysematous. 

Abdomen. — Abdominal  organs  healthy,  with  the  exception  of  an  abscess  the  size 
of  a hazel  nut,  in  the  cortical  substance  of  the  left  kidney. 

Microscopic  Examination. — The  pus  in  the  cerebral  abscesses  contained  pus  cells, 
with  delicate  walls,  floating  in  a liquor  puris  crowded  with  molecules.  The  indurated 
margin  of  the  abscesses  was  composed  of  a dense  aggregation  of  minute  molecules  of  a 
light  brownish  color,  gradually  diminishing  towards  the  healthy  portion  of  the  cerebral 
texture,  where  they  were  seen  to  be  infiltrated  among  the  tubes. 

Commentary. — In  these  two  cases,  abscesses  were  found  in  both 
hemispheres,  and  it  will  be  observed  that  the  symptoms  were  of  the 
same  general  character  as  those  of  meningitis  formerly  given.  The  only 
differences  observable  are  the  more  decided  convulsions  and  paralysis, 


CEREBRITIS. 


379 


and  the  less  degree  of  delirium,  somnolence,  and  stupor.  Indeed,  it  may 
be  said  to  be  impossible  to  distinguish,  with  any  thing  like  certainty,  in 
individual  cases,  acute  exudations  poured  into  the  substance  of  the  brain, 
from  those  affecting  the  meninges  or  ventricles.  The  reason  will  be 
obvious  when  we  reflect  that  the  phenomena,  in  every  instance,  are  in 
fact  attributable  to  pressure  on  the  encephalon,  and  that,  if  this  be  rapid 
’and  general,  it  can  matter  little  whether  it  originate  from  the  meninges 
or  the  centre  of  the  cerebral  lobe.  In  the  latter  case,  however,  as  the 
disease  progresses,  there  is  more  liability  for  the  cranial  ganglia,  con- 
nected with  motion,  to  become  affected,  and  hence  probably  the  greater 
amount  of  convulsion  and  paralysis. 

Lebert,"^  in  an  elaborate  Memoir  on  Cerebral  Abscesses,  in  which 
he  has  carefully  analysed  the  histories  of  80  cases,  has  come  to  the  con- 
clusion, that  what  debilitates  the  individual,  causes  a predisposition  to 
this  affection.  Such  is  also  my  own  opinion,  as  most  of  the  cases  I have 
seen  have  been  in  scrofulous  subjects,  and  more  especially  such  as  have 
labored  under  some  form  of  otitis,  connected  with  caries  of  the  temporal 
bone.  In  the  two  cases  recorded,  effete  tubercle  was  found  in  the  lungs, 
and  the  general  health  was  much  deteriorated.  Very  little  benefit  can 
therefore  be  expected  from  depleting  remedies.  Hitherto,  indeed,  almost 
all  these  cases  have  been  vaguely  ascribed  to  meningitis  or  apoplexy. 
But  as  regards  diagnosis,  we  are  exactly  in  the  same  condition  now  in 
reference  to  meningitis  and  cerebritis,  as  medical  men  were  in  during  the 
days  of  Cullen,  as  to  pleuritis  and  pneumonitis;  that  is,  we  cannot  sepa- 
rate them  by  the  aid  of  their  symptoms.  Hence  the  following  summary 
from  Lebert’s  memoir,  as  it  comprises  all  that  is  known  with  regard  to 
the  symptoms  in  80  cases,  is  deserving  attention  : — “ Sudden  headache  is 
the  symptom  which  most  frequently  first  excites  attention ; it  is  generally 
accompanied  by  febrile  symptoms,  vomiting,  difficult  articulation,  and 
convulsive  attacks  may  supervene;  the  patients  become  heavy  and  morose, 
and  show  delirium,  contraction  of  pupils,  photophobia;  numbness  and 
formication  may  supervene,  and  apoplectic  symptoms  may  occur ; but  ail 
these  symptoms  vary  much  in  different  cases.  The  intellect  suffers  com- 
paratively little;  sensibility  suffers  more  frequently;  the  headache  is 
more  or  less  intense,  generally  diffuse  at  first,  and  subsequently  unilateral. 
Coma  occurs  frequently,  but  often  only  temporarily.  Paralytic  states 
were  observed  in  almost  one  half  of  the  cases ; they  were  generally  local, 
but  showed  themselves  also  in  the  form  of  general  muscular  debility. 
Diminished  articulating  power  was  observed  in  10  cases.  In  regard  to 
the  special  senses,  only  the  affection  of  the  ears  presents  any  points  of 
importance.  No  special  symptoms  are  observed  in  reference  to  the  vas- 
cular or  respiratory  system.  Disturbance  of  the  digestive  organs  showed 
itself  in  the  form  of  vomiting  in  20  cases  ; involuntary  defaecation  occurred 
towards  the  fatal  termination  of  11  cases.  The  duration  of  the  disease 
appears  to  fluctuate  from  two  or  three  weeks  to  two  months ; there  is 
necessarily  a difficulty  in  determining  the  point,  as  the  commencement 
can  only  be  approximately  fixed  It  occurs  at  all  ages;  but  the  great- 
est frequency  prevails  between  the  sixteenth  and  thirtieth  years.”  f 

* Virchow’s  Archiv.  fur  Patholog.  Anat.  Band  x. 

f British  and  Foreign  Med.-Chir.  Review.  April  1857. 


380 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Case  XI.* — Chronic  Cerehritis ; Ejnlejytiform  Convulsions;  Hemi- 
'plegia  of  the  Right  Side  ; Loss  of  Smell ; Blindness  of  the  Left 
Eye  ; Amyloid  Bodies  in  the  Brain. 

History.— John  Bookless,  set.  48,  a plasterer,  admitted  January  7,  1855.  He  had 
enjoyed  good  health  until  two  years  ago,  when  he  first  complained  of  giddiness  and 
gradual  impairment  of  sight,  and  of  smell.  Twelve  months  ago  he  was  attacked  with 
“ fits,”  three  or  four  appearing  in  the  course  of  the  first  night.  They  have  occurred' 
occasionally,  at  considerable  but  irregular  intervals,  ever  since.  His  general  health 
had  remained  good,  until  the  3d  instant,  when,  about  12  o’clock  at  night,  a violent 
“fit”  appeared,  which  was  repeated  from  eighteen  to  twenty  times  before  six  o’clock 
on  the  following  morning.  On  the  4th  and  5th  he  was  comparatively  free  from  them  ; 
but,  on  the  Cth,  during  the  night,  they  recurred  more  frequently.  On  the  morning 
of  the  '7th,  it  was  observed  that  the  right  arm  and  leg  were  paralysed,  and  he  was  sent 
into  the  Infirmary. 

Symptoms  on  Admission. — On  admission,  it  was  observed  that  the  body  was  toler- 
ably robust ; that  he  was  hemiplegic  on  the  light  side ; that  the  head  was  obstinately 
kept  turned  towards  the  right  side  ; that  speech  was  slow  and  thick ; and  that  although 
conscious,  he  was  some  time  in  framing  an  answer  to  a question.  To  have  § j of  castor 
oil.  Careful  investigation  on  the  following  day  elicited  the  following  facts,  viz.,  com- 
plete blindness  of  the  left  eye — sight  in  the  right  eye  perfect — smell  absent — cepha- 
lalgia— frequently  applies  his  left  hand  to  the  left  side  of  the  head — other  special 
senses  normal — loss  of  voluntary  motion  over  right  side,  with  considerable  impair- 
ment, but  not  absence  of  sensibility — left  side  normal — pulse  96,  full — other  functions 
healthy.  Bowels  have  been  freely  open,  from  the  action  of  the  castor  oil.  Whilst  I 
was  examining  the  patient,  he  passed  through  two  attacks  of  an  epileptic  character — 
there  was  no  scream,  only  a slight  groan — the  muscles  of  all  the  limbs  became  rigid 
— the  toes  and  fingers  incurvated — the  face  flushed,  and  the  head  tetanically  twisted 
towards  the  right  side — the  mouth  was  drawn  somewhat  to  the  left — the  left  arm  and 
leg  convulsed,  the  right  arm  and  leg  rigid  and  trembling — there  was  complete  loss  of 
consciousness.  This  state  continued  about  one  minute,  when  the  face  became  pale, 
there  was  foaming  at  the  mouth,  the  rigidity  and  convulsions  subsided,  and  in  another 
minute  he  was  again  conscious  and  fully  restored  to  his  former  condition.  To  he 
cupped  in  the  neck  to  the  extent  of  ^ oz. — ice  to  he  applied  to  the  head. 

Progress  of  the  Case. — From  this  period  he  lay,  in  the  intervals  of  the  attacks, 
tolerably  tranquil ; the  evacuations  were  passed  involuntarily  ; took  nourishment  with- 
out difficulty.  The  whole  of  the  12th  he  was  free  from  convulsive  attacks,  but  on 
the  13th  they  returned ; pulse  106,  soft.  A blister  to  the  neck.,  and  §iv  of  wine.  On 
the  14th  the  epileptic  attacks  returned  every  ten  minutes,  until  one  o’clock  in  the 
morning  of  the  15th.  From  this  time  he  remained  free  from  them.  At  the  visit  he 
was  still  conscious,  slowly  answered  questions,  put  out  his  tongue,  etc.  The  respira- 
tions, however,  were  slightly  labored,  and  gradually  became  more  so,  until  he  sank, 
at  9 P.M.,  on  the  16th. 

Sectio  Cadaveris. — Fifteen  hours  after  death. 

Head. — On  removing  the  calvarium,  the  subarachnoid  cellular  tissue  was  infil- 
trated with  serum,  which  elevated  the  arachnoid  in  some  places  above  the  level  of  the 
convolutions.  On  slicing  the  brain  from  above  downwards,  its  substance  was  healthy. 
Both  lateral  ventricles  were  distended  with  clear  serum,  which,  on  being  carefully 
removed  with  a pipette,  measured  1 oz.  and  '7  drachms.  The  ventricles  were  some- 
what enlarged,  but  their  lining  walls  healthy.  The  foramen  of  Monro  was  the  size  of 
a fourpenny  piece,  its  edges  very  thin.  White  substance  of  the  fornix  and  central 
portion  of  the  brain  healthy.  The  left  eorpus  striatum  atrophied  and  shrunk  through- 
out, externally  of  a dull  mahogany  color,  and,  on  section,  composed  of  a diffluent 
fawn-colored  substance,  which  flowed  out,  leaving  an  irregular  cavity  the  size  of  a 
hazel  nut  Below  the  left  corpus  striatum,  the  optic  thalamus  presented,  on  section, 
a cribriform  appearance,  over  a space  the  size  of  a shilling,  dependent  on  chronic 
enlargement  and  thickening  of  small  vessels,  the  open  mouths  of  which,  on  being  cut, 
were  retracted  into  its  substance.  In  the  anterior  portion  of  the  right  corpus  striatum 
there  was  also  a diffluent  softening,  occupying  a space  about  the  size  of  a pea.  On 
removing  the  cerebral  lobes  from  the  cranium,  a dense  chronic  adhesion,  which  it  was 


* Keported  by  Mr.  W.  Gilfillan,  Clinical  Clerk. 


CEREBRITIS. 


381 


necessary  to  cut  through,  existed  between  the  inferior  surface  of  the  left  anterior  lobe 
and  the  dura  mater.  It  involved  the  optic  and  olfactory  nerves  of  that  side,  and 
extended  so  far  on  the  right  side  as  to  include  also  the  right  olfactory  nerve.  The 
portion  of  brain  in  immediate  connection  with  this  adhesion  was  unusually  indurated 
to  the  feel  throughout  a portion  of  substance  in  the  left  lobe,  about  the  size  of  a nut- 
meg ; but,  in  the  right,  confined  to  a thin  layer  of  cerebral  substance  externally,  about 
an  eighth  of  an  inch  in  thickness,  and  about  the  size  of  a shilling  in  its  area.  On 
cutting  through  the  indurated  substance  on  the  left  side,  it  felt  like  soft  bees’-wax  | 
under  the  knife,  was  of  a very  pale  straw  color,  gradually  disappearing,  as  did  the 
induration  into  the  healthy  structure,  without  any  obvious  limit  whatever.  About 
another  oz.  of  sanguineous  serum  was  found  collected  in  the  depending  portions  of 
the  cranial  cavity  after  the  brain  was  removed.  The  other  portions  of  the  brain 
were  healthy. 

Thoracic  and  abdominal  viscera  healthy. 

Microscopic  Examination. — The  fawn-colored  softenings  in  the  corpora  striata 
consisted  of  numerous  molecules,  granules,  granular  masses,  and  cells,  mingled  with 
vessels  coated  with  granular  exudation,  and  fragments  of 
the  tubes  of  the  cerebral  substance.  In  and  around  the 
cribriform  alteration  of  the  left  optic  thalamus,  numerous 
round  colorless  transparent  lioclies  were  observed  which 
refracted  light  strotigly,  and  were  apparently  solid.  They 
varied  in  size,  from  the  1-1 000th  to  the  l-500th  of  an 
inch  in  diameter.  Some  contained  an  included  globular 
body,  around  which  faint  concentric  circles  were  dis- 
cernible. On  the  addition  of  diluted  sulphuric  acid  and 
iodine,  they  did  not  give  the  reaction  of  starch  or  cellu- 
lose. They  were  unaffected  by  water,  acetic  and  nitric  rig.  406. 

acids.  Here  and  there  they  seemed  to  split  up,  not  unlike 

starch  bodies.  The  indurated  portion  of  brain  in  the  interior  lobes  presented  an 
obscure  amorphous  appearance,  consisting  apparently  of  the  normal  elements,  infil- 
trated with  a brownish,  exceedingly  fine,  molecular  substance.  The  serum  of  the 
ventricles  only  contained  a few  epithelial  cells,  distended  with  water  by  endosmose. 

Commentary. — The  symptoms  observed  during  the  life  of  this  man 
were  all  clearly  explained  by  the  morbid  cliange.s  demonstrated  after 
death.  Before  the  post-mortem  examination  took  place,  I ventured  to 
diagnose  chronic  softening  of  the  left  corpus  striatum,  with  a tumor  so 
situated  below  it  as  to  press  upon  the  left  optic  nerve,  and  both  olfactory 
nerves.  8uch  were  the  principal  lesions  discovered,  as  the  indurated 
brain  and  dense  adhesion  may  in  one  sense  be  looked  upon  as  a tumor, 
producing  the  destruction  of  the  special  nerves,  whilst  the  extensive 
lesion  of  the  left  corpus  striatum  sufficiently  explained  the  hemiplegia 
on  the  right  side  of  the  body.  Two  other  lesions,  however,  were  dis- 
covered, viz.,  1st,  The  limited  disease  in  the  right  striated  body;  and 
2dly,  the  effusion  of  serum  into  the  lateral  ventricles  and  subarachnoid 
cavity.  To  the  first  of  these  lesions  may  proabbly  be  ascribed  the  con- 
vulsions which  more  especially  attacked  the  left  side  of  the  body,  although 
alone  this  would  be  insufficient  to  account  for  its  paroxysmal  character — 
a phenomenon  which,  as  I have  elsewhere  endeavored  to  explain,  can 
only  be  referred  to  congestions  within  the  cranium.^  As  to  the  effusion 
of  serum,  I am  inclined  to  consider  it  as  having  occurred  during  the  last 
few  hours  of  life; — 1st,  Because  he  was  conscious  within  twelve  hours 
of  his  death,  and  was  free  from  delirium  and  stupor ; 2dly,  Because, 
after  death,  little  imbibition  of  serum  had  taken  place  into  the  central 

^ See  Articles  by  the  writer  on  Apoplexy,  Epilcp.sy,  etc.,  in  the  second  volume  of 
the  Library  of  Medicine. 

Fig.  406.  Amyloid  bodies  with  fragments  of  nerve  tubes,  in  the  cribriform  sub- 
stance of  the  optic  thalamus.  250  diam. 


382 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


white  substance  of  the  brain,  and  there  was  consequently  no  softening 
from  maceration. 

Case  XII.*  — Chronic  Meningo-Cerehritis  — Sudden  Convulsions 

Hemiplegia  of  Left  Side — Softening  of  Anterior  Lobe  of  Right 
Cerebral  Hemisphere — Adhesioiis  of  Arachnoid. 

History. — William  M’Donald,  ast.  38,  writer’s  clerk — admitted  November  22 
1852,  From  the  account  given  of  him  by  his  friends,  it  would  seem  that  his  habits 
have  been  of  rather  a dissipated  nature  for  several  years  back.  He  was  never  known 
to  have  delirium  tremens,  but  about  ten  months  ago  was  seized  with  cephalalgia, 
unusual  movements  of  the  shoulders,  and  inability  to  speak  or  write,  which  symp- 
toms, it  is  said,  soon  disappeared.  For  the  last  six  months  also,  he  has  been  out  of 
employment,  and  not  eaten  more  than  one  meal  in  the  day.  On  the  morning  of  the 
3 9th,  he  was  seized  with  a fit,  which  was  succeeded  by  profound  sleep  for  some  hours. 
The  next  day  he  was  so  far  recovered  as  to  be  able  to  walk  about,  and  in  the  evening 
he  went  to  the  theatre  with  one  of  his  friends,  who,  on  being  interrogated,  says  that 
he  did  not  consider  him  at  that  time  in  his  right  mind.  On  the  21st  he  had  another 
fit,  and  on  the  22d  several  others,  which  succeeded  one  another  at  intervals  of  ten 
minutes. 

Symptoms  on  Admission. — On  admission,  is  still  laboring  under  convulsive 
paroxysms,  with  loss  of  consciousness,  and  foaming  at  the  mouth.  These  were  always 
present  with  the  exception  of  intervals,  varying  in  duration  from  ten  minutes  to 
half  an  hour,  during  which  the  consciousness  returns,  and  he  answers  questions  cor- 
rectly. When  a paroxysm  begins,  he  generally  utters  a short  groan ; the  mouth 
becomes  twisted,  and  pulled  to  the  left  side ; the  eyeballs  incline  to  the  left  side. 
During  the  fit  the  pupils  are  slightly  dilated,  and  insensible  to  light ; the  left  arm 
is  thrown  into  violent  clonic  convulsions ; the  left  foot  is  extended  and  rigid,  and  the 
right  one  firmly  flexed.  Towards  the  end  of  the  paroxysm  there  is  foaming  at  the 
mouth ; respiration  is  somewhat  restrained,  not  stertorous ; there  is  no  aj)pearance  of 
suffocation,  nor  any  marked  lividity  of  the  countenance.  As  the  fit  passes  off,  the 
respiration  gradually  becomes  more  free  and  natural ; during  expiiation,  the  right 
cheek  is  puffed  out  like  a flaccid  bag.  After  recovering  consciousness,  he  can  move  the 
right  arm  and  leg  voluntarily,  but  the  extremities  of  the  left  side  are  quite  powerless 
and  insensible.  Pulse  98,  full,  but  not  strong.  Tongue  is  moist  and  clean,  and  the 
edges  marked  with  indentations  from  the  teeth.  On  being  protruded,  it  is  turned 
towards  the  left  side  ; no  distortion  of  the  face  during  the  intervals  ; urine  during  the 
fits  is  passed  involuntarily  ; bowels  open.  In  all  other  respects  the  bodily  functions 
are  normal.  Four  leeches  to  he  applied  to  each  temple.  The  head  to  be  shaved^  and  cold 
constantly  applied  to  the  scalp.  To  take  ten  grains  of  Lover’' s powder  at  bed-time. 

Progress  of  the  Case.  November  23,  7 a.m. — During  the  night  has  had  frequent 
convulsive  paroxysms,  such  as  have  been  previously  described  (66  were  counted).  The 
skin  never  is  hot,  but  moist.  Pulse  100,  full  and  firm  ; otherwise  the  same.  To  be 

cupped  on  the  temples.,  and  12  oz.  of  blood  abstracted.  To  have  immediately  after- 

tvards  an  opiate  enema.  At  the  visit  the  convulsions  are  almost  continuous,  with 
perhaps  a minute  of  interval,  and  then  another  minute  of  violent  struggles  and  clonic 
spasms.  Pulse  120,  strong  and  bounding,  increasing  in  frequency  and  tensity  during 
the  attack.  To  be  bled  15  oz.  and  the  cold  douche  applied  to  the  head.  3 p.m. — 
Is  now  unconscious  during  the  intervals.  Pulse  160,  soft.  The  fits,  which  became 
less  frequent  after  the  bleeding,  are  now  as  numerous  as  at  the  visit.  To  apply  liiq. 
Ammoniae,  wdth  a view  of  producing  vesication,  to  the  occiput.  2o  have  a table-spoon- 
ful of  brandy  every  half  hour.  Sinapisms  to  be  applied  to  the  calves  of  legs.  7 o’clock 
P.M. — Consciousness  returned  after  the  first  dose  of  the  brandy.  The  ammonia  has 
only  caused  redness  of  the  integument.  Pulse  120,  small  and  weak.  On  ausculta- 
tion of  chest  a loud  moist  rale  is  heard  over  whole  anterior  surface  of  chest.  Parox- 
ysms as  frequent  as  before.  Continue  brandy  at  intervals  of  two  hours,  with  beef-tea. 
November  24. — During  the  night  the  fits  became  less  frequent,  there  being  often 

intervals  of  a quarter  of  an  hour.  At  7 a.m.  they  ceased  entirely,  when  the  breath- 

ing became  stertorous,  and  stupor  came  on,  from  which,  however,  he  could  be  roused 
until  half  an  hour  preceding  death,  which  occurred  at  9 a.  m. 

* Reported  by  Mr.  Alex.  T.  M’ Arthur,  Clinical  Clerk. 


CEREBRITIS. 


383 


Sectio  Cadaveris. — Twenty-seven  hours  after  death. 

Body  moderately  robust,  face  and  surface  somewhat  livid. 

Head  and  Spine. — Dura  mater  rather  thicker  than  usual,  especially  so  over  both 
anterior  hemispheres,  but  in  texture  healthy.  There  was  a firm  adhesion  between 
the  dura  mater  lining  the  frontal  bone  and  the  arachnoid  covering  the  anterior  lobe  of 
right  hemisphere,  over  a space  f ths  of  an  inch  in  diameter.  The  arachnoid  membrane 
everywhere  moist.  Ventricles  do  not  contain  above  3 ss  of  serum.  Pia  mater  and 
choroid  plexuses  healthy.  The  substance  of  the  brain  everywhere  normal,  except  at 
the  place  in  the  anterior  right  lobe,  immediately  below  the  adhesion  formerly  noticed. 
Here  the  cerebral  substance  is  softened  to  an  extent  about  the  size  of  a hen’s  egg. 
The  grey  and  white  substance  cannot  be  distinguished ; and,  on  section,  the  morbid 
portion  is  of  a grey  or  dirty  white  color,  of  pultaceous  consistence,  readily  disappear- 
ing under  a fine  stream  of  water.  Frontal  bone  healthy.  The  spinal  cord  and  its 
membranes  healthy.  The  other  organs  could  not  be  examined. 

Microscopic  Examination. — Numerous  fatty  granules,  granular  masses  and  cells, 
both  loose  and  accumulated  round  the  blood-vessels  of  the  cerebral  softening,  were 
visible.  The  tubular  substance  also  was  greatly  disintegrated  and  broken  up. 

Commentary. — When  I first  saw  this  man  he  appeared  to  me  to  be  in 
an  epileptic  convulsion,  but  the  history  of  the  ease,  and  the  short  duration 
of  the  intervals  of  consciousness,  during  which  he  was  composed  and 
answered  questions,  pointed  to  an  organic  lesion  of  the  brain.  The  pulse, 
though  full,  was  not  very  strong.  Hence  eight  leeches  were  applied  to 
the  temples,  the  head  was  shaved,  and  ice  applied.  This  treatment  in  no 
way  alleviated  the  symptoms.  Next  day  the  pulse  was  lOO,  full  and 
firm.  He  was  now  cupped  over  the  temples,  and  12  oz.  of  blood  ex- 
tracted from  the  arm,  followed  by  an  opiate  enema,  but  without  benefit. 
Next  day  the  pulse  was  120,  strong  and  bounding.  Ho  was  now  bled 
to  15  oz.,  and  the  cold  douche  applied  to  the  head,  with  the  result  of 
making  him  much  worse,  for  shortly  afterwards  he  became  insensible 
even  during  the  intervals.  In  the  evening,  therefore,  I at  once  changed 
the  treatment,  and  gave  brandy  in  table-spoonful  doses,  with  the  effect 
of  causing  immediate  restoration  of  consciousness  and  a marked  improve^ 
ment.  Stimulants  with  nutrients  were  perseveringly  continued,  but  in 
vain.  Post-mortem  examination  demonstrated  the  existence  of  a chronic 
grey  softening  in  the  anterior  lobe  of  the  right  cerebral  hemisphere,  with 
old  dense  adhesions  of  the  membranes  over  it.  The  cephalalgia  and  ob- 
scure cerebral  symptoms  during  a period  of  ten  months,  were  evidently 
owing  to  these  combined  lesions  advancing  slowly  or  at  intervals.  The 
history  informs  us,  that  during  the  last  six  months  he  had  been  out  of 
employment  and  insufficiently  nourished,  a condition  highly  favorable  to 
the  disintegrating  process  in  the  brain,  which  at  length  arrived  at  such  a 
point  as,  probably  combined  with  an  unaccustomed  congestion,  to  pro- 
duce violent  irritation  of  the  motor  nerves,  together  with  such  disorgani- 
sation and  pressure  as  to  occasion  hemiplegia. 

If  this  be  the  correct  theory  of  the  case,  an  antiphlogistic  and  lower- 
ing system  of  treatment  could  not  be  supposed  very  well  adapted  to 
remedy  the  mischief,  to  prolong  life,  or  even  to  alleviate  the  symptoms. 
The  indication  generally  laid  down  in  practical  works  on  this  subject — 
viz.,  to  bleed  when  the  pulse  is  strong  and  full — was  here  carried  out,  and 
failed  in  the  most  signal  maimer.  Indeed,  the  most  approved  practice 
was  actively  followed,  with  the  result  of  making  the  patient  worse  in 
every  particular.  When,  however,  at  length  antiphlogistics  were  aban- 
doned and  stimulants  administered,  then,  and  then  only,  he  rallied,  and 


384 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


showed  for  a little  signs  of  amendment.  In  no  case  I ever  met  with 
have  I been  so  impressed  with  the  inutility  of  antiphlogistics,  even  when 
the  symptoms  seemed,  from  all  our  past  notions,  loudly  to  demand  them. 
Nor,  after  the  uselessness  of  these  had  been  demonstrated,  and  the  pa- 
tient reduced  without  benefit,  could  the  value  of  an  opposite  practice 
have  been  better  exhibited.  We  shall  afterwards  point  out  how  unrea- 
sonable such  lowering  practice  is  in  all  organic  diseases  of  the  brain. — 
(See  Cerebral  Hemorrhage.) 

Case  XIII.* — Chronic  Cerebri tis  of  the  Right  Hemisphere — Cancerous 
Ulcer  of  the  (Esophagus  and  neighboring  Glands — Fatty  Heart. 

History. — Robert  Millar,  aet.  72,  married — saddler — admitted  October  6,  1866. 
Patient  states  that,  for  the  last  month,  he  has  suffered  from  pain  in  the  epigastrium 
and  from  vomiting,  for  which  he  was  in  the  habit  of  using  Gregory’s  powder.  For  a 
week  past  had  vertigo,  accompanied  by  a staggering  gait.  On  the  evening  of  the  5th, 
his  feet  were  so  cold,  that  he  was  obliged  to  use  a hot  brick  in  bed  ; on  the  morning 
of  the  6th,  he  found  himself  deprived  of  the  use  of  his  legs,  and  was  accordingly 
brought  to  the  hospital.  According  to  the  account  of  his  wife,  he  has  experienced 
considerable  anxiety  of  late  ; and  she  thinks  that  his  mental  faculties  have  been 
slightly  impaired  in  consequence. 

Symptoms  on  Admission. — It  is  with  great  difficulty  that  the  patient  can  be  made 
to  understand  a simple  question ; and  his  answers  are  often  contradictory.  He  does 
what  he  is  bid  ; speech  is  slow ; there  is  slight  confusion  of  memory,  and  want  of  con- 
catenation of  ideas.  Sensibility  appears  to  be  present  in  all  parts  of  the  body  except 
in  the  inferior  extremities,  where  the  patient  states  that  he  feels  numbness.  He  has 
no  feeling  of  prickling  or  itching.  Special  sensation  appears  normal ; but  he  does  not 
see  so  well  as  formerly.  Complains  of  tenderness  over  the  spines  of  the  sacrum,  on 
pressure  and  motion.  Has  not  the  power  of  moving  the  left  inferior  extremity  ; and 
some  difficulty  in  moving  the  right.  The  left  arm  is  somewhat  stiff,  and  he  is  unable 
to  raise  himself  in  bed.  With  the  exception  of  an  unusual  jog  with  the  impulse  of  the 
heart,  it  appears  to  be  healthy.  Pulse  60,  of  good  strength.  Tongue  covered  with  a 
whitish-grey  fur,  but  red  at  the  edges.  Protruded  straight,  but  sometimes  spasmodi- 
cally jerked  to  the  sides.  Passes  his  urine  involuntarily;  which  is  brown,  opaque, 
with  a flocculent  white  sediment ; alkaline.  Habitually  constipated.  Face  is  thin  and 
pinched ; skin  dry,  somewhat  cool,  especially  at  the  feet.  Patient  states  that  he  has 
observed  himself  becoming  thinner  during  the  last  month.  Other  functions  normal. 
Habeat  Pit.  Colocyrdh.  Co.  ij  pro  re  nata. 

Progress  of  the  Case. — October  ^th. — Power  of  flexing  the  left  leg  has  returned 
to  a certain  extent,  but  he  is  still  quite  unable  to  extend  it.  He  can  flex  and  extend 
the  left  forearm,  but  has  no  power  of  raising  the  upper  arm  on  the  same  side.  Bowels 
quite  open;  is  only  able  to  swallow  fluids,  and  even  these  in  very  small  quantities; 
it  would  appear  that  matters  ingested  pass  only  a certain  extent  down  the  oesophagus, 
and  then  regurgitate.  October  2,bth. — Since  last  report  has  continued  much  the  same. 
Vomiting  still  continues  to  such  an  extent,  that  everything  swallowed  is  rejected 
immediately.  There  is  tenderness  on  pressure  in  the  epigastrium.  An  inch  below, 
and  to  the  right  side  of  the  umbilicus,  a tumor  of  the  size  of  a hen’s  egg  is  now  felt, 
which  communicates  to  the  hand  an  impulse  synchronous  with  the  arterial  pulse ; it 
can,  by  careful  manipulation,  be  moved  to  the  middle  line,  or  even  to  the  left  of  it. 
I^  Bismuth.  Alb.  3 j ; Pulv.  Opii  gr.  iij  ; Ext.  Gentian  Liq.  q.  s.  ft.  massa  inpil.  xxiv. 
dividenda.  Two  to  be  taken  thrice  a day.  Habeat  enema  domesticum.  November  \%th. 
— After  taking  the  pills  the  vomiting  was  much  alleviated  and  has  now  ceased. 
Otherwise  he  has  been  in  much  the  same  condition  as  at  last  report.  The  bowels 
have  required  to  be  moved  by  means  of  enemata  and  purgatives.  December  2d. — 
This  morning  he  expresses  himself  as  greatly  relieved,  and  states  that  his  appetite  is 
much  improved.  He  now  answers  questions  slowly,  and  is  occasionally  subject  to 
optical  delusions.  There  is  scarcely  any  perceptible  difference  between  the  left  arm 
and  the  right ; the  former  being  used  almost  as  freely  as  the  latter,  and  presenting 
little  or  no  appearance  of  stiffness.  He  can  also  move  all  the  joints  of  the  left  leg, 
but  with  difficulty  ; stating  that  it  is  stiff,  and  that  he  has  not  so  great  command  over 

* Reported  by  Mr.  H.  N.  Maclaurin,  Clinical  Clerk. 


CEREBRITIS. 


385 


it  as  over  the  right.  Feels  a sensation  of  prickling,  which  he  refers  to  the  affected 
limb.  Is  occasionally  subject  to  mental  aberration.  December  Ath. — Has  been  very 
violent,  and  quite  delirious  all  night.  This  morning  there  appears  to  be  still  some 
aberration  of  intellect,  and  occasional  optical  delusions.  He  understands,  however, 
what  is  said  to  him,  and  answers  intelligently,  though  slowly.  Pupils  very  much 
contracted,  and  when  a light  is  brought  close  to  the  eyes,  they  do  not  contract 
further.  December  ^th. — Again  vomits  his  food  usually  shortly  after  taking  it. 
Emaciation  great;  face  pinched,  with  anxious  expression  and  staring  eyes.  Repe- 
taniur  P\L  Bimmthi  cum  Opio^  Haheat  Vini  ^ iv  indies.  December  21.s^. — Has  not 
vomited  since  taking  the  pills.  The  delirium  and  excitement  subsided  shortly  after 
the  last  report.  He  again  took  food  and  rallied  somewhat,  and  continued  in  the 
same  state,  with  occasional  attacks  of  excitement  towards  evening.  During  the  last 
thi-ee  days,  however,  his  strength  has  been  gradually  diminishing ; there  has  been 
sopor,  and  latterly  coma,  and  he  died  this  morning  at  7 a.m. 


S^ctio  Cadaveris. — Fifty  four  hours  after  death. 


Head. — On  removing  the  calvarium  and  dura  mater,  a considerable  amount  of 
clear  serous  fluid  was  seen  to  exist  in  the  subarachnoid  space,  elevating  the  arachnoid 
above  the  level  of  the  convolutions.  On  slicing  the  right  cerebral  hemisphere  several 
small  patches  of  softening  were  observed.  These  were  met  with  chiefly  in  the  white 
matter  of  the  hemisphere,  but  one  or  two  were  seen  in  the  grey  matter  of  the  convo- 
lutions. The  softening  was  most  distinct  in  the  upper  part  of  the  hemisphere ; and 
disappeared  towards  the  upper  wall  of  the  lateral  ventricle.  The  softened  portions 
were  of  a pulpy  consistence,  and  of  a white  color,  with  here  and  there  a slight  tinge 
of  red  or  yellow.  No  such  condition  existed  in  the  left  cerebral  hemisphere.  Each 
lateral  ventricle  was  dilated,  ansi  contained  about  an  ounce  of  clear  serous  fluid.  The 
parts  within  the  ventricles  were  natural,  as  well  as  the  rest  of  the  brain  and  the  cere- 
bellum. The  arteries  at  the  base  of  the  brain  were  generally  opaque,  and  in  some 
places  rigid,  from  the  presence  of  atheromatous  and  a little  calcareous  matter. 

Chest. — On  removing  the  heart  the  coronary  arteries  appeared  unusually  promi- 
nent, and  felt  hard.  The  muscular  substance  was  soft  and  of  a fawn  color.  The 
aortic  valves  were  competent,  although  a little  calcareous  matter  was  deposited  at  the 
base  of  two  of  them.  There  were  one  or  two  minute  vegetations  on  the  free  margin 
of  the  mitral  valve.  The  whole  organ  weighed  11  oz.  The  lungs  were  somewhat 
emphysematous  superiorly  and  anteriorly,  with  one  or  two  slight  puckerings  at  both 
apices.  On  cutting  into  the  pulmonary  tissue,  a little  old  tubercular  matter  and  one 
or  two  minute  cretaceous  concretions  were  found. 

Abdomen. — The  lower  part  of  the  oesophagus  felt  firm  and  thickened  externally, 
and  on  passing  the  forefinger  into  its  interior,  a stricture  was  found  to  exist  at  the 
cardia,  through  which  it  could  with  difficulty  be  passed.  On  laying  open  the  ceso^ 
phagus  an  ulcer  was  found  occupying  nearly  the  whole  of  the  mucous  surface  imme- 
diately above  the  cardia.  When  spread  out,  this  ulcer  was  seen  to  be  of  an  almost 
regularly  circular  form,  having  a diameter  of  about  an  inch  and  a half.  The  face  of 
the  ulcer  was  depressed ; the  margins  prominent  and  hard.  The  base  was  on  the 
whole  smooth,  except  that  from  its  centre  projected  a sort  of  ridge,  about  half  an 
inch  in  length  (running  parallel  to  the  length  of  the  tube),  of  white  glistening  appear- 
ance, and  of  almost  cartilaginous  hardness.  This  ulcer  was  quite  limited  to  the  oeso- 
phagus ; and  its  surface  was  of  a dirty  greenish  color.  The  external  parts  were 
fir.mly  matted  to  the  portion  of  the  oesophagus  corresponding  to  the  ulceration.  Two 
or  three  enlarged  lymphatic  glands  were  here  met  with.  On  section  of  the  largest, 
which  was  about  the  size  of  a hazel-nut,  it  was  found  to  be  of  firm  consistency  exter- 
nally ; while  internally  it  consisted  almost  entirely  of  a glairy  juice  of  a slightly 
reddish  color.  The  mucous  membrane  of  the  stomach  and  intestinal  canal  was 
healthy.  The  other  organs,  with  the  exception  of  a slight  degeneration  of  the  kidneys, 
were  healthv. 


Arterial  System. — Many  of  the  arteries  had  their  coats  loaded  with  atheroma- 
tous and  calcareous  matter.  This  was  especially  noted  in  the  case  of  the  cerebral  and 
c ironary  arteries ; and  the  right  common  iliac  artery  was  swollen  out  into  a saccular 
dilatation,  more  than  an  inch  and  a half  long. 

Microscopic  Examination. — The  softened  portion  of  the  right  cerebral  hemi- 
sphere was  composed  of  fragments  of  nerve-tubes,  with  innumerable  granular  cor- 
puscles. and  granular  masses  coating  the  vessels.  The  muscular  fasciculi  of  the 
heart  presented  various  stages  of  fatty  degeneration.  The  ulcers  in  the  oesophagus 
25 


386 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


were  composed  externally  of  granular  matter,  in  which  a few  cells  in  various  stages 
of  degeneration  were  observable.  The  nature  of  these  was  determined  by  those  con- 
tained in  the  neighboring  glands,  which  abounded  in  cancer  corpuscles,  in  all  stages 
of  their  development.  The  atheromatous  matter  in  the  arteries  consisted  of  numer- 
ous fatty  molecules  and  granules,  associated  with  a few  granule  cells,  numerous  crys- 
tals of  cholesteriue,  and  masses  of  earthly  salts. 

Commentarif, — When  I first  saw  this  man  he  presented  the  usual 
symptoms  of  chronic  softening  of  the  brain,  including  failure  of  memory, 
confusion  of  ideas,  and  diminution  of  motor  power  on  one  side  of  the 
body,  with  rigidity.  The  leading  symptoms,  however,  were  constant 
vomiting,  from  an  obstruction  at  the  cardia,  and  consequent  emaciation 
and  weakness.  At  first,  nourishment  was  carefully  regulated  and  given 
in  small  quantities.  Subsequently,  pills  of  bismuth  and  opium  seemed 
to  alleviate  tlie  vomiting,  which  gradually  ceased.  He  then  rallied  con- 
siderably, was  enabled  to  take  food  more  freely,  and  became  much  stronger. 
The  paralysis  and  rigidity  of  the  affected  limbs  disappeared,  and  he  walked 
about  the  wards  affirming  that  he  was  quite  well.  Indeed  he  several 
times  desired  to  leave  the  house.  His  mental  faculties,  however,  re- 
manicd  confused,  and  he  became  garrulous,  and  was  subject  to  optical 
delusions  and  intellectual  aberration.  In  this  state  he  continued  about 
three  weeks,  when  he  began  to  wander  at  night,  and  became  delirious ; 
then  symptoms  of  effusion  within  the  cranium  manifested  themselves, 
and  the  vomiting  returned.  Again  the  pills  with  wine  caused  him  to 
rally  a little,  but  his  strength  gradually  diminished,  and  he  sunk.  On 
post-mortem  examination,  chronic  softening  of  the  right  hemisphere  was 
found,  explaining  the  effects  produced  on  the  left  side  of  the  body.  The 
old  cancerous  ulcer  of  the  oesophagus  was  indurated,  and  evidently  in  the 
act  of  healing  up  by  cicatrization,  a fact  which  will  be  subsequently 
alluded  to. — (See  Stricture  of  the  (Esophagus.)  The  subarachnoid  cavity 
and  ventricles  were  distended  with  serum,  explaining  the  delirium  and 
sopor  which  preceded  death. 

The  effects  of  treatment  in  this  case  offer  a marked  contrast  to  what 
was  observed  in  the  last  one.  It  was  (mite  remarkable  to  observe  Low 
there  followed,  on  cessation  of  vomiting  and  improved  nutrition,  io 
marked  an  abatement  in  all  his  symptoms.  Even  the  paralysed  and 
rigid  limbs  recovered  their  tone,  and  he  moved  about,  as  if  well.  On 
the  return  of  the  vomiting,  the  prostration  and  nervous  symptoms  came 
back,  and  he  again  rallied  on  checking  the  vomiting  and  giving  wine. 
No  better  argument  could  be  furnished  that  delirium,  or  other  evidence 
of  supposed  nervous  excitement,  is  in  fact  a proof  of  weakness,  and 
requires  for  its  treatment  nutrients  and  stimulants. 

Case  XIV. — Paralysis  of  the  Ahducens  Occuli  and  Auditory  Nerves — 

Nxophthalmia — Tumor  at  the  Base  of  the  Cranium — Partial  Recovery, 

History. — John  Wright,  set.  30,  typefounder — admitted  November  26,  1860. 
States  that  four  years  ago  he  had  a severe  attack  of  rheumatism,  soon  after  which  he 
experienced  considerable  pain  in  the  right  side  of  the  head.  His  right  eyeball  then 
became  painful,  and  began  to  protrude.  Hearing  also  on  the  same  side  was  at  first 
dull  and  then  abolished.  Ten  months  after  the  commencement  of  the  headache,  it 
abated  on  the  right  side,  but  became  violent  on  the  left,  where  it  has  continued  ever 
since.  He  was  treated  with  mercury  and  iodide  of  potassium.  Tw'o  years  since,  he 

* Reported  by  Mr.  Cunningham,  Clinical  Clerk. 


CEREBRITIS. 


387 


wa3  attacked  with  spasms  and  grinding  of  the  jaws,  and  on  two  occasions,  the  con- 
vulsions were  pretty  general  and  attended  with  loss  of  consciousness.  His  vision  was. 
quite  perfec::,  till  about  a fortnight  ago,  when  he  began  to  see  double.  He  continued 
to  work  until  the  28 J inst.,  wiien,  owing  to  the  imperfection  of  his  sight,  he  was 
oblige  1 to  desist. 

S'fMProMS  o.\'  Admission. — On  admission,  complains  of  cephalalgia,  most  severe  on 
the  left  side.  There  is  complete  deafness  on  the  right  side.  The  right  eyeball  is 
very  prominent ; can  be  turned  inwards  but  not  outwards.  Vision  is  perfect  in  the 
two  eyes,  but  from  the  axis  of  both  not  being  alike,  is  double.  He  cannot  lay  hold 
of  an  object  at  once,  an  1 in  attempting  to  grasp  it  his  hand  is  at  first  directed  to  one 
side.  There  is  no  other  form  of  paralysis,  and  the  other  functions  are  healthy. 

PaooaESS  of  the  Case. — Since  admission,  this  man  has  presented  considerable 
alterations  in  his  symptoms,  the  headache  being  sometimes  more  severe  than  at 
others ; and  on  such  occasions,  there  was  considerable  stupor,  loss  of  memory,  and 
confusion  of  ideas.  Ii.a  treatment  consisted  of  the  internal  use  of  iodide  of  potassium 
and  purgatives^  with  coanter-irritants  externally.  On  the  Mh  of  February.^  it  was 
noticed  that  the  right  eyeball  was  less  prominent.  On  the  25^A  it  was  ascertained,  on 
careful  examination,  that  he  was  not  perfectly  deaf  on  the  right  side,  and  that  the 
right  eyeball  could  be  everted  more  than  formerly.  On  the  \st  of  March  the  pro- 
minence of  the  right  eyeball  was  comparatively  slight.  He  could  abduct  it  fully, 
ani  vision  was  then  single.  The  pain  in  the  head  was  unabated,  but  more  erratic. 
By  the  15^7?.  of  March.,  the  cephalalgia  had  greatly  abated.  There  was  a marked  im- 
provement in  the  general  health.  Movements  of  the  right  eyeball  normal — deafness  on 
the  right  side  considerable.  Blisters  to  the  temples  and  neck,  and  a variety  of  reme- 
dies have  been  tried,  to  cause  sleep,  and  diminish  the  pain  ; of  which  M.  xij  of  the 
Tr.  of  Cannabis  Indica,  appeared  to  be  the  most  beneficial.  With  the  exception  of 
deafness,  ha  was  dismissed  May  22,  quite  w'ell. 

Commentary . — In  this  case,  the  doep-rooteJ  eephnlalgia,  the  exoph- 
thaliiiia,  the  paralysis  of  the  sixth  and  auditory  nerves  on  the  right  side, 
clearly  indicated  the  existence  of  a solid  body  pushing  out  the  eye,  and 
pressing  on  the  affected  nerves.  At  one  period,  also,  irritation  of  the 
motor  branch  of  the  fifth  pair  was  exhibited  by  spasms  of  the  jaws,  with 
other  cerebral  derangements.  The  tumor,  however,  latterly  diminished 
much  in  size,  as  indicated  by  the  following  facts  : — First,  return  of  the 
eyeball  within  the  orbit ; secondly,  recovery  of  the  functions  of  the  right 
abducens  occuli ; and  lastly,  improvement  of  hearing,  with  diminution, 
and  then  absence  of  the  cephalalgia.  The  nature  of  the  growth  in  this 
case  cannot  be  stated  with  certainty,  but  as  it  was  not  likely  to  be  a 
cancerous,  and  there  was  no  evidence  of  its  being  a tubercular  formation, 
so  it  was  more  probably  a simple  exudation. 

Acute  cerebritis  is  distinguished  pathologically  by  the  exudation  of 
liquor  sanguinis  into  the  substance  of  the  brain,  which,  if  it  be  poured 
out  in  quantity,  is  transformed  into  pus ; if  slowly  or  to  a limited  extent, 
it  usually  passes  into  granules  and  granular  cells,  and  becomes  chronic. 
In  the  latter  case  it  constitutes  one  of  the  forms  of  softening  previously 
described  as  exudative  softening  (p.  35 1).  I have  already  alluded  to  the 
opinion  of  those  who  Consider  this  to  be  a form  of  fatty  degeneration, 
and  have  shown  how  this  doctrine  fails  to  explain  the  occurrence  of  new 
cell-formation  in  the  white  substance  of  the  brain  (p.  257).  Besides, 
positive  research  has  convinced  me,  that  however  fatty  a true  inflam- 
matory softening  may  ultimately  become,  this  is  only  the  result  of  a 
transformation  of  the  exuded  blood-plasma.  Fig.  150  (p.  168)  repre- 
sents this  plasma  on  the  exterior  of  a blood-vessel  from  the  spinal  cord, 
in  which  a formative  process  is  going  on,  and  I have  seen  other  cases 
causing  rapid  death,  Vf’here,  on  examination  of  the  brain  afterwards,  the 


388 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


coagulated  liquor  sanguinis  has  been  observed  in  an  earlier  stage  of 
formation.  Thus,  iu  1843,  I recorded  the  case  of  a child,  John  Smith, 
aged  three  years,  who  on  the  3d  of  February  1842  awoke  from  his  sleep 
with  a loud  scream ; on  the  following  day  he  vomited  repeatedly,  and 
on  his  admission  into  the  Clinical  ward  under  Dr.  Traill,  February  12th, 
presented  as  symptoms  intense  headache,  constant  rolling  of  the  head, 
contracted  pupils,  quick  and  sharp  pulse,  considerable  tremor  of  the 
limbs,  great  restlessness,  especially  at  night,  but  without  convulsion.  He 
died  the  same  night,  and  on  examination  there  was  no  meningitis,  no 

softening,  nor  serous  elfusion 
into  the  ventricles.  The  blood- 
vessels, however,  of  the  fornix 
and  central  medullary  parts  w^e 
coated  with  a fine  molecular  exu- 
dation (Figs.  407,  408),  at  many 
points  two  and  even  three  times 
thicker  than  the  vessel  to  which 
it  was  attached  ; the  exudation 
contained  clear  round  granules, 
exactly  similar  to  the  nuclei  of 
the  cells  figured  p.  167.  To 
argue  that  such  matter  is  the 
result  of  a fatty  degeneration  of 
the  vascular  wall,  appears  to 
me  opposed  to  all  our  positive 
Fig.  408.  knowledge,  whereas  its  being  a 
recent  coagulation  of  the  exuded  liquor  sanguinis,  and  produced  coin- 
cideiitly  with  the  violent  symptoms,  is  consistent  with  every  known  fact. 
In  another  boy,  H.  B.,  two  and  a half  years  old,  whom  I saw  in  private 
practice,  who  was  previously  in  good  health,  the  same  fact  w as  observable. 
On  the  6th  of  July  1848  he  could  not  eat  his  breakfast;  at  1 p.m.  he 
vomited;  at  4 p.m.  febrile  symptoms  appeared;  during  the  night  there 
was  great  restlessness  with  occasional  screaming  ; on  the  niornii  g of  the 
7th  there  were  general  convulsions,  but  principally  on  left  side,  and  he 
died  at  half-past  6.  The  exa’niuation  was  performed  by  Mr.  Goodsir. 
With  the  exception  of  3 iss  of  slightly  turbid  serum  in  the  ventricles, 
nothing  was  found  in  the  brain  but  a yellow  discoloration  the  size  of  a 
sixpence  on  the  surface  of  the  right  corpus  striatum.  On  microscopic 


Fig.  407. 


examination,  this  was  seen  to 


o 

consist 


of  the  same  molecular  matter 


surrounding  the  blood-vessels,  as  represented  Fig.  407.  These  and 
many  other  observations,  therefore,  appear  to  me  a sufficient  proof  that 
there  is  a form  of  acute  cerebritis,  consisting  of  the  exudation  of  liquor 
sanguinis  and  the  coagulation  of  the  fibrin  around  the  vessels,  which 
may  prove  fatal  very  rapidly,  especially  in  children;  but  that  when  such 
changes  occur  in  the  adult  or  in  aged  persons,  it  has  a tendency  to 
become  chronic,  and  leads  to  what  may  be  called  exudative  softening. 
(See  p.  354.) 


Fig.  407.  A blood-vessel  from  the  central  substance  of  the  brain,  coated  w ith  a 
molecular  exudation,  and  with  nuclei  forming  in  it. 

Fig.  408.  Another  blood-vessel,  with  masses  of  recently  coagulated  exudation 
attached  to  it.  260  diam. 


CEREBRITIS. 


389 


Chronic  cerebr;ti.s  so  occasioned  can  only  be  distinguished  with 
certainty  by  a microscopic  examination.  It  may  present  various  shades 
of  color — white,  grey,  yellow,  or  fawn  colored.  I have  seen  white 
softenino-.s  which  to  the  naked  eye  exactly  resemble  such  as  are  caused 
by  imbibition  after  death,  but  which  show  under 
the  microscope  numerous  granule-cells  in  all 
stages  of  f )rmation,  proving  that  an  exudation 
and  a new  growth  must  have  been  established 
before  death.  In  the  same  way  a diffluent  grey 
softening  of  the  white  cerebral  substance,  which 
has  been  regarded  by  some  as  atrophic,  I have 
shown  by  its  structure  to  have  originated  in 
an  exudation  (Fig  40[)).  The  yellow  and  fawn- 
colored  softenings  generally  owe  their  color  to 
an  admixture  of  blood  to  a greater  or  less  extent,  Fig  439. 

but  are  otherwise  essentially  the  same.  Hence,  as  previously  stated,  I 
regard  the  microscopic  examination  of  such  lesions  to  be  absolutely 
necessary  to  ascertain  their  nature,  and  the  existence  of  granule  cells  in 
the  white  substance  of  the  brain  as  a positive  proof  of  exudation. 

We  have  previously  seen  that  it  is  a matter  of  great  difficulty  to  dis- 
tinguish in  the  living  subject  acute  cerebritis  from  meningitis.  Neither 
is  it  always  easy  to  separate  chronic  cerebritis  from  many  cases  of  soften- 
ing resulting  from  hemorrhage,  or  from  fatty  degeneration  resulting  from 
arterial  obstruction.  The  cause  of  this  is  obvious,  inasmuch  as  all  these 
lesions,  consisting  of  more  or  less  destruction  of  the  nervous  tissue,  may 
be  expected  to  affect  the  brain  in  the  same  manner.  In  their  mode 
of  onset,  however,  they  exhibit  a difference.  Thus,  as  a general  rule, 
hemorrhage  is  indicated  by  suddenness  of  attack,  whilst  uncomplicated 
chronic  cerebritis  gradually  affects  the  mental  and  motor  functions  in 
various  ways  and  degrees  according  to  the  portion  of  the  brain  affected. 
But  it  must  not  be  overlooked,  that  an  inflammatory,  a hemorrhagic,  and 
a primary  fatty  softening,  may  occur  together  in  the  same  individual,  as 
the  conditions  which  occasion  one  are  also  favorable  to  the  production 
of  the  others.  Hence  I must  refer  the  reader  to  the  considerations  on 
this  point  under  the  head  of  Cerebral  Hemorrhage. 

Great  discussion  has  taken  place  as  to  whether  a chronic  inflamma- 
tory softening  ever  undergoes  a cure.  Durand-Fardel  thinks  that  the 
curability  of  cerebral  softening  is  a fact  of  which  we  can  no  more  entertain 
disbelief  in  the  present  day,  than  we  can  of  the  curability  of  pulmonary 
tubercle.  Most  certainly  the  observations  of  Rostan,  Cruveilhier,  Sims, 
Bechambre,  and  Durand-Fardel,  have  fully  established  the  possibility  of 
this  occurrence.  Besides,  why  should  not  a coagulated  exudation  of 
blood-plasma  into  the  brain,  in  consequence  of  the  changes  whereby  it  is 
broken  down  and  disintegrated,  be  ultimately  absorbed  in  that  organ  as 
well  as  in  any  other  ? It  appears  to  me,  however,  that  the  anatomical 
appearances,  by  means  of  which  pathologists  have  endeavored  to 
dnnonstra^e  the  curability  of  a softening  are  not  to  be  depended  on. 
Durand-Fardel  points  to  the  softening  resembling  chalky  milk  as  a proof 

Fig.  400.  Structure  of  a chronic  grey  softening  of  the  cerebral  hemisphere,  re- 
sembling chalky  milk,  entirely  composed  of  exudation,  transformed  into  granules  and 
cells.  250  diam. 


390 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


of  the  passage  of  the  lesion  into  a state  of  cure,  and  Dr.  Sims  described 
fawn-colored  cavities  as  evincing  the  same  fact.  Now  I have  seen  cases 
where  the  grey  milky  softening  was  associated  with  hemiplegia  of  long 
standing,  but  which  presented,  on  microscopic  examination,  the  appear- 
ance represented  Fig.  409,  which  although  undoubtedly  evincing  great 
disintegration,  cannot  be  said  to  show  signs  of  healing.  The  fawn- 
colored  cavities  of  Dr.  Sims  I have  not  only  seen  to  be  filled  with 
granule-cells  in  all  stages  of  formation,  but  associated  with  intense  recent 
contraction,  on  the  opposite  side  of  the  body.  (See  p.  359.)  Neither 
of  these  lesions,  therefore,  appear  to  me  to  present  anatomical  proofs  of  a 
cured  softening.  Dr.  Todd  also  believes  in  the  cicatrization  of  chronic 
softenings,  and  even  considers  that  the  rigidity  which  occasionally  comes 
on  late  in  paralysed  muscles,  is  attributable  to  the  irritation  which  the 
contraction  produces  on  the  neighboring  healthy  cerebral  substance. 
Whether  the  yellowish  or  fawn-colored  indurated  spots,  which  are  very 
rarely  observed  in  the  brain-substance,  are  proofs  of  cured  softening,  it 
is  very  difficult  to  say,  for  I have  seen  such  indurations  crowded  with 
granule  cells.  (See  Case  XVII.)  Hence  the  morbid  anatomy  of  cured 
cerebral  softenings  is  a subject  still  demanding  careful  investigation. 

The  general  diagnosis  and  treatment  of  chronic  cerebritis  will  be 
considered  under  the  head  of  Cerebral  Hemorrhage,  with  which  it  is 
often  associated. 

CEREBRAL  DISEASE  FROM  OBSTRUCTION  OF  ARTERIES. 

Case  XV.'^ — Faralysis  rai)idhf  lecoming  general — Old  Ajyojilectic  Cgst  in 
right  Corpus  Striatum — Softening  of  Fons  Varolii — Clot  obstructing 
Basilar  Artery — Fneumonia  of  Left  Lung. 

History. — Alexander  Walker,  set.  60,  a pensioner,  admitted  December  3,  1855. 
According  to  the  account  of  the  patient’s  brother,  he  has  been  long  subject  to  vertigo, 
both  v/hen  at  home  and  as  a soldier  in  India.  For  this  complaint  he  has  been  bled 
fifteen  limes,  and  always  with  temporary  relief.  He  has  been  of  temperate  habits, 
and  has  lately  been  working  in  a printer’s  office,  where  he  was  accustomed  to  carry 
heavy  weights  on  his  head.  Yesterday,  having  undergone  unusual  bodily  fatigue  and 
great  mental  anxiety  in  consequence  of  his  sister’s  death,  he  was  suddenly  seized, 
about  4 p.  M.,  with  a feeling  of  pricking  and  numbness  in  his  left  arm,  which  com- 
menced at  the  fingers.  Shortly  after,  there  occurred  thickness  of  speech,  which 
rapidly  increased.  During  the  night  he  became  speechless,  but  could  make  signs, 
and  appeared  conscious.  In  the  morning  he  was  conveyed  to  the  Infirmary. 

Symptoms  on  Admission. — On  admission,  there  is  no  sensibility  in  the  left  arm — 
on  being  flexed  it  appears  peculiarly  rigid,  though  not  retracted.  On  stimulating  the 
left  leg,  there  is  evidence  of  only  slight  sensibility,  and  feeble  reflex  movements. 
Right  arm  moves  readily  on  the  a[)plication  of  stimuli,  but  the  right  leg,  though  some- 
what retracted,  is  partially  paralysed.  Left  pupil  somewhat  more  conti  acted  than  the 
right  one.  Face  pale,  without  distortion  of  the  features.  Cannot  speak  or  protrude 
the  tongue,  but  is  evidently  conscious,  listening  and  watching  movements  with  an 
anxious  expression  of  countenance.  Cardiac  sounds  inaudible ; pulse  88,  of  good 
strength ; inspirations  deep,  expirations  accompanied  witli  snoring  rales.  Skin  warm 
and  dry.  Bowels  constipated ; bladder  distended.  To  have  a turpentine  enema. 
The  urine  to  be  drawn  off  by  a catheter.  Iced-ivater  to  be  constanilu  applied  to  the 
scalp  (the  man’s  head  was  bald),  and  the  following  bolus  to  be  carefully  plaud  on  the 
podcrior  third  of  the  dorsum  of  the  tongue.,  so  as  to  ensure  deglutition.  R Old  t rotonis^ 
guti.j;  Pulv.  Jalap.  Co.  3i;  Confect.  Sennee.,  q.  s.fl.  bolus. 

Progress  of  the  Case. — December  4//i. — 30  oz.  of  healthy  urine  were  drawn  off 
yesterday  by  the  catheter.  This  morning  both  faeces  and  urine  were  passed  involun- 


* Reported  by  Mr.  John  Glen,  Clinical  Clerk. 


CEREBRAL  DISEASE  FROM  OBSTRUCTION  OF  ARTERIES. 


391 


tarily  in  bod.  Both  arms  and  legs  are  now  completely  paralysed,  and  do  not  movft 
on  the  application  of  strong  stimuli.  Respiration  is  more  labored;  pulse  120,  weak; 
still  conscious.  To  nourish  the  patient  as  much  as  possible  b>j  the  mouthy  and  if  neces- 
sary,  per  anum,  with  strong  beef  tea.  December  ^th. — Respirations  still  more  labored, 
and  the  chest  does  not  expand.  The  loud  snoring  with  expiration  masks  the  pulmo- 
nary sounds,  and  his  position  on  the  back  cannot  be  changed  to  admit  of  examination 
of  the  lungs.  In  other  respects  is  in  the  same  state,  but  weaker ; pulse  120,  weak. 
Is  motionless,  speechless,  with  the  lips  slightly  separated.  On  attempting  to  introduce 
nourishment  by  the  mouth,  the  jaws  are  firmly  closed,  and  matters  which  are  taken 
cannot  be  swallowed,  although  he  makes  efforts  to  do  so.  The  water  has  been  drawn 
off  regularly  by  catheter,  and  nutritive  enemata,  with  brandy,  administered.  He  is  still 
evidently  conscious.  December  (Sth. — Since  yesterday  has  been  gradually  sinking  ; the 
cheeks  are  distinctly  paralysed,  and  distended  at  each  expiration.  This  morning  the 
left  pupil  became  much  more  contracted  than  the  right ; the  corneae  became  dim,  and 
the  respirations  40  in  the  minute ; the  pulse  fluttering ; coma  supervened  ; and  he  died 
at  2 p.  M.  on  the  7th. 

Sectio  Cadaver  is. — Twenty  three  hours  after  death. 

Head. — Surfaces  of  the  arachnoid  moist ; slight  serous  eafusion  between  the  sulci 
of  the  cerebral  convolutions.  On  slicing  the  hemispheres,  their  substance  exhibits  a 
greater  number  of  bloody  points  than  usual.  They  are  symmetrical ; the  right  lateral 
ventricle  somewhat  smaller  than  the  left.  The  two  contained  3 iij  of  transparent 
serum.  The  right  optic  thalamus  was  decidedly  larger  than  the  left  one,  and  at  its 
base,  near  the  corpus  striatum,  presented  on  section  a well-marked  cribriform  appear- 
ance. In  the  posterior  fourth  of  the  substance  of  the  left  corpus  striatum  was  a dif- 
fluent mass  the  size  of  a pea,  which  flowed  out  on  section,  having  a small  cavity 
with  the  walls  of  a fawn  color.  Both  choroid  plexuses  contained  simple  cysts,  the 
greater  number  on  the  left  side.  On  cutting  through  the  pons  varolii,  its  centre  was 
found  softened,  and  of  a pulpy  consistence,  the  upper  half  more  than  the  lower,  and 
the  right  more  than  the  left  side.  The  whole  softened  portion  was  gradually  washed 
away  by  a thin  stream  of  water,  showing  a distinct  irregular  margin,  inclosing  a 
cavity  about  the  size  of  a hazel-nut.  The  basilar  artery,  throughout  its  whols 
course,  was  opaque,  its  coats  loaded  with  calcareous  and  atheromatous  matter,  and 
obstructed  by  a colorless  clot,  which  at  one  point  was  transformed  into  mineral  matter. 

Spinal  Cord. — The  spinal  cord  was  carefully  examined,  and  found  to  be  healthy. 

Chest. — The  inferior  lobe  of  left  lung  hepatized,  of  a dirty  grey  color,  and  in  the 
upper  lobe  two  masses  of  pneumatic  condensation  about  the  size  of  walnuts.  Mar- 
gins of  both  lungs  emphysem  itous.  Heart  healthy. 

All  the  other  organs  were  healthy. 

Microscopic  Examination. — The  contents  of  the  old  apoplectic  cyst  in  right  corpus 
striatum  had  disappeared,  but  the  indurated  walls  consisted  of  a dense  aggregation  of 
brownish  opaque  molecules,  which  gradually  diminished  in  number  externally,  and 
were  gradually  lost  among  the  tubular  and  granular  substance  of  the  striated  body. 
The  softened  portion  of  the  pons  varolii  was  entirely  composed  of  the  disintegrated 
tubular  and  vesicular  structure  of  this  portion  of  the  encephalon.  There  were  no 
granule-cells  or  granular  masses,  such  as  are  found  in  softening  from  an  exudation. 
But  the  nerve-cells  contained  an  unusual  number  of  minute  brownish  granules,  and 
floated  about  isolated  in  the  softened  substance,  as  seen  in  Fig.  405.  The  clot  in  the 
basilar  artery  contained  irregular  masses  of  phosphate  of  lime,  which  at  one  point 
were  so  closely  aggregated  together  as  in  themselves  completely  to  block  up  the  vessel. 
The  hepatization  of  the  left  lung  presented  all  the  stages  of  the  congestive,  exudative, 
and  suppurative  stages  of  pneumonia.  These  were  remarkably  well  seen  in  the  two 
masses  in  the  upper  lobe,  in  which  the  centres  were  soft  and  purulent,  the  air  vesi- 
cles filled  with  pus,  and  the  surrounding  mass  indurated,  exhibiting  different  stages 
of  the  transformation  of  an  amorphous  exudation  into  cells.  (See  Fig.  154,  p.  174, 
which  was  drawn  from  a demonstration  made  from  one  of  these  masses.) 

Commentary . — After  vertigo  and  other  head  symptoms  for  many 
years  for  which  he  was  in  the  habit  of  being  bled,  this  man,  in  conse- 
quence of  unusual  bodily  exertion  and  mental  anxiety,  was  suddenly 
seized  with  paralysis  in  the  left  arm  without  loss  of  consciousness.  This 
was  followed  by  paralysis  of  speech,  and  of  the  other  limbs,  inability  to 


392 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


pass  urine  or  retain  the  faeces,  and  spasmodic  closure  of  the  jaws.  These 
symptoms  indicated  a lesion  of  the  central  part  of  the  brain,  which, 
from  the  suddenness  of  their  occurrence,  1 supposed  would  be  a hemor- 
rhage either  in  or  pressing  upon  the  pons  varolii.  But  on  examination 
there  was  found  an  old  apoplectic  cyst  in  the  left  corpus  striatum,  which 
did  not  appear  to  have  caused  any  of  his  recent  symptoms,  and  is  not 
accounted  for  in  his  history.  The  general  paralysis  was  evidently  owing 
to  the  softening  of  the  pons  varolii,  and  this  in  its  turn  was  certainly 
not  dependent  on  an  exudation  from  the  blood-vessels,  a fact  which  I 
ascertained  by  careful  and  prolonged  microscopical  examination.  I could 
not  therefore  resist  the  conclusion,  that  the  disorganization  of  the  nervous 
substance  was  attributable  to  the  obstruction  in  the  basilar  artery,  and 
a peculiar  fatty  degeneration  commencing  in  the  nerve  cells.  Of  this 
lesion  we  shall  be  able  to  form  a better  idea  after  examining  the  facts 
of  the  following  case  : — 

Case  XVI.* — Apoplexy — Hemiplegia  of  left  side — Convulsive  attacks— 
Cardiac  and  Renal  Disease — Old  Clot  in  the  right  Cerebral  Hemisphere^ 
with  surrounding  softening. 

History. — Elizabeth  Ross,  set.  26,  married,  admitted  May  23,  1853.  States  that 
about  4-^  years  ago  she  suffered  from  acute  rheumatism,  on  recovering  from  which  she 
frequently  experienced  palpitations,  and  during  the  last  18  months  there  has  been 
occasional  epistaxis,  preceded  by  giddiness,  dimness  of  vision,  and  muscie  volitantes. 
Last  January,  when  quietly  sitting  in  a chair,  she  suddenly  fell  to  the  ground  insen- 
sible, in  which  condition  she  remained  48  hours.  On  recovering  her  consciousness, 
she  could  not  speak ; the  left  half  of  the  body  and  face  was  deprived  of  motion  and 
sensibility.  Five  weeks  afterwards  she  began  to  regain  her  speech  and  the  command 
of  the  left  arm  and  leg,  but  observed  at  the  same  time  an  oedematous  state  of  the  feet 
and  legs,  and  that  this  gradually  spread  over  the  whole  body.  Three  weeks  ago  she 
again  became  suddenly  insensible,  and  continued  so  1|  hours,  during  which  time  she 
was  much  convulsed.  She  had  three  similar  fits  during  the  succeeding  ten  days, 
which  were  preceded  by  a choking  sensation  in  the  throat,  palpitation  and  uneasiness 
in  the  precordial  region. 

Symptoms  on  Admission. — On  admission  there  is  still  partial  paralysis  of  the  left 
side  of  the  body,  which  is  much  colder  than  the  right  side.  On  attempting  to  walk 
she  cannot  raise  her  left  foot  completely  from  the  ground,  but  drags  it  behind  her. 
She  cannot  bend  her  left  wrist  or  arm,  or  raise  them  so  readily  as  she  can  those  of  the 
right  side.  Her  mouth  is  slightly  drawn  to  the  right  side,  and  the  tongue  when 
protruded  appears  to  be  somewhat  to  the  left  of  the  mesial  line.  The  sensibility  over 
the  whole  left  side  is  somewhat  impaired.  She  complains  of  uneasiness  in  the  precordial 
region.  Action  of  heart  strong,  but  rhythm  regular.  Apex  beats  between  the  6th  and 
6th  ribs,  about  half  an  inch  to  the  outer  side  of  the  nipple.  Transverse  cardiac  dulness 
2^  inches.  A blowing  murmur  is  heard  with  the  first  sound  at  the  apex,  and  a double 
blowing  murmur  at  the  base,  of  which  that  with  the  second  sound  is  the  loudest  and 
longest,  and  is  distinctly  audible  in  both  infra-clavicular  spaces.  Immediately  above 
the  right  sterao-clavicular  articulation  considerable  pulsation  is  visible  to  the  eye, 
but  no  tumor  can  be  defined  upon  manipulation.  Over  this  part  a harsh  single 
blowing  murmur  is  audible,  and  fremitus  is  very  perceptible  to  the  finger.  No  venous 
pulsation.  Radial  pulse  87  per  minute,  strong  and  hard,  communicating  a jerking 
sensation  to  the  finger.  The  voice  is  weak,  and  articulation  difficult  and  indistinct. 
Respirations  irregular  and  spasmodic,  20  per  minute.  No  dyspnoea.  Cough  short: 
expectoration  scanty.  Chest  resonant  everywhere  on  percussion,  and  the  only  abnor- 
mal sound  audible  is  a fine  moist  rattle  with  inspiration  over  the  two  lower  thirds  of 
left  lung  posteriorly.  Tongue  is  red  and  dry ; appetite  very  bad,  and  dysphagia  to 
such  a degree  that  she  can  only  take  liquid  food.  Slight  epigastric  tenderness. 
Bowels  costive.  Micturition  difficult,  painful,  and  frequent.  Urine  of  pale  color, 
neutral  reaction,  sp.  gr.  1010,  with  deposit  of  triple  phosphate  on  cooling;  quantity 


Reported  by  Mr.  Joseph  Johnston,  Clinical  Clerk. 


CEKEERAL  DISEASE  FROM  OBSTRUCTION  OF  ARTERIES.  393 


passed  small,  and  deposits  when  heated  a considerable  coagulum.  There  is  general 
ceJoina  of  the  whole  surface  of  the  body,  but  especially  of  the  inferior  extremities. 
IJ  Pd.  Scillceet  Digitalis,  vj  ; Siimat  uiiam  bis  in  die.  Pil.  Opii,  gr.  i.  hora  somni 
sumend.  Haheat  Elect.  Laxans  l\]\et  repetatur  post  koras  sex  si  opus  sit. 

Progress  of  the  Case. — May  2oih. — Sleeps  better.  Bowels  relieved.  (Edema 
of  upper  part  of  body  diminished.  Urine  still  in  small  quantity,  highly  coagulable, 
and  containing  waxy  and  fatty  casts.  Heart’s  action  not  so  strong.  Jane  tsth. — 
Since  last  report  has  been  gradually  improving.  She  can  use  the  extremities  of  left- 
side more  freely,  and  the  sensibility  is  more  acute.  Can  rise  and  return  to  bed  with- 
out assistance.  Speech  more  distinct.  Impulse  and  murmur  over  sternum  greatly 
diminished.  Heart’s  impulse  more  feeble,  and  blowing  sounds  not  so  loud.  Pulse 
90,  still  jerking.  Complains  of  pain,  but  without  tenderness,  in  right  lumbar  region. 
(Edema  of  lower  limbs  still  considerable,  though  diminished.  Digestive  functions 
normal.  Renal  symptoms  the  same.  His  been  taking  half  a grain  of  the  proto-iodine 
of  mercury  every  night,  with  mild  diuretics  and  occasional  laxatives.  June  ^th. — Yes- 
terday afternoon  at  4 p.m.,  she  became  giddy  and  soon  fell  into  an  unconscious  state, 
accompanied  with  convulsions  equally  strong  in  the  limbs  of  both  sides  ; screams  and 
moaning.  The  pupils  were  dilated,  and  the  eyeballs  turned  outwards  and  uj)wards. 
She  had  no  foaming  at  the  mouth,  but  frepuently  shut  her  jaws  with  great  violence, 
so  that  her  tongue  could  with  great  diificulty  be  kept  from  being  injured.  The  attack 
lasted  ten  minutes.  During  the  evening,  she  had  four  other  attacks  of  about  the  same 
duration.  After  each  fit  she  remains  for  some  time  in  a drowsy  condition,  and  cannot 
answer  questions  perfectly.  After  the  first  attack  six  leeches  we.e  applied  to  the 
temples,  anl  a turpentine  enema  given.  In  the  evening  a blister  was  applied  to  the 
head.  To-day  is  much  better.  June  9th. — Had  another  slight  attack  yesterday  morn- 
ing, and  a third  last  night.  Paralysis  not  increased  ; other  symptoms  the  same.  June 
19th. — Since  last  report  has  been  complaining  of  various  wandering  pains,  more  espe- 
C’ally  in  right  hypocondrium.  The  gums  on  the  14th  became  slightly  tender,  when 
the  proto-iodide  of  mercury  was  omitted.  Since  the  10th  there  has  been  diarrhoea, 
the  bowels  having  been  opened  6 or  7 times  daily,  notwithstanding  the  employment 
of  various  astringents  with  opium  by  the  mouth  and  rectum.  About  4 p.m.,  without 
any  precursory  symptoms,  she  suddenly  became  unconscious  and  convulsed.  She 
strained  and  struggled  violently  for  about  fifteen  minutes  ; the  convulsions  at  first  being 
equally  severe  on  both  sides,  although  latterly  they  were  entirely  confined  to  the  left 
side.  Her  mouth  was  drawn  towards  the  right,  and  the  lower  jaw  was  incessantly 
carried  from  one  side  to  the  other,  with  a semi-rotatory  motion,  as  in  grinding  foo  i. 
The  eyelids  remained  permanently  open,  and  the  eyeballs  were  carried  in  an  upward 
and  outward  direction,  in  which  position  they  remained  during  the  continuance  of  the 
fit.  The  breathing  became  slow,  sometimes  interrupted  and  irregular,  attended  with 
sfeertor  during  inspiration,  and  a puffing  out  of  the  cheeks  during  expiration.  There 
was  also  foaming  at  the  mouth.  These  phenomena  soon  subsided,  and  the  patient  was 
left  in  a comatose  condition.  Two  hours  thereafter  these  phenomena  recurred  twice, 
without  the  patient  at  intervals  regaining  the  slightest  degree  of  consciousness.  The 
faeces  and  urine  were  passed  involuntarily.  During  the  last  attack  the  inhalation  of 
chloroform  was  tried,  but  the  breathing  becoming  more  stertorous  and  hurried,  an  1 
the  pulse  intermitting  and  almost  imperceptible,  it  was  instantly  stopped.  Abradatur 
Capillitium  ; Applicetur  Capiti  Emp.  Gantharid.  (4  x 6.)  June  29lh — Became  con- 
scious last  night  about  8 o’clock,  when  she  could  answer  questions  directly,  but  slowly, 
and  in  an  articulate  manner.  She  complains,  when  interrogated,  of  great  exhaustion 
and  severe  frontal  headache.  Diarrhoea  continues  and  is  involuntary.  Pulse  90,  weak, 
almost  imperceptible.  Stupor  at  intervals.  Haheat  Vini  § ij.  June2\st. — No  return 
of  convulsions.  Stools  not  passed  involuntarily  as  formerly.  No  pain  in  head,  and 
says  she  is  free  from  suffering.  Countenance  dull  and  stupid  ; pupils  natural ; expres- 
sion of  eye  sluggish.  Respiration  slow  and  snoring.  Over  both  sides  of  chest  anteri- 
orly, loud  moist  rales  are  audible.  Pulse  90,  very  weak.  Other  symptoms  unaltered. 
Habeat  Vini  ^ iv  indies.  Nutritive  food  and  drinks.  Towards  evening  the  mucous 
rattle  in  chest  became  very  loud,  and  the  breathing  snoring,  and  occasionally  interrupted; 
no  pain  anywhere.  Could  with  difficulty  be  roused  to  answer  questions.  Died  at 
1.30  a.m. 


Sectio  Cadaveris. — Thirlyfive  hours  after  death. 

Body  pale,  not  emaciated ; lower  extremities  very  oedematous. 


394 


DISEASES  OF  THE  NEEYOUS  SYSTE^H. 


Head. — The  arachnoid  membrane  presents  its  natural  degree  of  moisture.  On  sec- 
tion of  the  right  hemisphere  of  the  brain,  a softened  portion  is  situated  above  and  to 
the  outer  side  of  the  corpus  striatum.  It  measured  by  1 inch,  and  extends  exter- 
nally close  to  the  cerebral  convolutions.  In  its  centre  there  is  a hard  round  nodule 
about  tlie  size  of  a small  hazel  nut,  of  a dark-red  color,  with  a zone  of  bright  yellow 
extending  about  a quarter  of  an  inch  into  the  softened  cerebral  suostance.  This  is 
of  friable  consistence,  and  of  a yellowish  hue  in  the  centre,  becoming  of  an  ash-grey 
tint,  and  of  almost  diffluent  consistence  towards  the  circumference.  Externally  the 
diseased  substance  gradually  passes  into  the  healthy  cerebral  structure.  Arteries 
healthy. 

Cjiest. — Pericardium  distended,  containing  S^oz.  of  pale  straw-colored  fluid. 
Left  ventricle  firm,  its  cavity  dilated.  The  mitral  orifice  admits  the  entrance  of  two 
fingers ; but  the  anterior  segment  of  its  valve  has  on  its  external  surface  a few  scat- 
tered fibrinous  granules,  while  its  posterior-inferior  angle  is  thickened  and  covered 
with  small  masses  of  fibrin,  which  extend  along  the  shortened  chordae  tendineae,  giving 
them  a fringed  appearance.  The  aortic  valves  are  much  thickened,  hard  and  inelastic, 
especially  at  their  free  boi  ders,  upon  which  also  a few  aggregations  of  fibrinous  gran- 
ulations are  seen,  similar  to  those  on  the  mitral  valve.  They  contain  in  their  interior 
a small  amount  of  atheroma,  wdiich  extends  into  the  aorta  for  about  three-quarters 
of  an  inch.  They  admit  the  passage  of  water  through  them  rapidly,  on  its  being 
poured  upon  them  from  above.  The  pleurae  on  both  sides  are  partially  adherent  by 
long  bands  of  chronic  lymph.  The  right  pleural  cavity  contains  about  six,  and  the 
left  about  three  ounces  of  serum.  The  lungs  are  shghtly  collapsed,  flaccid,  and  im- 
perfectly crepitant.  In  several  places  are  indurated  masses,  varying  in  size  from  a 
pea  to  a hazel  nut,  composed  of  infiltrated  blood.  Other  portions  of  the  lungs  pour 
out,  from  their  cut  squeezed  surfaces,  a small  quantity  of  turbid  serum,  with  pus  from 
the  smaller  bronchi. 

Abdomen.— Cavity  of  the  peritoneum  contains  a considerable  quantity  of  serum. 
Liver  of  natural  size,  but  the  color  daik,  from  venous  congestion.  Spleen  of  firm  con- 
sistence, 7 inches  long  by  4 broad.  Both  kidneys  slightly  larger  than  usual,  of  firm 
consistence,  puckered  surface,  and  stellate  irregular  vascularity.  On  section,  they 
present  the  usual  characters  of  the  waxy  degeneration.  Other  abdominal  organs 
healthy.  No  leucocythemia. 

Microscopic  Examination. — The  central  portion  of  the  diseased  cerebral  struc- 
ture is  principally  composed  of  fibre  cells,  distinctly  nucleated,  infiltrated,  how'ever, 
with  sanguineous  coloring  matter,  in  various  stages  of  degeneration,  and  mingled 
with  purple  and  ruby  crystals  of  hematoidine.  The  more  external  yellow  and  grey 
softenings  present  granules  and  granular  masses  in  great  abundance,  mingled  with 
reddish  and  yellow  portions  of  disintegrated  blood ; the  latter  with  a few  crystals  of 
hematoidine,  are  most  abundant  towards  the  centre.  Externally  the  softening  is 
principally  composed  of  disintegrated  nerve-tubes,  presenting  various  forms  with  double 
lines. 


Commentary . — In  this  young  ■woman  valvular  disease  of  the  heart 
had  supervened  upon  acute  rheumatism,  and  vegetations  had  formed  upon 
the  rurfaces  of  the  mitral  and  aortic  valves.  These  vegetations,  as  we 
shall  subsequently  see,  are  deposits  of  the  fibrin  in  the  blood  which  may 
become  detached,  and  be  carried  by  the  circulation  into  more  distant 
and  smaller  vessels.  Four  months  previous  to  admission,  when  quietly 
sitting  in  her  chair  she  became  suddenly  apoplectic;  and  on  recovering 
her  consciousness  labored  under  hemiplegia  of  the  left  side  and  paralysis 
of  speech.  Five  weeks  subsequently  symptoms  of  renal  disease  mani- 
fested themselves ; then  there  supervened  another  attack  of  apoplexy, 
followed  by  a long  train  of  nervous  phenomena,  which  exhausted  her 
strength  and  caused  death.  I took  charge  of  the  case  in  the  middle  of 
June,  b}'  which  time  she  was  so  reduced  that  wine  and  nutrients  failed 
to  rally  her.  On  post-mortem  examination  the  arteries  of  the  brain  were 
healthy,  but  evidence  of  an  old  hemorrhage  existed,  and  the  question 
that  arises  is,  whether  or  not  ihis  had  been  caused  by  obstruction  of  the 


CEREBRAL  DISEASE  FROM  OBSTRUCTION-  OF  ARTERIES. 


S95 


middle  cerebral  artery,  from  one  of  the  clots  derived  from  the  heart  ? 
Though  this  cannot  be  affirmed,  it  appears  to  be  very  probable.  The 
lesion  so  produced  by  its  irritating  action  in  the  surrounding  brain  tissue, 
conjoined  with  occasional  congestions,  is  quite  sufficient  to  explain  all 
the  nervous  phenomena  which  followed. 

Case  — Two  sudden  attacks  of  Apoplexy — Hemiplegia — Cardiac 

Disease — Persistent  Alhurninaria — Enlarged  and  diseased  Spleen — 
Cerebral  Softening- — Anasarca — Atheroma  of  Arteries — Obstruction  of 
left  middle  Cerebral  Artery. 

History. — James  Balfour,  sot.  38,  a smith — admitted  April  13, 1857.  The  patient 
has  been  a man  of  temperate  habits,  accustomed  to  good  diet,  and  in  the  enjoyment 
of  excellent  health  for  the  greater  part  of  his  life.  For  nearly  a twelve-month  before 
admission,  his  wife  had  noticed  that  he  was  not  looking  as  well  as  formerly,  but  he 
himself  had  no  feeling  of  illness,  and  continued  to  follow  his  usual  occupation  until 
three  months  ago.  At  that  time,  one  day,  while  engaged  at  his  work,  he  was  sud- 
denly seized  wdth  headache  and  vertigo,  the  pain  being  so  severe  as  to  compel  him  to 
return  home  and  go  to  bed.  He  became  insensible,  and  remained  comatose  for  three 
days.  On  recovei  ing  from  this  state,  he  found  he  had  lost  the  power  of  his  right  side, 
and  that  his  features  were  drawn  to  the  left.  Ilis  speech  was  not  affected.  From 
this  state  he  gradually  recovered,  and  in  four  weeks  was  able  to  return  to  work. 
Three  weeks  subsequently,  while  in  the  act  of  shoeing  a horse,  he  again  suddenly 
lost  to  a considerable  extent  the  power  of  his  right  side,  and  his  speech  now  became 
affected.  Since  the  second  attack  he  has  never  been  able  to  resume  his  work  ; for, 
although  ho  has  recovered  the  power  of  his  right  side  almost  entirely,  he  has  gradu- 
ally become  weaker.  For  the  last  five  or  six  weeks  his  legs  have  swollen  towards 
night,  and  during  the  same  period  there  has  been  slight  diarrhoea,  wliich  has  increased 
considerably  during  the  last  ten  days,  but  which  causes  no  pain.  Two  weeks  ago  he 
was  attacked  with  severe  vomiting,  the  matters  ejected  being  apparently  bilious,  and 
since  then  ho  has  suffered  from  pain  in  the  splenic  I'egion,  especially  when  he  stands 
or  moves  about. 

Symptoms  on  Admission. — On  admission,  the  patient  talks  in  a loud  monotonous 
tone,  indistinctly,  and  with  stammering ; he  cannot  whisper,  though  he  can  speak  in 
lower  tones  than  usual.  When  speaking,  the  voice  often  becomes  whining ; he  cries 
and  sheds  tears  without  any  obvious  cause.  The  sensibility  of  both  sides  of  face,  of 
the  trunk,  and  limbs,  seems  unimpeared,  tongue  slightly  protruded  to  the  right  side, 
while  tlie  mouth  is  drawn  to  the  left;  when  the  patient  eats,  the  food  lodges  in  the 
right  cheek ; he  tastes  and  feels  as  well  on  the  right  side  of  the  tongue  as  on  the  left. 
The  grasp  of  the  right  hand  is  as  firm  as  that  of  the  left,  and  the  patient  walks  with- 
out a limp,  but  there  seems  a want  of  certainty  in  planting  the  right  foot,  and  he 
staggers  slightly  on  turning  quickly  round.  His  intelligence  and  memory  are  unim- 
paired. lie  cannot  write  now  as  well  as  formerly,  being  unable  to  form  the  letters ; 
but  he  can  read  writing  and  printing.  On  percussion,  the  transverse  dulness  of  the 
heart  is  found  to  be  2^  inches,  and  for  an  inch  external  to  this  the  note  is  flat.  On 
auscultation  at  the  apex,  a blowing  murmur  ie.  heard  with  the  first  sound,  and  the 
second  is  somewhat  lengthened.  At  the  base  there  is  a blowing  murmur  with  both 
first  and  second  sounds.  This  double  murmur  is  propagated  along-  the  great  vessels, 
and  is  heard  most  distinctly  along  the  sternum  and  in  tlie  epigastrium.  The  pulse  is 
76  per  minute,  soft  and  weak.  Tongue  has  a dark  coat  in  the  centre,  and  is  furred 
round  the  edges ; appetite  small ; food  neither  causes  pain  nor  inconvenience,  and  is 
not  vomited.  There  is  considerable  tenderness  on  pressure  all  over  the  left  side.  Has 
painless  diarrhoea,  with  frequent  watery  stools  of  a dark-brown  color,  and  faecal  odor. 
Hepatic  dulness  is  not  easily  determined,  but  appears  about  4^  inches  vertically.  In 
the  splenic  region  there  is  a large  area  of  dulness  extending  into  the  abdomen,  where 
a tumor  is  felt.  The  dulness  commences  at  the  seventh  rib,  an  inch  and  a half  below 
the  level  of  the  nipple,  and  extends  vertically  for  8 inches.  On  pressure  over  the 
enlarged  spleen  the  patient  complains  of  pain.  When  he  lies  on  right  side,  the  upper 
margin  of  the  dulness  is  found  to  be  lower  than  when  he  lies  on  the  back ; the  anterior 
limit  does  not  change.  Urine  slightly  albuminous ; contains  a sediment,  consisting  of 

* Reported  by  Mr.  T.  J.  Walker,  Clinical  Clerk. 


396 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


mucus,  squamous  epithelial  scales  and  numerous  tube  casts,  chiefly  granular,  but  a 
few  waxy,  containing  one  or  two  epithelial  scales.  There  is  slight  pitting  on  pressure 
over  the  feet  and  ankles.  Respiratory  system  normal.  Ordered  an  astringent  powder 
to  he  taken  at  bed-time. 

Progress  of  the  Case. — The  treatment  for  the  diarrhoea  by  astringent  powders 
was  continued  until  the  20th  April  with  no  good  result,  but  the  pain  in  the  splenic 
region  was  considerably  relieved  by  the  exhibition  of  a terebinthinate  followed  by  an 
opiate  epithem.  Astringents  succeeded  in  arresting  the  diarrhoea  on  the  24th,  and  it 
did  not  recur  throughout  the  progress  of  the  case.  The  amount  of  urine  passed 
during  the  week  diminished  from  62  to  23  ounces,  and  again  increased  to  43  ounces 
daily.  From  the  'lUh  April  until  May  6^/?,  the  physical  signs  and  symptoms  con- 
tinued much  the  same,  but  during  this  period  the  urine  diminished,  the  anasarca  in- 
creased, the  aspect  became  more  heavy,  the  weakness  more  marked,  the  articulation 
more  embarrassed,  and  the  ideas  seemed  to  be  i^ormed  slowly  although  correctly.  No 
leucocythemia.  On  May  ^tth  there  was  marked  tenderness  on  pressure  in  both  hypo- 
chondria. At  the  apex  of  the  heart  a long  blowing  murmur  synchronous  with  both 
sounds  still  audible,  and  at  the  base  a double  blowing  murmur.  Great  dyspnoea  and 
prostration.  Coma.  He  died  the  following  morning. 

Sectio  Cadaveris. — Seventy-five  hours  after  death. 

Head. — Surface  of  brain  was  natural ; but  the  ventricles  contained  2|  ounces  of 
clear  serum,  and  their  lining  membrane  was  tough,  thickened,  and  almost  of  a leathery 
feel.  On  the  surface  of  the  right  corpus  striatum  there  occurred  two  patches  (the 
larger  being  2 lines  by  1,  and  the  smaller  being  half  that  size)  of  an  opaque  yellow 
color — slightly  depressed — quite  superficial — not  softer,  but  rather  tougher  than  usual. 
On  the  surface  of  the  left  corpus  striatum,  a similar  patch,  not  larger  than  a h.emp 
seed,  occurred.  On  the  inner  surface  of  the  lower  part  of  the  descending  coinu  of 
the  left  ventricle,  there  was  observed  a mass,  the  size  of  a small  pea,  consisting  of 
gritty  matter,  embedded  in  a membranous  cyst,  and  surrounded  by  a soft  substance 
of  a dark,  reddish-brown  color.  The  choroid  plexuses  and  other  portions  of  the  brain 
healthy.  The  middle  cerebral  artery  on  the  right  side,  in  the  fissure  of  Sylvius, 
close  to  its  division  into  two  branches,  looked  opaque  and  felt  firm,  being  obstructed 
over  the  last  two  lines  of  its  course  by  a yellowish  mass,  which  also  extended  one 
line  along  the  larger  of  the  two  branches.  The  other  arteries  of  the  brain  and  both 
carotids  were  healthy,  presenting  the  merest  trace  of  atheroma  at  the  division  of  the 
common  carotids. 

Thorax. — Heart  weighed  19  ounces.  On  the  anterior  flap  of  the  mitral  valve 
numerous  small  vegetations  occurred  in  the  left  ventricle.  The  aorta  at  its  origin 
was  almost  completely  obstructed  by  a mass  of  vegetations,  some  the  size  of  a pin’s 
head,  others  about  the  size  of  a small  pea,  and  one  nearly  as  large  as  a filbert.  They 
were  clustered  on  the  ventrical  surface  of  the  right  and  left  semi-lunar  valves,  and 
on  the  margin  of  lacerations  in  their  vicinity  which  occurred  in  the  endocardium. 
There  was  no  posterior  semi-lunar  valve,  its  substance  having  apparently  been  broken 
away,  leaving  only  a ragged,  soft,  atheromatous  edge  close  to  the  aorta.  The  endo- 
cardium was  thickened  and  opaque  over  the  ventricle.  The  mitral  valves  were  much 
thickened  at  their  edges,  with  nodular  swellings  projecting  towards  the  auricles. 
The  pleurae  contained  each  two  pints  of  clear,  rather  dark-colored  serum ; the  lungs 
were  collapsed  posteriorly,  and  a little . emphysematous  anteriorly,  but  everywhere 
crepitant. 

Abdomen. — The  peritoneum  contained  more  than  a quart  of  dark-colored  dear 
serum.  In  the  intestines  there  was  no  trace  of  ulceration,  but  the  mucous  membrane 
of  the  colon  and  of  the  lower  part  of  the  ileum  was  congested.  The  liver  weighed  4 
lb.  1 oz.,  presented  congestion  of  the  hepatic  veins,  but  in  structure  was  normal.  The 
spleen  measured  inches,  weighed  21b.  2 oz.,  and  on  section  presented  one-third  of 
its  area  normal  in  color,  consistence,  and  minute  structure ; but  the  other  two-thirds 
were  of  a fawn  yellow  color,  of  firm  consistence,  without  trace  of  vascularity.  The 
kidneys  weighed  14  oz.,  were  of  smooth  surface,  but  on  section  presented  portions  of 
a dark  red,  and  others  of  a yellowish-grey  color.  The  dark  red  color  was  due  to  the 
extravasation  of  a thin  layer  of  blood. 

Microscopic  Examination. — The  serum  in  the  ventricles  contained  a few  epi- 
thelial cells.  The  superficial  indurated  patches  on  the  surface  of  the  corpora  striata 
w'ere  chiefly  composed  of  numerous  granules  and  molecules,  containing  many  granule 
cells,  closely  aggregated  together  aud  apparently  in  a state  of  disintegration.  The 


CEREBKAL  DISEASE  FROM  OBSTRUCTION  OF  ARTERIES.  397 

gritty  matter  in  the  centre  of  the  old  apoplectic  clot  dissolved  with  effervescence  in 
sulphuric  acid  (carbonate  of  lime).  The  brown  matter  surrounding  it  consisted  of 
numerous  oily  granules,  mingled  with  masses  of  yellow  and  brown  pigment.  The 
vegetations  covering  the  aortic  valves  consisted  entirely  of  granular  matter,  evidently 
undergoing  the  fatty  degeneration.  The  yellow  portion  of  the  spleen  consisted  of  a 
translucent  substance,  in  which  the  normal  elements  of  the  organ  appeared  shrunk 
and  decayed.  The  kidneys  presented  the  usual  appearance  of  partial  fatty  degenera- 
tion of  these  organs. 

Commentary . — On  the  entrance  of  this  man  into  the  house,  it  was 
recognised  that  he  labored  under  obstructive  disease  of  both  valves; 
and  it  is  observable  that  the  history  says  nothing  of  his  having  ever  been 
affected  with  rheumatism.  He  had  previously  experienced  two  attacks 
of  apoplexy,  followed  by  hemiplegia  on  the  leh  side,  and  when  he  come 
into  the  house  there  were  superadded  symptoms  of  cerebral  softening, 
of  Bright’s  disease,  and  of  enlargement  of  the  spleen.  I subsequently 
determined  that  there  was  no  leucocythernia.  On  post-mortem  examina- 
tion^ organic  alterations  of  the  heart,  brain,  spleen,  and  kidneys  were 
discovered.  The  slight  indurations  in  the  corpora  striata  were  curious. 
They  were  composed  structurally  of  numerous  granules  and  granule 
cells,  and  it  may  be  asked  whether  they  were  the  results  of  previous  he- 
morrhagic extravasations,  or  of  exudations.  I think  the  latter,  as  they 
appear  to  have  been  very  chronic  in  their  nature,  and  not  to  have  been 
connected  with  any  recent  symptoms.  The  apoplectic  attacks  and 
hemiplegia  on  the  right  side  seem  to  have  depended  on  the  limited 
hemorrhage  on  the  inner  surface  of  the  descending  cornu  of  the  left  ven- 
tricle. It  is  true,  we  have  historically  an  account  of  two  apoplectic 
attacks  with  hemiplegia,  and  only  the  trace  of  one  hemorrhage.  It  is 
observable,  however,  that  the  centre  of  this  old  clot  presented  a different 
structure  from  its  circumference,  and  that  consequently,  the  blood  of 
which  it  was  composed  may  have  been  thrown  out  at  differeiit  times. 
This,  however,  is  a matter  of  opinion,  and  did  not  admit  of  demonstra- 
tion. It  should  also  be  noticed  that  the  clot  found  in  the  artery  of  the 
Sylvian  fissure  on  the  right  side  did  not  appear  to  have  occasioned  any 
symptoms,  or  to  have  produced  other  structural  alteration.  These  chronic 
cjrebral  lesions  seemed  ultimately  so  to  have  affected  the  circulation 
within  the  cranium,  as  to  have  caused  effusion,  the  two  ventricles  being 
greatly  distended  with  serum,  to  which  the  coma  preceding  death  was 
probably  attributable. 

The  three  cases  now  given  appear  to  me  to  afford  evidence  of  disease 
of  the  brain,  being  occasioned  by  obstruction  of  the  arteries,  an  idea  that 
was  distinctly  put  forth  by  Carswell  and  Bright,  but  the  confirmation 
of  which,  based  on  combined  pathological  and  clinical  observations,  was 
reserved  for  more  recent  observers,  and  especially  for  Virchow,  Kirkes, 
Tufnell,  and  others.  This  obstruction  may  arise  in  two  ways — 1st,  From 
disease  of  an  artery,  causing  coagulation  of  the  blood,  and  obstruction 
immediately  within  the  portion  of  the  vessel  affected.  2d,  In  consequence 
of  coagula  from  the  heart  becoming  loosened,  then  carried  in  the  course 
of  the  circulation,  and  subsequently  arrested  in  some  distant  and  smaller 
artery.  An  example  of  cerebral  disease  produced  in  the  first  way  is  ob- 
served in  Case  XY.,  and  illustrations  of  the  second  mode  are  given  in 
Cases  XVI.  and  XVII. 

Gulliver  was  the  first  to  demonstrate  that  the  so-called  ossification  of 


398 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


arteries,  commonly  observed  in  old  persons,  was  in  fact  a fatty  degenera- 
tion of  the  vessels,  consisting  of  numerous  oil  granules  and  crystals  of 
cholesterine,  accumulated  between  their  coats,  and  frequently  associated 
with  deposits  of  earthy  salts.  This  disease  of  the  arteries,  however,  is  a 
true  arteritis  (Donders  and  Jansen),  originating  in  an  exudation  betw^een 
their  coats,  from  the  vessels  which  supply  them,  which  exudation  sub- 
sequently undergoes  the  fatty  degeneration.  This  lesion  induces  slight 
constriction  of  the  vascular  calibre,  thickening  of  the  arterial  w'all,  and 
occasional  roughness  of  the  internal  surface — circumstances  which  favor 
coagulation  of  the  blood  at  the  part,  and  cause  more  or  less  obstruction. 
In  chronic  cases  the  vessel  becomes  brittle,  and  hence,  on  any  unaccus- 
tomed exertion  it  gives  way,  and  occasions  heniorrliage.  These  obstruc- 
tions and  ruptures  of  the  vessels  from  chronic  arteritis,  are  the  most 
common  causes  of  chronic  cerebritis  and  hemorrhagic  apoplexy.  The  case 
of  Walker,  however  (Case  XV.),  demonstrates  another  mode  in  which 
SQftening  may  be  occasioned.  Here  obstruction  of  the  basilar  artery  had 
occurred,  occasioned  by  a local  arteritis,  and  subsequent  mineral  degene- 
ration of  the  clot.  The  result  was  a peculiar  kind  of  softening,  which, 
as  the  sole  lesion  ot  the  cerebral  substance,  I observed  in  this  man  for 
the  first  time.  In  the  pons  varolii  the  tubes  and  nerve  cells  w^ere  loos- 
ened and  easily  broken  down,  without  any  exudation  from  the  vessels, 
granules,  or  granule  cells,  such  as  are  observed  in  chronic  cerebritis.  The 
nerve  cells,  however,  were  enlarged,  and  contained  an  unusual  number  of 
small  fatty  molecules,  forming  masses  of  various  sizes,  so  as  to  constitute 
a partial  mould  of  their  interior.  Many  of  these  masses  were  naked,  and 
swam  about  in  the  fluid,  but  were  easily  recognised  by  their  shape  to  have 
originally  been  formed  in  the  interior  of  cells  (Fig.  405).  I have 
frequently  seen  this  alteration  associated  with  exudative  and  hemorrhagic 
softenings;  but  as  constituting  the  sole  lesion,  and  occasioning  an  ex- 
tensive softening,  producing  such  undoubted  symptoms  in  the  living 
body,  this  is  the  only  case,  so  far  as  I am  aware,  in  which  it  has  been 
clearly  described.  It  appears  to  me  to  consist  of  a primary  fatty  dege- 
neration of  the  nerve  cells,  and  to  depend  upon  altered  nutrition  of  the 
part;  a condition  hypothetically  put  forth  as  a cause  of  softening  by  De- 
laberge  and  Monneret,  but  now  for  the  first  time  demonstrated. 

That  foreign  solid  bodies  floating  in  the  blood  would  obstruct  the 
smaller  vessels  and  occasion  exudations,  was  first  shown  by  the  experi- 
ments of  Magendie,  Cruveilhier,  Gaspard,  and  others,  who  injected  starch, 
quicksilver,  and  various  substances  into  the  blood,  with  the  effect  of  pro- 
ducing fatal  inflammations.  Cases  by  Virchow,  Kirkes,  Tufuell,  and 
others,  have  further  shown  the  probability  that  the  coagula  and  so  called 
vegetations  formed  in  the  interior  of  the  heart,  may  in  like  manner  be 
occasionally  loosened,  carried  by  the  blood  to  a distant  part,  such  as  the 
brain,  lungs,  or  extremities,  and  become  impacted  in  a distant  artery.  If 
so,  they  may,  by  causing  obstruction,  induce  hemorrhage,  exudation,  and 
perhaps  the  kind  of  lesion  from  diminished  nutrition  of  which  I have 
just  spoken.  Many  cases  are  now  on  record,  and  Cases  XVI.  and  XVII. 
are  good  examples  of  them,  where,  in  conjunction  with  valvular  vegeta- 
tions in  the  heart,  clots  have  been  found  in  the  arteries  leading  to  im- 
portant organs,  causing  in  the  same  individual  cerebritis,  pneumonia,  ne- 
phritis, splenitis,  etc.  etc.  But  although  it  is  certain  that  solid  plugs 
may  block  up  arteries  and  occasion  serious  results,  it  is  by  no  means 


CEREBRAL  DISEASE  FROM  OBSTRUCTION  OF  ARTERIES. 


399 


clear  tliat  all  the  instances  of  disease  which  have  been  cited  as  proof  of 
this  in  the  living  body  really  depend  on  arterial  obstruction,  or  because 
cerebral  hemorrhage  and  softening  or  pneumonia  are,  as  is  well  known, 
common  sequelae  of  diseased  heart,  that  therefore  plugs  of  coagulated 
fibrin,  derived  from  the  last  named  organ,  should  originate  these  secon- 
dary lesions.  I need  scarcely  point  out  that  increased  or  diminished  im- 
pulse of  - the  heart  itself,  arising  from  hypertrophy  or  fatty  degeneration 
of  its  fasciculi,  are  equally  powerful  causes  of  cerebral  disease,  and  that 
this  in  its  turn  very  commonly  occasions  pneumonia  by  its  paralysing 
influence  on  the  vagi  nerves.  Besides,  although  clots  are  often  found  in 
arteries,  associated  with  cardiac  vegetations,  I am  not  aware  of  any  facts 
which  demonstrate  that  the  clot  originating  in  one  place  is  the  identical 
clot  which  has  been  found  in  another.  Much  stress  has  been  laid  upon 
the  form  of  the  clot,  the  broken-off  looking  appearance  of  its  ends,  its 
structure,  etc.  etc.  It  has  been  supposed  that  whilst  spontaneous  coa- 
gulations, or  such  as  are  induced  by  arteritis,  are  gradually  converted 
into  fibrous  tissue,  those  coming  from  cnc  place  and  impacted  in  a vessel 
at  a distance,  break  down  and  undergo  a disintegrating  process.  At- 
tempts even  have  been  made  to  show  that  the  broken  ends  of  impacted 
coagula  correspond  with  and  fit  the  surfaces  of  other  coagula  in  the  heart, 
or  on  the  cardiac  valves  from  which  they  have  been  supposed  to  origi- 
nate. All  I shall  sa}’-  with  regard  to  such  arguments  is,  that  numerous 
investigations  into  the  structure  of  coagula  under  a variety  of  circum- 
stances have  convinced  me  that  we  possess  no  certain  means  of  distin- 
guishing one  clot  from  another,  and  that  all  such  statements  should  be 
received  with  great  caution.  Otherwise,  every  case  of  apoplexy  and 
softening  will  have  to  be  ascribed  to  wandering  coagula. 

At  the  same  time  the  probability  of  this  occurrence  is  so  great,  and 
its  explanation  of  certain  facts  so  simple,  that  it  has  every  claim  to  be 
entertained  in  practical  medicine.  Tims  cases  have  occurred  where  the 
pulse  of  an  artery  has  suddenly  stopped,  followed  by  more  or  less  numb- 
ness and  coldness  of  the  parts  to  which  it  led.  Tying  arteries  has  pro- 
duced similar  effects.  Fragments  separated  from  the  aortic  valves  would 
readily  pass  into  the  carotids  or  vertebrals,  especially  the  former,  and 
become  impacted  in  the  cerebral  arteries.  Hence  local  congestions, 
causing  headache  and  other  symptoms,  followed  by  exudations  and 
hemorrhages,  producing  convulsions  or  paralysis.  In  the  same  manner, 
coagula  formed  in  the  right  side  of  the  heart  may  pass  into  the  branches 
of  the  pulmonary  artery,  causing  pneumonia  more  or  less  extensive. 
Spontaneous  coagulations  also  may  occur.  Thus,  in  the  spring  of  1856, 
Professor  Miller  asked  me  to  examine  a clot  which  formed  a mould  of 
the  pulmonary  artery,  and  was  unusually  firm  and  fibrous.  It  had 
apparently  occurred  during  life,  in  an  elderly  gentleman,  who  was  sud- 
denly seized,  when  in  a warm  bath,  with  symptoms  of  oppression  in  the 
chest  and  dyspnoea,  and  shortly  after  died.  On  examination,  no  other 
lesion  could  be  discovered  but  the  clot  referred  to.  Similar  cases  of 
sudden  death  owing  to  a like  cause  have  been  recorded  by  Paget, 
Virchow,  and  others.  The  true  lesion  in  all  these  cases  is  obstruction  of 
the  vessels,  however  produced,  whether  by  coagulation  of  the  blood  from 
unknown  causes,  by  arteritis  or  aneurisms  causing  clots  to  form  within 
the  vessel,  or  by  such  clots  travelling  from  o.:e  place  to  another,  which, 
however,  I am  disposed  to  think  has  very  rarely  been  demonstrated. 


400 


DISEASES  OF  THE  NERVOUS  SVSTEM. 


Virchow  has  sought  to  elevate  this  simple  matter  into  pathological  doc- 
trines, under  the  names  of  lltromhosis  and  Enibolismus. 

CEREBRAL  HEMORRHAGE. 

Case  XVIII.^ — Apoplexy^  followed  by  Hemiplegia  of  Left  Side — Recovery. 

History. — Andrew  Bryce,  aet.  '72,  tailor — admitted  Jan.  29,  1851.  He  states  that 
on  the  9th  October  last,  while  walking  up  Dundas  Street,  he  suddenly  felt  very  dizzy, 
and  was  obliged  to  sit  down.  He  lost  his  senses  completely  for  several  minutes,  and 
when  he  again  became  conscious  he  found  he  could  not  walk.  He  was  assisted  home, 
and  on  the  afternoon  of  the  same  day  admitted  into  No.  10  of  the  Eoyal  Infirmary. 
He  was  freely  purged,  and  has  been  confineil  to  bed  ever  since.  Since  his  admission 
he  has  been  gradually  gaining  power  in  the  paralysed  side. 

Symptoms  on  Admission. — At  present  he  complains  of  occasional  frontal  head- 
ache, increased  during  cold  weather.  His  intelligence  is  unaffected.  The  special 
senses  also  normal.  He  cannot  raise  himself  into  a sitting  posture.  He  can  move 
the  left  hand,  but  is  unable  to  direct  it  steadily  to  a distant  object ; neither  can  he 
place  it  on  the  top  of  his  head.  While  in  bed  the  left  leg  moves  as  steadily  as  the 
right,  but  he  cannot  stand  upon  it.  The  sensibility  of  he  lett  leg  appears  to  be  at 
present  normal,  but  that  of  the  left  arm  is  slightly  impaired.  There  is  also  a little 
rigidity  of  the  left  arm.  The  tongue  is  protruded  in  the  median  line.  On  laughing, 
the  mouth  is  drawn  slightly  tovv^ards  the  right  side.  Sensibility  of  the  face  un- 
impaired. The  pulse  88 ; is  of  natural  strength.  The  urine  is  not  so  copious  as 
formerly,  and  is  made  in  a smaller  stream  and  more  frequently.  He  has  sometimes 
passed  gravel,  and  observed  his  urine  of  a high  color — sp.  gr.  1023 — non-albuminous 
— a copious  deposit  of  phosphates. 

Progress  of  the  Case. — This  man  remained  a few  days  in  the  ward,  during 
which  no  change  occurred  in  the  symptoms,  and  on  Feb.  7th  he  returned  to  No.  10, 
from  which  he  was  dismissed  with  the  power  of  the  left  side  nearly  restored,  May  13, 
1851. 

Case  XIX.* — Apoplexy.,  followed  by  Hemiplegia  of  Right  Side. — Recovery. 

History. — Anthony  Caron,  hairdresser,  a Frenchman — admitted  Feb.  6,  1851,  in 
a state  of  coma,  in  which  condition  he  was  found  lying  on  the-  Granton  road,  and 
was  immediately  brought  to  the  Infirmary. 

Symptoms  on  Admission. — When  first  examined,  he  appeared  to  be  about  fifty 
years  of  age,  and  of  robust  habit  of  body.  He  was  perfectly  unconscious  of  surround- 
ing objects,  and  as  if  in  a deep  sleep — the  surface  pale,  the  countenance  calm,  and 
respirations  natural.  The  mouth  was  slighily  drawn  to  the  left  side.  The  right  arm, 
allowed  to  fall  down  after  being  raised,  sunk  rapidly  like  an  inert  mass — the  left, 
similarly  treated,  fell  slowly.  Pricking  the  right  leg  and  foot  caused  no  shrinking 
of  the  limbs ; but  the  left  limbs  when  pricked  were  rapidly  withdrawn.  Pulse  60, 
rather  full,  but,  considering  his  habit  of  body,  probably  of  natural  strength.  On 
returning  to  him  an  hour  after  the  first  examination,  consciousness  had  to  a consider- 
able extent  returned.  He  opened  the  mouth  when  asked  to  do  so,  and  the  tongue 
was  ascertained  to  be  covered  with  a white  fur.  He  also  raised  the  left  arm  and  leg 
readily,  but  could  not  move  the  limbs  on  the  right  side.  The  pulse  remained  the 
same.  In  consequence  of  this  change  in  his  condition,  the  full  bleeding  which  was 
previously  determined  on  from  his  arm,  was  changed  into  the  removal  of  § xij  of 
blood,  by  means  of  cupping,  from  the  nape  of  the  neck.  He  was  ordered  a pill 
containing  01.  Crotonis  min.  i,  and  ext.  colocynth.,  gr.  v,  to  be  taken  every  four  hours 
until  the  bowels  were  freely  moved.  Cold  was  to  be  applied  to  the  head,  and  the 
most  perfect  quietude  enjoined. 

Progress  of  the  Case. — The  following  day  he  was  much  better — consciousness 
had  returned,  and  from  this  time  he  gradually  improved,  and  was  dismissed  May  17, 
the  arm  having  somewhat  recovered  its  motion,  but  with  the  leg  still  lame  and  para- 
lysed. 

Commentary. — The  term  apoplexy  has  been  used  in  two  senses. 
By  the  older  writers  and  clinical  observers,  it  was  used  to  denote  a 
sudden  loss  of  consciousness  and  volition,  independent  of  the  various 
morbid  lesions  which  may  occasion  these  symptoms.  By  the  followers 
* Reported  by  Mr.  Cunningham,  Clinical  Clerk. 


CEREBRAL  HEMORRHAGE. 


401 


of  tliG  French  School  of  pathology  the  same  word  has  been  applied  to 
an  extravasation  of  blood  into  an  organ;  and  hence  the  terms  apoplexy 
of  the  lung,  apoplexy  of  the  spinal  cord,  apoplexy  of  the  kidney,  etc. 
Ecchymosis  of  the  skin,  the  result  of  a contusion — such  as  is  present  in 
what  is  commonly  called  a ‘ black  eye  ” — is  in  this  sense  an  apoplexy.  I 
believe  it  better  to  adhere  to  the  meaning  of  our  ancestors,  the  more  so 
as  it  is  not  always  possible  to  determine  when  a cerebral  hemorrhage  is 
present.  Hence  the  two  cases  which  have  been  given,  characterised  by 
sudden  loss  of  consciousness  and  volition,  coming  on  spontaneously,  are 
called  apoplexy.  But  should  such  cases  prove  fatal,  and  we  are  enabled 
to  speak  positively  as  to  the  cause  of  the  apoplexy  from  post-mortem 
examination,  then  we  may  denominate  them  with  more  propriety  cerebral 
hemorrhage,  softening,  etc.  ete.,  according  to  circumstances. 

In  the  two  cases  before  us  there  is  great  similitude — both  were 
seized  suddenly  with  apoplexy  wdiile  walking.  In  the  first  case,  how- 
ever, the  apoplectic  state  was  of  a few  minutes’  duration;  in  the  second, 
it  continued  several  hours.  The  one  case  occurred  between  three  and 
four  months  before  it  came  under  our  observation;  in  the  other,  he  was 
seen  in  the  apoplectic  c mlition,  or  immediately  afeer  he  emerged  from 
it.  In  both  there  was  perfect  hemiplegia;  but  in  the  one  case  there  has 
been  complete  recovery  of  sensation  and  partial  recovery  of  motion,  ai 
regards  the  affected  side.  In  the  other,  both  sensibility  and  motion  are 
still  completely  lost. 

On  examining  Case  XIX.,  the  practical  question  to  decide  on  was 
whether  he  should  be  bled  f But  the  patient  shortly  after  exhibited 
signs  of  coming  out  of  the  apoplectic  condition,  and  it  was  clear,  there- 
fore, that  the  pressure  on  the  brain  was  spontaneously  diminishing,  t!ie 
pulse  was  steady  and  of  natural  strength.  How  could  a bleeding  have 
benefited  him  ? The  chief  point  here,  therefore,  was  not  to  interfere 
with  the  operations  of  nature,  but  assist  her  as  much  as  possible  in  the 
operation  she  had  next  to  perform — that  is,  causing  absorption  of 
the  clot.  This  I presu  ne  to  be  best  accomplished  by  quietude,  by  the 
avoidance  of  all  circumstances  which  could  excite  the  heart’s  action, 
regularity  of  the  excretions,  and  moderate  diet.  These  are,  therefore, 
the  measures  which  were  adopted,  and  his  recovery,  though  slow,  was 
satisfactory. 


Case  XX. ^ — Palsy — Plemiplegia  of  Left  Side — Recovery. 

History. — Jessie  Fleming,  mt.  4.5,  single,  milliner — admitted  Nov.  27,  1856. 
Since  last  May  the  mind  of  patient  has  been  in  an  unsettled  state ; previously  she 
enjoyed  good  health.  During  last  summer  her  digestion  was  much  impaired,  and 
she  sutferel  from  severe  cramps  in  the  left  leg,  especially  during  the  night.  On 
Friday  last,  Nov.  21st,  while  engaged  at  her  work,  she  suddenly  fell  down,  and 
though  retaining  her  senses,  felt  unable  to  rise  without  assistance ; shortly  after  she 
quite  lo.st  the  use  o.^  the  left  side.  When  put  to  bed,  she  experienced  great  pain  in 
the  head,  for  which  she  was  cupped  over  the  back  of  the  neck,  to  the  amount  of  13 
ounces ; and  next  day  a large  blister  was  applied  to  the  same  part ; two  pills  were 
taken  every  three  hours  till  her  bowels  were  freely  moved.  On  the  23d  of  November, 
soma  leeches  were  applied  to  the  temples,  and  on  the  24th  she  was  removed  to  the 
Infirmary. 

Symptoms  on  Admission. — Great  pain  is  felt  over  the  top  of  the  head,  which  is 


26 


^ Reported  by  Mr.  M‘Arthur,  Clinical  Clerk. 


402 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


constant,  and  prevents  the  patient  from  stooping.  Speech  thick  and  imperfect. 
The  muscles  of  the  left  superior  extremity  are  completely  paralysed,  and  do  not  ad- 
mit of  extension;  the  muscles  of  the  head  and  face  are  not  affected,  nor  is  Ki  .-ibility 
impaired.  Cannot  move  the  left  leg,  but  on  applying  an  irritant  to  the  sole  of  the  loot 
the  limb  is  at  once  retracted.  Pulse  120,  of  good  strength;  other  symptoms  noimal. 
The  head  to  be  shaved^  and  ice  to  be  applied  to  the  scalp.  To  have  a purgative  lolvs. 

Progress  of  the  Case. — On  the  following  day  the  pain  in  the  head  was  nmch 
relieved,  and  from  this  time  she  slowly  regained  the  use  of  her  arm  and  leg.  Her 
recovery,  however,  was  retarded  by  a carbuncle  which  formed  over  the  light  inter- 
sca})ular  region,  and  subsequently  by  an  exanthematous  eruption,  acconq.anied  by 
considerable  fever.  She  was  dismissed  April  8th,  when  she  could  walk  with  the  aid 
of  slight  assistance,  and  move  the  arm  of  the  affected  side  without  difficulty. 

Commentary. — In  this  case  sudden  hemiplegia  occurred  without  loss 
of  consciousness,  when  the  individual  was  wide  awake  and  performing 
her  household  duties,  a fact  which  was  established  by  frequent  interro- 
gation and  by  the  accounts  of  others.  It  may  be  presumed  that  a vessel 
had  suddenly  given  way,  causing  hemorrhage  into  the  right  cerebral 
hemisphere.  The  clot  must  have  been  larger  than  in  the  last  case,  not 
only  b‘-;cause  the  paralysis  was  more  extensive,  but  from  the  longer  time 
necessary  for  recovery. 

Case  XXI. ^ — Sudden  Paralysis  of  Face  and  Left  Arm — Pneumonia — 
Bright's  Disease — Recovery, 

History. — Christina  Hutchinson,  set.  40,  married,  a sempstress — admitted  Novem- 
ber V,  1854.  She  states  that  on  the  6th  inst.,  at  half-past  1 o’clock  a.m.,  on  waking 
from  sleep,  she  found  that  she  w^as  unable  to  lift  the  left  aim,  and  that  she  had  lost 
the  power  of  speech.  She  also  experienced  intense  general  headache,  as  well  as  great 
pain  in  the  right  side  of  the  face,  which  was  greatly  swollen.  She  does  not  know 
whether  she  was  insensible  previously.  On  the  preceding  evening  she  had  gone  to 
bed  healthy  and  strong,  though  with  a sense  of  fulness  in  the  head.  Though  habit- 
ually enjoying  good  health,  she  had  occasionally  had  palpitations,  with  dizziness  of  the 
head,  dimness  of  sight  and  tinnitus  aurium,  especially  brought  on  by  stooping. 
Seventeen  months  ago  she  had  an  attack  of  acute  rheumatism. 

Symptoms  on  Admission. — Her  speech  is  somewhat  embarrassed,  and  her  intelli- 
gence dull,  though  she  is  quite  conscious  of  surrounding  objects.  Hearing  perfect. 
Sees  dimly.  Left  pupil  does  not  contract  so  readily  on  exposure  to  light  as  the  right. 
The  face  is  dragged  to  the  right  side.  Cannot  lilt  up  the  left  aim,  though  she  can 
m'ove  it  slightly  by  a strong  effort  of  volition ; neither  tan  she  grasp  an  object  firmly 
with  the  left  hand.  Sensibility  of  the  limb  much  diminished  but  not  lost.  The  left 
leg  and  side  unaffected.  Tongue  when  protruded  seen  to  be  loaded  and  apparently 
turned  to  the  left,  although  this  is  really  owing  to  dragging  of  the  mouth  to  the  right 
side.  Deglutition,  especially  of  liquids,  difficult.  Bowels  constipated.  Slight  pain 
in  the  loins.  Urine  slightly  coagulable,  sp.  gr.  1014.  Pulse  86,  small  and  weak. 
Heart  normal.  Other  systems  healthy.  A blister  to  be  applied  to  the  nape  of  the  neck. 
To  have  01.  Ricini  § ss.  Quietude  and  rest  enjoined. 

Progress  of  the  Case. — November  14/A. — Since  admission,  has  gradually  recovered 
her  intelligence  and  power  of  speech,  the  features  of  the  face  are  less  distorted,  and 
the  sensibility  in  the  left  arm  has  been  augmented.  There  has  been  constipation, 
which  required  pills  of  colocynth  and  croton  oil  to  overcome.  To-day  complains  of 
a sharp  pain  in  the  left  lateral  region  of  the  mamma,  increased  on  deep  inspiration. 
The  dulness  on  percussion  but  slight ; sibilation  audible  on  auscultation.  November 
28^A. — Since  last  report,  has  had  an  attack  of  pneumonia,  involving  two-thirds  of  the 
left  lung,  and  characterised  by  all  the  signs  and  symptoms  of  that  disease.  (See 
Pneumonia.)  To-day  she  has  completely  recovered,  the  pulmonary  disease  has  passed 
througli  its  usual  course,  leaving  her,  however,  weak  and  thin.  The  appetite  is  now 
good,  the  strength  improving.  The  sensibility  and  power  of  motion  in  the  left  arm 
nearly  restored.  Dragging  of  the  mouth  nearly  disappeared.  December  Wth. — Since 
last  report  all  trace  of  tlie  pulmonary  disease  has  disappeared.  A week  ago,  however, 

* Reported  by  Mr.  0.  Beaugeard,  Clinical  Clerk. 


CEREBRAL  HEMORRHAGE. 


403 


she  experienced  considerable  pain  in  the  lumbar  region,  and  on  examining  the  urine 
it  was  found  tluit  tlie  albumen  had  greatly  increased.  To-day  microscopic  examina- 
tion demonstrates  in  addition  numerous  fatty  and  waxy  casts  of  the  tubes.  Urine 
j)ale,  passed  in  good  quantity,  sp.  gr.  1010.  She  states  that  the  ankles  swell  towards 
evening.  JLibmt  Fotaas.  BUari.  I j ter  die.  January  Is^.— Has  been  gradually  gain- 
in"  stren"th  ; all  trace  of  the  paralytic  attack  has  now  left  the  face  and  arm.  Careful 
exTuninatTun  of  the  left  lung  can  detect  no  remains  of  the  pneumonia.  The  urine  is 
still  coa"ulable  on  the  addition  of  heat,  but  much  less  so  tlian  formerly.  But  it  con- 
tains no^asts  of  the  tubes,  is  passed  in  good  quantity,  and  the  oedema  of  the  feet  tias 
disappeared.  Dismissed  at  her  own  request. 

Commentary. — The  peculiarit}"  in  this  case  was  the  sudden  occur- 
rence of  palsy  m the  left  arm  and  left  side  of  the  face  during  sleep. 
This  was  most  probably  owing  to  a limited  hemorrhage  compressing  the 
origin  of  those  nervous  filaments  more  immediately  in  relation  with  the 
neiwes  supplying  those  parts.  Such  hemorrhage  was  not  likely  to  have 
been  extensive,  as  we  may  assume  that  recovery  followed  on  the  gradual 
absorption  of  the  clot.  It  is  worthy  of  observation,  that  this  woman 
had  formerly  suffired  from  an  attack  of  acute  rheumatism,  and  was 
liable  to  palpitations  of  the  heart.  On  admission,  no  valvular  lesion 
could  be  discovered,  and  yet  there  supervene  1 many  of  those  phenomena 
supposed  to  result  from  coagnla  in  the  blood,  causing  first,  cerebral 
hemorrhage,  then  pneumonia  on  the  left  side,  then  renal  disorder.  The 
occurrence  and  gradual  recovery  from  each  of  these  diseases  in  succession 
is  rarely  observed. 

Case  XXII.* — Apoplexy — Extravasation  of  Blood  into  the  Left  Corpus 
Striatum — Pneumonia — Arrested  Tubercle  of  Lung. 

History. — Isabella  Bain,  set.  69 — admitted  May  20th,  1855.  She  was  brought  to 
the  Infirmary  by  some  policemen,  who  had  found  her  insensible  in  a common  stair. 

Symptoms  on  Admission. — On  admission  she  was  completely  comatose;  the 
breathing  stertorous;  pupils  contracted;  countenance  pale;  pulse  120,  weak  and 
irregular.  One  drop  of  croton  oil  was  administered  immediately  on  a piece  of  sugar, 
and  afterwards  a turpentine  enema. 

Proorfss  op  the  Case. — May  21a-U — Coma  continues.  The  enema  brought  away 
some  scybalous  faeces,  and  she  has  since  had  several  loose  stools,  which  were  passed 
in  bed.  There  is  now  complete  paralysis  of  the  right  side,  and  the  mouth  is  sti  ongly 
drawn  to  the  left  side.  Head  to  be  shaved,  and  cold  constantly  applied.  May  23c?. 
Has  continued  insensible.  She  now  breathes  with  difficulty,  and  with  heaving  of  the 
chest.  There  is  marked  dulness  over  inferior  two-thirds  of  right  lung,  but  no  mur- 
murs are  audible  there,  in  consequence  of  the  stertor.  May  24^A. — Slight  occasional 
movements  have  been  observed  in  left  arm.  In  other  respects  the  same.  Paralysis  of 
right  side  of  face  well  marked.  Loud  moist  rattles  are  now  audible  over  right  side  of 
chest.  Dyspnoea  more  urgent.  Blister  to  the  head.  Died  at  two  a.m.  on  the  25th. 

Sectio  Cadaveris. — Thirty -four  hours  after  death. 

Head. — The  arachnoid  membrane  covering  the  convolutions  considerably  elevated 
above  the  sulci,  in  consequence  of  fluid  in  the  subarachnoid  cavity.  The  veins  cover- 
ing the  hemispheres  everywhere  turgid  with  blood.  On  slicing  the  left  hemisphere 
from  above  downwards,  the  knife  passed  through  a clot  of  blood  in  its  centre,  about 
the  size  of  a walnut.  The  left  lateral  ventricle  was  also  filled  with  recent  coagulated 
blood  and  sanguineous  fluid  On  removing  the  brain,  and  cutting  through  the 
diseased  parts,  it  was  seen  that  the  seat  of  extravasation  was  the  left  corpus  striatum, 
the  posterior  third  of  which  was  broken  up,  and  reduced  to  a pulpy  consistence  of  a 
red  color.  It  was  surrounded  by  a zone  of  hemorrhagic  purple  spots  closely  aggre- 
gated together,  extending  half  an  inch  into  the  surrounding  white  substance,  and  this 
again  surrounded  by  another  zone  of  a gamboge  yellow  color,  gradually  dying  away 


* Reported  by  Mr.  D.  Maegregor,  Clinical  Clerk. 


404 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


into  the  healthy  white  structure  of  the  cerebrum.  The  choroid  plexuses  both  contained 
several  cysts,  one  or  two  of  which  were  the  size  of  large  peas,  and  filled  with  an  opaque 
yellow  fluid.  The  vessels  in  the  Sylvian  fossae  were  unusually  large,  thick,  and  rigid 
from  atheromatous  deposit.  The  right  hemisphere  was  normal.  Some  of  the  more  fluid 
portion  of  the  clot  on  the  left  side  had  infiltrated  itself  below  the  cerebellar  arachnoid  and 
was  accumulated  in  a thin  layer  over  the  convex  margin  of  the  cerebellum  on  both  sides. 

Thorax. — A lew  atheromatous  patches  on  the  lining  membrane  of  aorta  and  of  the 
mitral  and  aortic  valves.  The  heart  was  healthy.  The  pleurge  on  the  right  side  were 
everywhere  united  by  chronic  adhesions.  The  two  inferior  lobes  of  the  right  lung 
were  hepatized,  readily  sinking  in  water,  with  a few  scattered  tubercles  The  apex 
was  oedematous  and  spongy.  The  apex  of  right  lung  was  indurated,  strongly  puck- 
ered, of  blackish  color,  and  contained  several  cretaceous  and  calcareous  concretions 
varying  m size  from  a pin’s  head  to  that  of  a small  walnut.  The  rest  of  the  lung  was 
spongy,  but  at  the  base  were  two  or  three  masses  of  chronic  tubercle  the  size  of  fil- 
berts, surrounded  by  a dark  ring  of  pneumonic  condensation. 

Abdomen. — Abdominal  organs  healthy. 

Microscopic  Examination.— The  softened  portion  of  cerebral  substance  sur- 
rounding the  clot  consisted  of  disintegrated  nerve-tubes  and  blood  globules,  and  con- 
tained no  granule  cells.  The  opaque  fluid  in  the  cysts  of  the  choroid  plexus  contained 
numerous  delicate  cells,  globular  in  form,  and  varying  in  size  from  the  l-2000th  to 
l-500th  of  an  inch  in  diameter.  They  contained  a single  nucleus,  also  varying  in  size, 
sometimes  clear,  at  others  containing  numerous  granules.  There  were  als*o  numerous 
irregular  masses  of  granules  and  mineral  bodies,  which,  on  the  addition  of  nitric  acid, 
were  rendered  very  transparent,  w hilst  the  larger  ones  presented  a series  of  concentric 
rings  surrounding  a nucleus.  They  resembled  the  amyloid  bodies  so  commonly 
found  in  the  choroid  plexus.  (See  Fig.  393.) 

Commentary. — This  case  is  an  example  of  death  from  primary 
hemorrhage  into  the  left  ventricle  and  corpus  striatum,  the  result  of 
chronic  arteritis.  She  died  five  days  subsequent  to  the  attack,  during 
which  period  a pneumonia  had  been  developed  in  the  right  lung,  one  of 
the  most  common  sequelse  of  severe  lesion  at  the  base  of  the  brain.  The 
woman  was  apparently  in  good  health  previous  to  the  attack,  which  was 
induced  by  ascending  a stair. 

Case  XXIII. — Ajyoplexy — Hemiplegia  of  left  side — Hemorrhage  into 
right  Cerebral  Hemisphere — Diseased  Heart — Pnevmonia. 

History. — Margaret  Wales,  mt.  65,  married — admitted  January  10,  1849.  On  the 
1st  instant  patient  and  her  husband  left  their  home  quite  well,  and  walked  about  the 
str<^ets  for  about  two  hours,  wdien,  feeling  cold,  they  enteied  a spirit  shop  and  drank 
each  a glass  of  whisky.  On  leaving  the  shop  she  suddenly  fell  down  on  the  left  side, 
insensible.  Next  morning  she  began  gradually  to  revive,  being  evidently  conscious, 
though  not  speaking.  Her  friends  say  that  she  remained  quiet  in  bed,  with  the  eyes 
mostly  closed.  There  was  no  distortion  of  the  face.  The  right  aim  and  leg  felt 
very  cold,  but  were  frequently  moved.  The  left  arm  and  leg  of  natural  temperature, 
but  completely  paralysed.  On  the  evening  of  the  4th  she  became  delirions,  mutteiing 
and  roaring  out.  This  continued  until  the  '7th.  Euiing  this  time  she  was  seen  fie- 
quently  to  move  the  right  arm  and  leg,  but  not  the  left.  On  the  8th  w as  somewhat 
drowsy,  but  so  far  conscious  as  to  speak  w hen  roused.  On  one  occasion  asked  for  a 
glass  of  w'hisky,  but  had  some  tea  given  her.  In  the  evening  of  this  day  again  be- 
came comatose,  and  has  continued  in  this  state  until  admission.  Has  had  no  medical 
attendance,  and  the  bowels,  it  is  said,  have  not  been  relieved  since  the  attack. 

Symptoms  on  Admission. — On  admission  the  face,  hands,  and  feet  are  cold,  and 
of  bluish  aspect,  not  unlike  that  of  cholera.  The  trunk  moderately  waim;  eyelids 
closed ; pupils  slightly  contracted,  and  insensible  to  light.  She  is  quite  insensible, 
the  strongest  stimuli  failing  to  rouse  her.  There  is  considerable  dyspnoea  (respira- 
tions 40  in  the  minute);  no  stertor,  but  some  tracheal  rales;  pulse  100,  soft  and 
small.  Bronchial  moist  rales  are  very  general  on  auscultation  over  anterior  surface 
of  chest,  which  is  also  resonant  on  percussion,  with  the  exception  of  lower  half  of 
right  chest,  wdiere  there  is  comparative  dulness.  Heart’s  sounds  are  weak,  and 

* Reported  by  Mr.  James  Struthers,  Clinical  Clerk. 


CEREBRAL  HEMORRHAGE. 


405 


masked  by  bronchial  rales.  The  right  arm  and  leg,  on  being  pinched,  move  slightly, 
but  tiie  left  arm  and  leg  are  completely  paralysed.  The  left  side  ot  face  also  com- 
pletely paralysed,  but  no  distortion ; slignt  movement  of  facial  muscles  on  the  right 
side,  wueu  they  are  pricked  with  a pointed  instrument.  No  injury  of  scalp  or  cra- 
nium can  be  detected.  Olei  crotonis  gutt.  ij  ; Extr.  colocyydh.  comp.  q.  s.  ft.  piL.  to 
bs  taken,  iiameliatelg.  A large  sinapism  to  be  applied  to  each  leg.  head  to  be  shaved,, 
and  a blister  applied  to  the  occiput. 

Progress  oe  the  Case. — January  ll^A. — Continues  in  the  same  condition. 
Bo  wels  not  open.  To  have  a pill,  with  ol.  crotonis  gut.  iv.  A piece  of  lint  H inches 
squTLre  to  be  dipped  in  strong  aqua  atnmoniee,  and  ajjplied  to  the  vertex.  Jatiuary  \'lth. 
— No  improvemeut,  though  the  bowels  have  been  opened  once  copiously.  Breathing 
is  more  rapid,  with  tracheal  rale.  Surface  cold,  and  covered  with  a clammy  sweat; 
pulse  almost  imperceptible.  Died  in  the  evening. 

Seclio  Ca.daveris.  — Twenty-three  hours  after  death, 

Consilerable  livor,  with  oedema  of  hands  and  feet.  Integuments  loaded  with  fat. 

Head. — On  reflecting  the  scalp  no  wound  or  contusion  wms  anywhere  visible. 
Membranes  of  the  brain  healthy.  On  slicing  the  brain  from  above  downwards,  a slight 
prominence  was  observed  over  the  right  lateral  ventricle,  and  the  cerebral  substance 
forming  its  roof  was  softened,  and  of  a reddish  brown  color.  On  opening  the  right 
lateral  verntricle,  its  posterior  half  was  seen  to  be  occupied  by  a clot  of  blood,  which 
also  infiltrated  the  surrounding  cerebral  substance  to  the  depth  of  several  hues,  which 
beyond  the  infiltrated  portion  was  also  softened  to  the  extent  of  half  an  inch,  the 
dark  red  gradually  parsing  through  fawn-colored  into  white  softening.  The  left 
ventricle  was  slightly  distended  with  serum.  The  foramen  of  Monro  enlarged  so  as 
to  admit  a goose  quill.  Cerebral  arteries  studded  with  patches  of  atheroma. 

Thorax. — Heart  slightly  hypertrophied,  otherwise  healthy.  Aorta  healthy.  Both 
lungs  much  congeste  1,  and  the  bronchi  filled  in  many  places  with  muco-purulcnt 
matter.  The  lower  half  of  the  inferior  lobe  on  the  right  side  hepatized.  On  section 
it  presents  a dusky  red  color,  containing  here  and  there  circumscribed  purulent- 
looking  deposits  about  the  size  of  a millet  seed. 

Abdo.\ien. — Liver  slightly  enlarged,  its  right  lobe  adherent  to  the  diaphragm  by 
chronic  adhesions.  Gall  bladder  greatly  distended;  colon  loaded  with  indurated 
faeces.  Other  viscera  healthy. 

Microscopic  Examination. — The  white  softening  of  the  brain  surrounding  the 
clot  externally  consisted  of  the  mechanical  breaking  up  of  the  nerve  tubes,  as  figured 
Fig.  401.  The  fawn-colored  and  reddish  portions  of  the  softening  contained  nume- 
rous granule  cells,  mi.xed  with  broken-down  clots  of  blood,  some  of  which  were  of  a 
bright  orange  color,  mingled  with  numerous  crystals  of  hematoidine.  (Fig.  349.) 

Commentary. — This  case  was  very  like  the  last,  viz.,  chronic  arteritis, 
followed  by  extensive  heraoirhage  into  one  of  the  ventricles,  induced 
by  walking  about  the  streets,  after  the  excitement  of  drinking  whisky. 
Pneumonia  of  one  lung  was  also  induced.  She  rallied  somewhat  from 
the  attack,  but  again  relapsed  into  coma,  which  is  a very  unfavorable 
sign.  The  importance  of  administering  a purgative  was  here  well 
demonstrated,  the  paralysis  having  affected  the  bowels,  and  caused 
constipation  for  ten  days,  which  was  with  the  greatest  difficulty  even 
imperfectly  overcome.  After  death  the  colon  was  found  loaded  with 
indurated  faeees. 

Case  XXIV .* — Apoplexy — Hemorrhage  at  the  base  of  the  brain  in  a 
hoy  aged.  14  years. 

History.  Thomas  Pitbladdo,  ast.  14,  a house-paiuter’s  apprentice — admitted  on 
the  evening  of  June  6,  1856.  His  father  states  that  he  has  generally  been  a healthy 
lad,  but  occasionally  complained  of  pain  in  his  head.  This  morning  he  got  up  as 
usual  and  went  to  his  work.  He  ate  his  breakfast  and  dinner  at  the  usual  times,  not 
so  heaitil}/,  it  is  said,  as  he  was  accustomed  to  do,  but  he  made  no  complaint.  Between 
2 and  5 o’clock  p.m.,  he  was  in  the  streets  carrying  errands  for  his  master,  durino- 
V.  Inch  time  he  purchased  and  ate  several  partially-decayed  oranges.  On  returning  tc 

* Reported  by  Dr.  Wilson  Fox,  Resident  Physician. 


406 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


the  workshop  he  was  noticed  by  the  workmen  “ nearly  to  fall  ” from  giddiness,  and 
to  vomit  several  times,  bringing  up  the  oranges  he  had  eaten.  At  hail  past  V p.m, 
his  father  was  sent  for,  and  Ibund  him  complaining  of  pain  in  the  head  and  abdunen. 
Subsequently  he  was  observed  to  grind  his  teeth.  An  emetic  of  ihccLcnanha  was 
obtained  from  a neighboring  druggist,  which  operated  once,  slightly.  He  was  brought 
to  the  Infirmary  at  iO  p.m. 

Symptoms  on  Admission. — On  admission  he  complained  of  pain  in  the  abdomen 
on  which  he  pressed  his  hands.  Coma  was  apparently  coming  on.  Pupils  dilated. 
Ko  strabismus.  Pulse  natural. 

Progress  of  the  Case. — On  being  conveyed  to  bed,  an  attempt  was  made  to  pass 
the  stomach-pump,  under  the  impression  that  the  case  was  one  of  poisoning.  Ihis, 
however,  failed  in  consequence  of  the  firm  spasmodic  contraction  of  the  jaws,  accom- 
panied by  grinding  of  the  teeth.  Warm  fomentations  also  weie  aj  plied  to  the 
abdomen.  He  now  became  completely  comatose,  and  it  was  observed  that  there  w'as 
strabismus  inwards  of  the  left  eye  with  contracted  pupil,  the  right  one  being  fixed 
with  dilated  pupil.  He  lay  motionless,  with  the  exception  of  slight  clonic  spasms 
of  the  left  hand  and  forearm.  A purgative  enema  was  given,  winch  returned  un- 
changed. He  was  then  placed  in  a w'arm  bath.  The  spasmodic  contraction  of  the 
jaws,  however,  continued,  the  respirations  giadually  became  more  laborious,  and  he 
expired  about  one  a.m.  on  the  '7th,  without  having  had  any  convulsion. 

Sectio  Cadaveris. — Tivelve  hours  after  death. 

Considerable  rigor  mortis.  Sugillation  strongly  marked  ; jugular  veins  turgid  with 
fluid  blood.  The  blood  in  the  heart  and  all  the  vessels  fluid. 

Head. — No  marked  congestion  of  the  scalp.  On  raising  the  dura  mater,  both 
surfaces  of  the  arachnoid  were  observed  to  be  unusually  diy.  Substance  of  hemi- 
sphere healthy.  The  lateral  ventricles  contained  about  § ij  of  sanguineous  serum. 
At  the  base  of  the  brain  was  a clot  of  blood,  foiming  a icund  tumor  the  size  of  a 
walnut,  situated  below  the  arachnoid,  and  breaking  up  the  cerebial  substance  sur- 
rounding the  fifth  and  third  ventricles,  and  the  inferior  portion  of  the  optic  thalami, 
between  the  pillars  of  the  fornix,  thereby  communicating  interiorly  with  the  lateral 
ventricles.  The  sanguineous  mass  was  about  an  inch  in  depth.  Arteries  everywhere 
healthy. 

Thorax  and  Abdomen. — Thoracic  and  abdominal  organs  healthy,  with  the  ex- 
ception of  an  ecchymotic  circular  patch  of  a brick-red  color,  four  inches  in  circum- 
ference, in  the  mucous  membrane  lining  the  great  curvature  of  the  stomach. 

Microscopic  Examination. — The  clot  composed  of  recently  coagulated  blood. 
The  surrounding  softened  cerebral  substance  exhibited  the  nerve-tubes  broken  up  to 
a remarkable  degree,  and  presenting  numerous  rounded  bodies,  with  double  outlines 
either  isolated  or  attached  to  the  tubes.  The  varicosities  of  the  tubes  also  could 
readily  be  increased  by  pressure.  (See  Fig.  404,  which  was  drawn  from  a demonstia- 
tion  of  the  softening  in  this  case.) 

Commentary — Cerebral  liemorrliage  is  a rare  idiopathic  lesion  in 
very  young  persons,  and  the  causes  leading  to  its  occurrence  in  this 
case  are  inexplicable.  There  was  no  heart  disease,  nor  could  coagula 
be  found  in  any  of  the  vessels.  On  receiving  the  patient  at  night,  the 
house  physician,  as  stated  in  the  report,  was  led  to  suj  pose  that  the  boy 
had  eaten  some  poisonous  substance,  and  the  treatment  was  founded  on 
this  supposition.  Pathologically,  it  is  interesting  to  observe  how  the 
same  lesion,  which  in  an  elderly  person  would  Lave  occasioned  coma 
and  paralysis,  in  the  boy  caused  grinding  of  the  teeth,  trismus,  and 
spasms.  Coma  subsequently  came  on,  probably  from  the  accumulation 
of  serum  in  the  ventricles. 

Case  XXV.^ — Apoplexy,  followed  hy  Deliriwm,  and  proving  fatal  in 
eight  hours — Hemorrhage  into  the  Meninges  of  the  Brain. 

TTtstopy. — Elizabeth  Vicars,  <et.  59,  brought  by  the  police  to  the  waiting-room 
of  tlie  Infirmary,  at  2.30  a.m.,  May  30,  1857.  Three  and  a half  hours  before  admis- 

* Reported  by  Dr.  John  Glen,  Resident  Physician. 


CEREBRAL  IIEMORIillAGE. 


407 


sion  patient  was  seated  in  her  own  house  (Canongate)  by  the  fireside  undressing. 
She  is  reported  up  to  that  date  quite  healthy,  although  of  intemperate  habits,  and 
given  to  quarrelling  with  her  daughter.  She  was  not  subject  to  giddiness;  never 
attacked  by  fits  nor  by  palsy.  Suddenly  at  11  p.m.,  29th  of  May,  she  was  observed 
to  fall  off  the  seat,  not  striking  her  head  against  anything.  She  remained  insensible 
for  1 0 minutes,  and  on  emerging  from  unconsciousness,  rolled  on  the  tioor  and  shouted 
— “ Murder— Police — I’m  mad,”  etc.,  and  could  not  be  kept  quiet. 

Symptoms  on  Admission. — When  seen  in  No.  X.  she  was  lying  quiet  on  her  left 
side,  as  laid  down  by  the  police ; heart’s  sounds  normal.  Respiration  not  stertorous, 
but  natural ; pulse  80,  of  ordinary  strength ; legs  rather  cold ; body  warm.  The  pu- 
pils were  equal,  rather  contracted  than  dilated ; lips  not  blanched,  face  naturally  pale ; 
the  eyelids  had  been  closed.  On  their  being  opened,  patient  began  to  show  restless- 
ness, and  this  increased  when  her  lower  garments  were  Ijeing  removed.  She  shouted 
and  moved  from  side  to  side,  putting  her  legs  out  of  bed,  and  moving  both  arms  freely. 

The  mattress  was  laid  on  the  floor.  Warm  bottles  were  applied  to  the  feel,  and  cold 
to  the  head.  Rest  and  perfect  quietude  enjoined.  She  was  seen  again  about  3 a.m., 
by  the  house-physician  (Dr.  Glen) ; at  that  time  she  was  lying  quiet.  She  is  reported 
to  have  had  a spontaneous  recurrence  of  the  restlessness,  and  tendency  to  vociferate, 
again  sinking  into  apparent  repose.  At  7 a.m.  she  was  recognised  by  the  nurse  to 
be  dead. 

Sectio  Cadaveris. — Fifty-Jive  hours  after  death. 

Body  well  formed,  somewhat  emaciated. 

Head. — On  removing  the  dura  mater,  a hemorrhagic  extravasation  was  found  to 
have  occurred  below  the  arachnoid.  It  covei’ed  nearly  the  whole  of  the  surface  of  the 
hemispheres,  and  formed  a thin  layer,  thickest  towards  the  lateral  external  surface 
on  both  sides.  The  extravasation  was  still  more  abundant  over  the  base,  where  it 
was  half  an  inch  thick ; it  extended  from  a little  anterior  to  the  optic  commissure  to 
the  commencement  of  the  spinal  cord ; it  was  particularly  abundant  around  the 
medulla  oblongata.  The  blood  was  of  a dark  color  and  very  loosely  coagulated. 
The  fourth  ventricle  contained  a clot  of  similar  character.  There  was  a cavity  filled 
with  blood  in  the  anterior  portion  of  the  right  hemisphere,  communicating  with  the  ex- 
travasation into  the  meninges.  It  was  of  the  size  of  a chestnut,  but  did  not  extend  l»ack 
into  the  lateral  ventricle — the  parts  contained  in  which  were  quite  normal.  The  arteries 
at  the  base  of  the  brain  were  atheromatous ; numerous  opaque  yellowish  patches  being 
found  on  nearly  all  the  branches.  No  ruptured  vessel,  however,  could  be  made  out. 

Thorax. — Heart  weighed  1 lA  oz. ; the  left  ventricle  being  slightly  enlarged, 
appeared  paler  and  browner  than  usual,  being  found  on  microscopic  examination  to 
be  in  an  advanced  state  of  fatty  degeneration.  The  valves  were  healthy.  On  the 
anterior  flap  of  the  mitral  valve,  and  on  the  endocardium  below  the  origin  of  the 
aorta,  there  occurred  several  opaque  atheromatous  patches.  The  surface  of  the 
aorta,  chiefly  in  the  ascending  portion,  but  also  down  to  the  bifurcation  of  the  ab- 
dominal aorta,  was  irregular  from  hypertrophy  of  the  lining  membrane,  with  athe- 
romatous and  slight  calcareous  degenerations.  Various  of  the  branches  were  simi- 
larly affected,  but  to  a less  degree.  There  were  a few  old  adhesions  of  the  pleurie, 
and  slight  emphysema  anteriorly  of  both  lungs. 

Abdomen. — Abdominal  organs  healthy. 

Microscopic  Examination. — The  coagula  of  blood  presented  nothing  unusual,  and 
the  brain  surrounding  the  extravasation  in  the  anterior  lobe  of  the  right  hemisphere 
was  only  mechanically  broken  up.  The  atheromatous  patches  in  the  cerebral  arteries 
exhibited  the  usual  structure  of  that  lesion. 

Commentary. — In  this,  as  in  preceding  cases,  chronic  arteritis  had 
led  to  hemorrhage,  which,  however,  was  for  the  most  part  poured  into 
the  subarachnoid  cavity.  The  symptoms  in  consequence  presented  a 
remarkable  modification,  for  after  the  first  apoplectic  phenomena  had 
disappeared,  she  exhibited  no  paralysis,  but  great  restlessness,  and 
delirium  with  vociferation.  These  are  exactly  the  effects  which  result 
from  any  acute  disorder  of  the  meninges,  and  indicate  how  all  lesions, 
by  affecting  the  same  parts  of  the  nervous  mass,  produce  similar  symp- 
toms. (See  p.  153.) 


408 


BISExVSES  OF  THE  NERVOUS  SYSTEM. 


Case  XX  VI.^ — Hemorrhage  into  the  Right  Crus  Cerebri — Meningitis 
at  the  base  of  the  Encephalon — Serous  Effusion  into  the  Lateral 
Ventricles — Chronic  Phthisis — Vertigo — Paralysis — Spasms  of  the 
Jaw — Delirium  and  Coma, 

History. — George  Crichton,  aet.  28,  brewer — admitted  Jan.  31,  1861.  For  the  last 
six  months  he  has  suffered  from  a short  dry  cough,  and  has  sweated  profusely  at  night. 
His  appetite  has  been  good,  and  he  considered  himself  in  good  health.  Three  weeks 
ago  he  felt  pain  in  his  head,  which  gradually  increased  in  intensity,  although  he  con- 
tinued at  his  work.  On  the  26th,  feeling  the  headache  very  severe,  he  apiilied  eight 
leeches,  but  without  relief.  On  the  following  day,  as  he  was  going  to  his  work,  he 
had  a severe  fit  of  coughing,  and  expectorated  a teaspoonful  of  florid  blood.  Imme- 
diately after  he  felt  giddy  and  stupid,  being  obliged  to  support  himself  against  a wall. 
He  says  he  never  lost  his  recollection,  recovered  himself  in  a few  minutes,  and  walked 
home,  but  with  difficulty  ; afterwards  he  felt  weak,  but  had  perfect  command  over 
all  his  muscles.  On  Tuesday  evening  he  felt  drowsy,  and  on  awakening  from  one  of 
his  short  sleeps,  he  discoVered  that  the  power  of  moving  the  left  arm  was  much 
diminished.  The  left  leg  was  unaffected. 

Symptoms  on  Admission. — On  admission,  appears  weak  and  emaciated ; com- 
plains of  pain  in  the  forehead  ; most  severe  on  the  right  side ; has  no  pain  else- 
where. His  intelligence  seems  but  little  affected.  He  speaks  slowly,  reluctantly, 
and  with  an  effort.  The  special  senses  are  unimpaired.  The  power  of  motion  in 
his  left  arm  and  leg  is  almost  entirely  gone.  He  can  neither  stretch  or  flex  his  aim 
or  leg.  His  leg  has  become  much  more  useless  within  the  last  twenty-four  hours. 
Sensibility  of  the  parts  is  unimpaired,  and  he  feels  impressions  made  upon  them. 
His  mouth  is  very  slightly  twisted  to  the  right  side ; tongue  protruded  straight. 
During  the  examination  before  the  class,  he  was  seized  with  spasmodic  movements 
of  the  lower  jaw,  lasting  for  a minute  and  a half,  unattended  with  pain.  This  was 
first  observed  on  Wednesday, — when  it  occurred  nine  times, — and  has  returned  at 
irregular  periods  since.  Pulse  60,  not  increased  in  strength.  Cardiac  sounds  normal. 
Appetite  good.  Tongue  clean  in  centre  ; covered  with  a white  fur  at  edges.  Bowels 
generally  costive ; not  opened  by  medicine  last  night.  Urine  102*7  sp.  gr. — deposits 
a copious  sediment  of  mucus  and  phosphates.  Has  occasional  slight  cough ; there  is 
dulness  on  percussion  under  left  clavicle,  with  harsh  inspiration ; and  great  increase 
of  vocal  resonance.  He  was  ordered  ice  to  the  head ; quietness  to  be  maintained. 

Progress  of  the  Case. — Feh,  2. — To-day  headache  is  abated,  he  complains  of 
weakness  in  the  right  eye,  which  he  cannot  keep  open  without  an  effort.  On  frown- 
ing, the  corrugations  are  more  distinct  over  the  left  eye.  The  right  pupil  is  less  con- 
tracted than  the  left.  Feh.  3. — Slept  ill  last  night,  had  a good  deal  of  convulsive 
twitching  of  the  unaffected  side.  Is  more  confused.  Tongue  has  a dense  white  fur 
over  it.  Bowels  costive.  I^  Olei  Ricini  § iss,  to  be  followed  by  laxative  enema,  if 
required.  Feh.  4. — Bowels  moved  after  administration  of  the  injection.  Has  had 
a good  deal  of  muttering  delirium, — passes  his  urine  in  bed.  Appears  to  know'  he 
is  addressed,  if  spoken  to  in  a loud  voice,  but  gives  no  answ'er.  Pulse  60.  Small 
and  weak.  Twitchings  more  distinct  and  decided.  Breathing  not  labored.  IJ  Carh. 
Ammon,  gr.  xij ; Mist.  Camph.  § vj ; M.  Signa,  iuco  table  spoonfuls  every  third 
hour:  Applicetur  Vesicat.  (3  x 4)  ad  Nucham. — Cold  to  head.  deh.  6. — Muttering 
delirium  last  night;  does  not  seem  to  feel  a prick  on  his  left  leg;  is  restless  when 
spoken  to,  but  never  speaks.  Pulse  60,  still  small,  but  stronger  than  yesterday  ; 
has  some  dysphagia.  Feh.  6. — Quiet  during  the  night ; had  a slight  attack  of 
general  convulsions;  bowels  opened  by  enema.  Pulse  *75,  of  good  strength.  Fth. 
1. — Was  more  restless  during  the  night ; picking  the  bedclothes ; no  muttering ; 
respiration  is  more  hurried  and  labored ; there  is  puffing  of  the  left  cheek  during 
expiration;  left  pupil  more  contracted  than  right;  jactitation  of  the  right  arm. 
Feh.  8. — Dysphagia  is  increasing.  Pulse  80.  Twelve  leeches  were  applied  to  the 
temples.  To  have  one  drop  of  croton  oil  every  four  hours.  Feh.  9. — Breathing 
more  hurried  and  labored.  Pulse  116,  small  and  weak.  Bowels  freely  opened 
by  the  croton  oil.  Appeared  to  feel  the  bites  of  the  leeches.  This  morning  he  had 
a return  of  the  general  convulsions,  more  severe,  and  lasting  for  a longer  period 
than  the  former,  accompanied  with  frothing  at  the  mouth.  Feh.  10. — Last  night, 
about  8 P.M.,  he  began  to  moan  and  cry  out,  but  no  convulsions.  The  respiration 

* Reported  by  Mr.  Cunningham,  Clinical  Clerk. 


CEREBRAL  HEMORRHAGE. 


409 


became  more  labored,  and  accompanied  by  a tracheal  rale.  At  12  p.m.  he  died 
comatose. 

Sectio  Cadaveris — Thirty -six  hours  after  death. 

Head  — On  removing  the  calvarium,  the  sinuses  of  the  dura  mater  were  found 
almost  empty ; the  longitudinal  one  contained  a small  decolorised  coagulum.  The 
cerebral  arachnoid  was  very  dry,  the  surfaces  of  the  hemispheres  flattened,  and  the 
convolutions  pressed  together.  The  ventricles  were  distended  by  13  drachms  of 
colorless  limpid  serum,  and  freely  communicated  with  each  other  by  means  of  the 
foramen  of  Monro,  which  was  much  enlarged.  The  fornix,  septum  lucidum,  floor  of 
the  fourth  ventricle,  and  corpus  callosum,  were  of  pultaceous  consistence,  and  readily 
broke  down  under  the  fingers.  On  removing  the  brain,  a semi-opaque  exudation  of 
yellowish-white  color  was  seen  in  the  subarachnoid  space  at  the  base  of  the  brain, 
extending  to  the  sylvian  fissures  laterally,  surrounding  the  chiasm  of  the  optic  nerves 
anteriorly,  and  stretching  as  far  back  as  the  fifth  pair  posteriorly.  Here,  however, 
the  coagulated  exudation  was  very  thin  and  soft,  whereas  immediately  behind  the 
optic  commissure,  it  was  one-eighth  of  an  inch  thick,  and  of  considerable  density. 
On  slicing  the  optic  thalamus  from  above  downwards  on  the  right  side,  there  was  dis- 
covered below  that  ganglion,  in  the  crus  cerebri,  a clot  of  dark-red  blood  the  size  of  a 
pea,  surrounded  by  several  smaller  red  spots,  the  result  of  capillary  hemorrhage.  The 
cerebral  substance  surrounding  it  was  softened  to  the  extent  of  a quarter  of  an  inch 
all  around.  In  the  pons  varolii,  two  masses,  the  largest  the  size  of  a millet  seed,  of 
yellowish  indurated  chronic  exudation,  were  discovered. 

Chest. — Pleurae  of  both  lungs  were  adherent  at  the  apex,  especially  on  the  left 
side.  The  lining  membrane  of  the  bronchi  appeared  congested,  and  of  a reddish  color. 
The  bronchial  glands  were  loaded  with  pigment.  A cavity  was  broken  into,  when 
separating  the  dense  adhesion  at  apex  of  left  lung,  and  a dirty  greyish  white,  tolerably 
tenacious,  fluid  escaped.  This  cavity  was  capable  of  holding  a hen’s  egg.  Walls 
were  irregular,  and  lined  by  no  distinct  membrane.  The  surrounding  texture  was  of 
a deep  red  color,  and  displayed  on  section  numerous  yellowish  hard  miliary  tubercles. 
These  were  also  found  scattered  over  the  lower  part  of  the  left  lung.  The  right  lung 
was  crepitant  throughout,  and  displayed  here  and  there  on  section  the  same  bodies  as 
above  described. 

Abdomen. — Numerous  yellowish  miliary  tubercles  were  found  in  the  cortical  and 
tubular  portions  of  both  kidneys.  Other  viscera  healthy. 

Microscopic  Examination. — The  exudation  at  the  base  of  the  brain  was  composed 
of  bands  of  molecular  fibres,  mingled  with  curled  and  spiral  elastic  filaments.  In  the 
softer  parts  of  the  exudation,  the  delicate  molecular  fibres  at  irregular  intervals  con- 
tained nuclei,  most  of  which  were  oval,  and  a few  fusiform.  The  centre  of  the  clot  in 
the  crus  cerebri  was  composed  of  numerous  blood  corpuscles,  and  the  surrounding 
softened  cerebral  substance  contained  numerous  granules  and  granular  cells.  The 
serum  in  the  ventricles  was  structureless,  and  the  cerebral  softening  of  the  white  sub- 
stance contained  no  granule  cells,  the  normal  structure  being  only  more  easily  separ- 
ated and  capable  of  being  broken  up  when  crushed  between  glasses. 

Commentary. — This  is  an  instructive  characteristic  case  of  that  form 
of  apoplexy  which  has  been  called  inyravescent.,  commencing  with  head- 
ache, fallowed  by  temporary  loss  of  consciousness  and  voluntary  motion, 
then  recovery,  and,  after  a period  varying  from  a few  hours  to  several 
days,  gradual  return  of  the  coma,  almost  always  followed  by  death. 
Such  return  of  coma  is  usually  the  result  of  gradually  increasing  pres- 
sure on  the  brain,  but  the  pathological  cause  of  that  pressure  is  not 
always  easy  to  determine.  Most  commonly  it  is  the  result  of  a hemor- 
rhage slowly  increasing,  and  at  length  forming  a large  coagulum.  Occa- 
sionally it  is  caused  by  an  effusion  of  serum  into  the  ventricles,  and  a 
few  cases  have  been  observed  where  it  was  the  effect  of  a congestion 
which  either  might  or  might  not  leave  traces  after  death.  In  the 
present  case  we  found  four  lesions  of  the  nervous  structure — 1st, 
Chronic  exudation  at  the  base  of  the  brain  ; 2d,  A hemorrhagic  clot  in 
the  right  crus  cerebri ; 3d,  Accumulation  of  serum  in  the  lateral  ven- 


410 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


tricles;  4tli,  Softening  of  the  central  structures  of  the  brain.  Of  these 
lesions  the  three  first  doubtless  united  in  producing  the  syiiiptoins, 
vhilst  the  last  was  post-mortem,  dependent  on  imbibition  of  the  serum 
after  death.  Here  it  is  important  to  observe,  that  the  exudation  of  the 
base  was  chronic,  for  in  structure  it  was  firm  and  fibrous,  characters 
which  I have  never  seen  in  recent  exudations  into  the  subarachnoid 
cavity,  which  are  generally  purulent.  It  is  exceedingly  probable,  there- 
fore, that  the  headaclie  and  premonitory  symptoms  were  occasioned  by 
the  meningitis  ; whilst  the  subsequent  twitchings  and  convulsions  were 
attributable  to  the  presence  of  the  exudation,  more  especially  the 
pressure  and  irritation  occasioned  at  the  base  of  the  encephalon  by  the 
subsequent  changes  through  which  it  passed.  Then  the  apoplectic 
attack  on  the  27th  w'as  entirely  owing  to  the  hemorrhage  into  the  right 
crus  cerebri.  This  hemorrhage  was  small  in  amount,  and  the  apoplectic 
condition  w'as  momentary.  It  probably,  how^ever,  increased  somewhat 
afterwards,  and  broke  up  the  nervous  structure  of  the  crus;  and  the 
result  was  interruption  of  the  conducting  power  between  the  brain  and  left 
side  of  the  body — in  other  words,  hemiplegia.  Lastly,  the  exudation 
and  clot  combined  must  have  exercised  pressure  on  the  veins,  producing 
dropsy  of,  or  eifusion  into,  the  lateral  ventricles,  whereby  was  produced 
a gradually  augmenting  pressure  on  the  whole  organ,  occasioning  the  in- 
gravescent coma.  It  may  be  a question  how  far  the  spasms  of  the  jaw 
were  occasioned  by  the  clot  in  the  crus  cerebri  irritating  the  deep  origin 
of  the  motor  branch  of  the  fifth,  or  by  the  exudation  surrounding  its 
superficial  origin  from  the  pons  varolii.  I am  inclined  to  think  the  first 
theory  the  true  one,  because  both  divisions  of  the  fifth  were  alike  sur- 
rounded by  the  exudation  at  the  base,  and  yet  spasm  only  was  caused, 
and  no  pain. 

The  treatment  of  this  case  was  very  carefully  considered,  the  more  so 
as  it  was  the  evident  opinion  of  the  examining  class,  and  of  the  clerks, 
that  it  should  be  treated  actively  by  blood-letting.  The  student  and 
young  practitioner  is  generally  an  advocate  for  active  treatment ; and 
this  was  certainly  a case  in  which  a difference  of  opinion  might  be  ex- 
pected to  exist  even  among  the  most  experienced.  The  circumstances, 
however,  which  forbade  general  bleeding,  were — the  condition  of  his  pulse, 
which,  though  of  good  strength,  was  never  full  or  hard  ; the  paleness  of 
his  countenance,  and  his  general  habit  of  body,  which  was  far  from 
robust.  The  existence  of  phthisis  did  not  influence  me  at  the  time ; but 
I think  it  supports  the  correctness  of  the  conclusion  I arrived  at.  Many 
years  ago,  when  studying  the  subject,  nothing  struck  me  more  in  care- 
fully analysing  the  cases  of  Abercrombie,  in  reference  to  this  question, 
than  the  fact,  that  notwithstanding  he  waited  until  the  circulation 
rallied,  and  the  pulse  rose,  the  almost  constant  statement  is,  that  a full 
blood-letting  produced  “ no  benefit,”  “ no  relief,  “ not  the  smallest 
benefit,”  and  so  on.  And  in  such  cases,  when  pressure  is  caused  by  a 
solid  coagulum  or  local  obstruction  to  some  part  of  the  venous  system, 
inducing  effusion,  how  can  bleeding  lessen  the  pressure  %vlien  the  heart's 
action  is  not  increased?  We  have  already  seen  that  the  idea  of  diminish- 
ing the  amount  of  fluids  within  the  cranium  by  bleeding  is  visionary, 
and  experience  fully  proves  its  uselessness,  even  in  the  hands  of  men 
who  inculcate  the  practice.  All  agree,  however,  that  you  can  only 


CEREBRAL  HEMORRHAGE. 


411 


relieve  pressure  on  the  brain  by  influencing  the  force  of  the  heart’s  con- 
tractions. But  in  the  present  case,  so  far  wei-e  these  coiitractijiis  fro.n 
being  increased,  that  they  were  normal  when  he  was  first  admitted,  and 
exhibited  a tendency  to  diminish  in  force.  Indeed,  so  low  was  the 
pulse  on  4th  February,  that  I administered  stimulants,  under  which  he 
rallied.  Looking:,  then,  retrospectively  at  this  case,  it  appears  to  me 
certain  that  bleeding,  by  diminishing  the  force  of  the  general  circulation, 
would  have  increased  the  tendency  to  effusion  in  the  lateral  ventricles, 
and  would  have  hastened  rather  than  retarded  the  fatal  result. 

Case  XXVII. — Apoplexy — Hemorrhage  into  right  Optic  Thalamus^  earn- 
ing Hemiplegia  on  left  side — Progressive  llecovery — Two  months 
afterwards,  Hemorrhage  into  Fo7is  Varolii  ayid  Memhra7ies  on  right 
side — Death  in  seven  hoai's. 

History. — Margaret  Lockie,  let.  57,  a sempstress — admitted  on  the  evening  of  De- 
cember 8,  1851.  A friend  who  accompanied  her  said  that  the  patient  had  been  very 
much  addicted  to  drinking,  and  had  an  attack  of  delirium  tremens  a month  ago,  for 
which  she  was  treated  in  the  Infirmary,  and  dismissed  cured  after  a week’s  treatment. 
She  continued  well  until  three  days  ago,  when,  sitting  in  a neighbor’s  house,  she  sud- 
denly fell  from  her  chair  insensible.  This  occurred  about  five  o’clock  p.m.,  without 
any  obvious  cause,  as  at  the  time  she  was  pursuing  her  usual  employment  of  sewing. 

Symptoms  on  Admissio.n. — On  admission,  tlie  face  presents  its  natural  appearance, 
and  is  in  no  way  distorted.  The  intelligence  is  much  impaired,  although  she  is  so  far 
conscious,  that  when  loudly  spoken  to,  she  mutters  something,  and  with  great  elfort 
can  articulate  indistinctly  “ Yes,”  and  “ No.”  The  eyes  are  suttused  and  red  ; the 
pupils  normal ; the  right  hand  and  arm  are  paralysed,  though  the  sensibility  is  not 
absolutely  gone.  Sensibility  is  also  greatly  diminished,  and  motion  comiiletely  lost  in 
tho  right  inferior  extremity.  The  left  leg  is  abruptly  retracted  on  pinching  it ; the  left 
arm  and  hand  unaifected.  There  has  been  no  convulsion,  nor  is  there  any  muscular 
rigidity.  Slie  cannot  protrude  the  tongue.  State  of  digestive  system  cannot  be 
ascertained.  Heart  sounds  normal  in  character,  but  weak.  Pulse  at  the  wrist  GO, 
barely  perceptible.  One  drop  of  croton  od  to  he  administered  in  the  form  of  bolus 
immediately.  A sinapism  to  be  applied  to  the  back  of  the  neck.  § iss  of  sherry  wine 
to  be  taken  every  two  hoars. 

Progress  of  the  Case. — December  9th. — Is  more  conscious.  Urine  loaded  with 
lithates,  otherwise  healthy.  Bowels  have  not  been  relieved.  December  10th. — Has 
had  a dose  of  castor  oil,  and  the  bowels  have  been  freely  relieved  twice.  Is  now  so 
far  conscious  that  she  attempts  to  speak  voluntarily,  and  she  can  mutter  various 
words.  On  smiling,  it  is  distinctly  seen  that  the  mouth  is  dragged  to  the  left  side, 
and  that  the  right  half  of  the  face  is  paralysed.  She  can  now  also  protrude  the 
tongue,  which  is  very  foul.  Skin  of  natural  temperature.  Pulse  68,  still  weak,  but 
of  better  strength.  Has  taken  nourishment.  To  have  § iij  of  sherry  daily.  From 
this  time  she  rapidly  recovered  her  consciousness.  On  the  20th  she  could  readily 
answer  questions,  and  the  mind  seemed  perfect,  but  the  articulation  is  still  difficult. 
On  the  81st  articulation  is  nearly  distinct,  January  lAth — Paralysed  parts  still  im- 
movaole,  but  their  sensibility  has  to  a great  extent  been  restored.  January  2'bth. — 
Galvanic  currents  to  be  applied  to  the  right  leg  and  arm.  February  Is'. — Can  now 
move  the  right  arm  voluntarily  to  a certain  extent.  Right  leg  still  immovable. 
Paralysis  of  jaw  has  disappeared.  February  11th. — Had  been  doing  well  up  to  four 
o’clock  this  morning,  when,  after  having  been  assisted  out  of  bed,  she  suddenly  began 
to  moan,  and  was  seen  by  the  nurse  to  apply  her  left  hand  to  the  head.  She  was 
seen  by  the  house  physician  (Dr.  M‘Laren)  ten  minutes  afterwards,  and  was  found  to 
be  quite  unconscious,  breathing  heavily.  The  left  pupil  dilated,  the  right  contracted, 
and  bo  h were  insensible  to  light.  Ail  the  limbs  were  powerless,  and  fell  on  being 
raised  like  inert  masses.  The  respirations  rapidly  became  more  laborious  and  less 
frequent,  and  she  died  at  eleven  o’clock. 

8ectio  Cadaveris. — Fifty  hours  after  death. 

Head.— On  removing  the  calvarium  and  dura  mater,  the  surface  of  the  arachnoid 
* Reported  by  Mr.  Almeric  Seymour,  Clinical  Clerk! 


412 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


was  observed  to  be  unusually  dry.  In  the  right  temporal  region  was  a thin  extra- 
vasation of  blood,  in  the  subarachnoid  cellular  tissue.  The  lateral  ventricles  con- 
tained above  ^ ij  of  sanguinolent  serum,  and  communicated  freely  with  each  other  by 
means  of  the  foramen  of  Monro,  which  was  the  size  of  a goose’s  quill.  The  right 
corpus  striatum  and  optic  thalamus  were  healthy,  but  the  left  optic  thalamus  was  dis- 
organise>l  throughout,  its  centre  being  occupied  by  a clot  of  blood  the  size  of  a hazel- 
nut, dark  in  the  centre,  of  a brick-red  color  externally,  surrounded  by  softened 
cerebral  matter  of  a yellow  fawn-color.  On  removing  the  brain,  the  extravasation 
formerly  noticed  on  the  right  side  was  seen  to  extend  downwards  over  the  base  of  the 
brain  on  the  right  side,  and  over  a portion  of  each  lobe  of  the  cerebellum,  forming  a 
thill  layer  of  blood  between  the  pia  mater  and  arachnoid  membranes.  The  arteries 
at  the  base  of  the  brain  presented  numerous  opaque  patches  of  athevonia.  On  cutting 
into  the  pons,  an  extravasation  of  blood  had  taken  place  into  its  substance,  disinte- 
grating the  whole  of  it ; it  was  of  a dark  red  color,  evidently  recently  poured  out, 
and  was  Iluid  in  some  places,  and  loosely  coagulated  in  others. 

Chest — With  the  exception  of  a few  atheromatous  patches  on  the  aorta  and  mitral 
valve,  which  latter  in  no  way  impeded  efficiency,  the  thoracic  organs  were  healthy. 

Abdomen. — Abdominal  organs  also  healthy. 

Microscopic  Examination. — The  softening  of  left  optic  thalamus  consisted  of  dis- 
integration of  the  tubes  ; fatty  granules  accumulated  in  the  ganglionic  cells  ; numer- 
ous granule  cells,  several  tinted  of  an  orange  color,  and  others  of  a dusky  red,  were 
in  the  immediate  neighborhood  of  this  clot,  mingled  with  several  crystals  of  hematoid- 
ine,  and  masses  of  blood  varying  in  tint.  The  centre  of  the  clots  presented  a series 
of  laminae  of  a brownish  black  color.  The  broken-up  pons  varolii  was  infiltrated 
with  blood  corpuscles,  and  the  tubes  were  more  or  less  disintegrated. 

Commentary . — In  this  case  circumscribed  hemorrhage  into  the  right 
optic  thalamus  caused  apoplexy  and  hemiplegia  on  the  left  side,  from 
which  she  was  gradually  recovering,  when  an  unusual  exertion  caused  a 
secondary  fatal  hemorrhage  into  the  pons  varolii.  Here  the  primary 
disease  was  chronic  arteritis,  causing  brittleness  of  the  vessels.  In  all 
such  cases  too  much  care  cannot  be  taken  to  avoid  sudden  exertion, 
agitation  of  mind,  and  every  other  circumstance  which  is  likely  to  pro- 
duce increased  pressure  on  the  blood-vessels. 

Case  XXVIII.'^ — Five  years  before  admission^  Ilemipleyia,  followed  ly 
Recovery — Four  months  before  admission  Apoplexy^  with  convulsions 
and  Partial  Recovery — Pulmonary  Pisease — Peath  by  Asp>hyxia — 
Chronic  Softeniny  of  Riyht  Corpus  Striatum — More  recent  Hemorrhage 
into  the  Pons  Varolii — Cardiac  Hypertrophy^  with  mitral  constriction 
— Hemorrhage  into  the  Lungs. 

History. — Mrs.  Maepherson,  act.  34,  admitted  December  22,  1850 — of  intemperate 
habits.  She  has  been  troubled  for  the  last  four  years  more  or  less  with  cough. 
Five  years  ago  she  had  an  attack  of  paralysis  affecting  the  left  side  of  whole  body. 
Her  speech  was  thick.  The  left  cheek  appeared  more  prominent  than  natural ; there 
were  twitchings  also  of  the  left  arm.  Leg  not  affected.  Intellect  unimpaired.  She 
recovered  perfectly  in  two  or  three  months.  She  continued,  however,  her  intem- 
perate habits,  and  was  addicted  to  taking  laudanum.  Four  months  ago,  after  taking 
a drachm  of  laudanum,  she  was  suddenly  seized  with  violent  convulsions,  sprang  a 
little  distance,  and  fell  on  her  face.  She  was  quite  unconscious  at  the  time,  a condi- 
tion from  which  she  gradually  emerged,  but  her  mind  has  ever  since  been  affected, 
and  the  power  over  the  left  side  is  mucli  impaired.  Since  the  second  attack,  she  has 
been  subject  to  violent  and  sudden  fits  of  coughing,  lasting  for  hours  without  inter- 
mission, which  have  latterly  increased. 

Symptoms  on  Admission. — On  admission,  she  leans  to  the  right  side  when  sitting. 
Countenance  anxious,  motions  of  chest  rapid,  with  much  elevation  of  thorax  during 
inspiration.  Dyspnoea  urgent.  Cough  constant  and  paroxysmal.  Expectoration 
copious.  On  percussion  the  anterior  surface  of  the  chest  sounds  resonant.  There  is 
dulness  over  the  infra-scapular  region  of  left  side.  On  auscultation,  the  inspiration 

* Reported  by  Mr.  Pearse,  Clinical  Clerk. 


CEREBRAL  HEMORRHAGE. 


413 


is  short,  and  the  expiration  much  prolonged,  and  accompanied  with  sibilant  and 
sonorous  rales  over  the  whole  anterior  surface  of  both  sides  ; loud  crepitating  and 
mucous  rales  over  the  inferior  portion  of  left  back,  with  distinct  crepitation  also 
inferiorly  in  right  back.  Vocal  resonance  is  increased  over  left  infra-clavicular 
region.  Heart’s  sounds  normal,  distant.  Tongue  of  a brown  color,  moist.  Appetite 
baJ.  Bowels  regular.  Catamenia  regular.  Has  no  pain  in  head  or  any  part  of  her 
boJy.  Skin  hot  and  moist. 

Prooress  of  the  Case. — December  30^A. — She  has  been  treated  with  various 
anodyne  expectorant  mixtures,  sulphuric  and  nitric  ether,  ipecacuan  wine,  chloroform, 
morphia,  etc.,  to  relieve  the  cough  and  difficulty  of  breathing,  but  with  little  benefit. 
Is  weaker  to-day.  Countenance  sunk  and  anxious.  Tossing  about  of  arms.  Breath- 
ing short  and  rapid.  Cough  almost  ceased.  Expectoration  greatly  diminished. 
Pulse  weak,  scarcely  perceptible.  Ordered  two  ounces  of  whisky  and  one  pint  of 
porter  daily.  January  Is^. — Exhaustion  still  greater.  With  difficulty  roused  to 
answer  questions  ; incoherent  in  her  conversation  ; sleeps  little  ; breathing  rapid, 
short,  and  labored ; paroxysmal  cough.  The  rales  formerly  noticed  still  continue  ; 
dulness  over  the  left  back  more  extensive  and  complete.  Pulse  small.  Haheat  Sph'it. 
commun.  ^ iv.  January  2d. — Since  yesterday  there  have  been  coldness  and  lividity 
of  face,  with  stupor  gradually  increasing.  Dyspnoea  very  urgent.  E.xpecto ration 
scanty.  These  symptoms  increasing,  she  died  at  3 a.  m.,  January  3d. 

Sectio  Cadaveris. — Nine  hours  after  death. 

Head. — The  dura  mater  and  arachnoid  membrane  were  healthy  in  structure,  but 
the  subarachnoid  cavity  contained  superiorly  a small  quantity  of  serum  between  the 
sulci.  Both  lateral  ventricles  contained  about  a drachm  of  fluid,  but  that  on  the  right 
side  was  opaque,  of  a greyish  color  like  dirty  milk,  while  that  on  the  left  side  was 
colorless  and  clear.  Three-fourths  of  the  right  corpus  striatum  posteriorly  was 
reduced  to  a f iwn-colorel  diffluent  pulp,  from  which  a turbid  grey  fluid  flowed  out  on 
puncture,  similar  to  what  had  tinged  the  serum  in  the  ventricle.  The  white  substance 
external  to  the  corpus  striatum  was  not  alfected,  the  lesion  being  limited  to  a space 
about  the  size  of  an  almond  nut.  On  cutting  through  the  softened  texture,  a few 
bright  yellow  patches  were  observable,  about  the  size  of  a millet  seed,  closely  resem- 
bling in  appearance  the  reticulum  often  seen  in  soft  cancer.  On  slicing  the  pons  va- 
rolii,  there  was  observed  near  its  centre,  a little  to  the  right  of  the  median  line,  a he- 
morrhagic extravasation  the  size  of  a small  pea,  the  centre  of  a dark  red,  and  the  cir- 
cumference passing  into  a rusty  brown.  Other  portions  of  the  encephalon  were  healthy. 

Chest. — The  left  ventricle  of  the  heart  was  somewhat  hypertrophied,  the  apex 
rounded,  the  mitral  orifice  was  smaller  than  usual — just  admitting  the  thumb — but 
there  was  no  thickening  or  disease  of  the  lining  membrane.  Lining  membrane  of  the 
heart  and  large  vessels  stained  of  a claret  color — blood  fluid.  Both  lungs  anteriorly 
emphysematous.  The  lining  membrane  of  the  bronchi  of  dark  mahogany  color,  and 
more  or  less  filled  with  sanguinolent  mucus.  Inferior  lobe  of  left  lung  greatly  engor- 
ged, containing  coagulated  masses  of  extravasated  blood,  varying  in  size  from  a pea 
to  a moderate-sized  orange.  Inferior  lobe  of  right  lung  also  engorged,  with  similar 
masses  of  blood,  but  not  so  numerous  nor  so  large  as  on  the  opposite  side. 

Abdomen. — Abdominal  organs  healthy. 

Microscopic  Examination. — The  turbid  fluid  in  the  right  ventricle  of  the  brain 
contained  numerous  floating  granular  cells  and  masses.  The  softened  portion  of 
the  corpus  striatum  was  infiltrated  with  them  throughout,  and  the  bright  yellow 
masses  were  composed  of  an  aggregation  of  the  same  cells  and  masses  mingled  with 
innumerable  molecules  and  granules.  The  clot  in  the  pons  varolii  contained  seven'll 
round  and  oval  celloid  bodies,  varying  in  size  from  the  four  to  the  six  hundredth  of 
an  inch  in  diameter,  crowded  with  blood  corpuscles  (Fig.  316).  No  granular  cells 
were  anywhere  visible  in  its  neighborhood. 

Commentary . — The  history  of  what  occurred  to  this  woman  previous 
to  her  admission,  involving  the  account  of  the  two  paralytic  seizures,  was 
obtained  after  her  death  from  the  husband,  who  attended  the  post-mortem 
examination.  During  the  period  she  was  under  treatment,  the  pulmonary 
symptoms  were  those  that  excited  chief  attention.  The  weakness  stated 
to  exist  on  the  left  side  of  the  body  was  certainly  very  slight,  as,  in  the 
frequent  examinations  which  occurred,  it  was  observed  that  she  sat  up 


414 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


■when  desired  to  do  so,  presented  either  hand  when  bid  to  have  the  pulse 
felt,  and  frequently  got  out  of  bed  without  assistance.  The  crepitating 
and  mucous  rales,  with  the  dulness  of  percussion  and  great  prostration  of 
the  patient,  however,  left  little  hopes  from  the  first  of  her  recovery;  and 
of  these  symptoms  she  alone  complained,  never  speaking  of  a former  or 
a present  palsy.  These  facts  in  themselves  are  very  curious,  when  com- 
pared with  those  narrated  when  the  brain  was  examined,  although  here 
it  must  be  confessed  that  the  investigation  of  the  nervous  phenomena, 
from  the  dislike  to  interrogate  closely  a woman  evidently  dying,  was  not 
very  minute.  There  can  be  little  doubt  that  the  first  attack  was  owing 
to  disease  (perhaps  a hemorrhage  into  the  right  corpus  striatum)  five 
years  previously,  and  the  second,  four  months  before  admission,  to  the 
limited  hemorrhage  into  the  pons  varolii. 

Case  XXIX. — Three  attach  of  Apoplexy — The  first  dependent  on  He- 
morrhage into  the  right  Corpus  Striatum^  in  May  1861 ; the  second 
on  Hemorrhage  into  the  left  Cerebral  Lobe  and  right  Optic  Thalamus^ 
November  1831 ; and  the  third  on  Hemorrhage  into  the  Arachnoid 
Cavity^  March  18C’J.  Atheroma  of  the  Blood-vessels — Hypertrophy 
of  Heart — Chronie  Disease  of  Lungs,  Liver,  and  Kidneys. 

History. — John  Gow,  act.  56,  hawker,  was  brought  to  the  hospital  March  12, 
1802,  by  strangers  who  found  him  insensible  on  the  road  near  Penicuick.  His  wife 
gives  the  following  account: — Previous  to  the  month  of  May  1861,  he  had  been  a 
strong  and  healthy  man.  At  that  time,  when  walking,  he  suddenly,  without  any  cry, 
fell  down  insensible.  He  had  no  convulsions,  but  foamed  slightly  at  the  mouth. 
371100  he  recovered  his  consciousness  he  was  able  to  walk,  but  the  left  leg  was  dis- 
tinctly dragged  after  him.  His  mind  was  at  this  time  unimpaired,  but  his  speech  w'as 
altered  and  hesitating.  From  this  period  till  November  last  he  remained  in  much  the 
same  condition,  w'hen  he  had  another  fit,  again  falling  down  quite  insensible.  He 
foamed  at  the  mouth,  and  bled  from  the  nostrils.  He  remained  insensible  for  several 
hours.  On  becoming  conscious,  both  legs  and  arms  were  paralysed.  He  was  for  six 
weeks  confined  to  bed,  during  which  time  his  mind  has  been  impaired.  The  speech 
was  rambling  and  not  to  be  understood,  either  as  regards  sense  or  articulation.  He 
asked  for  nothing,  but  was  constantly  muttering.  Deglutition  has  been  unimpaired, 
but  it  was  necessary  to  feed  him  with  a spoon.  In  May  1862  he  was  able  to  get  up 
and  walk  about  a little,  but  dragged  both  his  legs,  and  the  arms  hung  listlessly  at  his 
side.  On  March  10th,  having  previously  confined  his  walks  to  about  the  door  of  his 
house,  he  contrived,  unknown  to  his  wife,  to  reach  Penicuick,  seven  miles  from 
Edinburgh.  How  she  does  not  know.  She  heard  nothing  further  about  him  till  she 
discovered  he  w^as  in  the  Infirmary. 

Symptoms  ox  Admission. — He  is  able  to  understand  and  answer  questions  in 
monosyllables.  He  is  drowsy,  and  like  a person  in  a state  of  collapse.  He  moves 
his  anns  and  legs  freely  in  bed,  when  asked.  Sensibility  is  unimpaired.  The  muscles 
on  the  right  side  of  the  face  are  more  contracted  than  on  the  left.  The  tongue  is  pro- 
truded straight.  Appears  depressed  and  exhausted.  Whole  surface  cold.  No 
oedema.  His  pupils  are  slightly  contracted,  but  they  obey  the  stimulus  of  light.  Dis- 
tinct arcus  senilis  in  both  eyes.  Considerable  emaciation.  Slight  cough.  No 
dyspiKca.  No  expectoration.  Respirations,  12  per  minute,  not  labored  nor  stertorous. 
Respiratory  murmurs  harsh.  Percussion  resonance  over  the  chest  less  clear  than 
natural  posteriorly.  Pulse  66,  weak.  The  second  sound  of  the  heart  is  clear  and 
ringing.  Radial  artery  corded  and  tortuous.  Tongue  covered  with  a dirty  white  fur. 
Deglutition  unimpaired.  The  urine  dribbles  away  in  bed.  A catheter  was  passed, 
and  about  half  an  ounce  of  urine  w^as  obtained.  It  was  albuminous  and  contained 
fatty  and  granular  tube-casts.  Habeat  Pidv.  Jalap.  Co.  statim  3 i ; et  Haust.  Sennee 
3 ij,  post  fertias  koras.  To  be  dry-cupped  over  the  loins.  Half  a pint  of  strong  beef- 
tca  to  be  given,  and  hot  bottles  applied  to  the  extremities. 


* Reported  by  Mr.  R.  B.  J.  Cunynghame,  Clinical  Clerk. 


CEREBRAL  HEMORRHAGE. 


415 


Progress  of  the  Case. — Five  p..\r.  Surface  still  cold,  pulse  very  feeble,  5G  per 
minute.  IZb  have  w>ne  3 i evert)  houi\  vrilh  strong  heef-tea.  In  the  evening,  hrandg 
3 ss  every  hour  was  administered,  March  V-V.h. — lias  passed  urine  freely  in  bed  and 
at  stool  since  ; he  was  cupped  yesterday.  Bowels  were  moved  this  morning.  \Varmth 
has  returned  to  the  surface.  Just  before  visit  to-day,  he  passed  nine  ounces  of  urine 
which  was  highly  albuminous,  and  contained  fatty  and  granular  tube-casts,  with  urates 
and  phosphates  in  excess ; pulse  5G,  rather  stronger  ; takes  food  well.  B d^otass. 
Biiart,  3 £S  ter  in  die  egatho  aqiioe.  Beef-tea  and  vnne  to  be  continued.  March  \-^th. — 
In  much  the  same  condition.  Got  out  of  bed  last  night,  and  was  able  to  stand  leaning 
against  a pillar.  He  fell  in  making  the  attempt  a second  time.  Drowsiness  continues. 
]dmj)last.  Lgttce  michae  appUcandurn.  March\^th. — Appetite  good.  Pulse  72.  Tongue 
hard  and  (Iry,  covered  with  sordes.  He  is  quiet,  and  sleeps  well.  Pupils  immobile 
to  light.  Brandy  dailg.  March  lHh. — Tongue  very  dry.  There  is  great  foetor  of 
the  breath.  Pulse  GO,  very  feeble,  intermittent.  Evacuations  passed  in  bed.  Urine 
free  from  albumen.  March  %)th. — He  is  very  weak.  Pulse  76,  irregular,  intermit- 
tent. He  has  not  slept  well.  Appetite  failing.  From  this  date  the  patient  gradually 
sank.  He  became  insensible  on  the  23d,  and  died  at  4 p.m.  on  tbe  24th. 

Sectio  Cadaveris. — Twenty-one  hours  after  death. 

Body  emaciated,  looks  older  than  assigned  age.  Costal  cartilages  ossified. 

Head. — On  removing  the  calvarium  and  dura  mater,  there  was  found  on  the  right 
side  a good  deal  of  subarachnoid  effusion,  and  the  membrane  was  rather  thicker  and 
more  opaque  than  natural.  In  the  cavity  of  the  arachnoid,  over  the  left  hemisphere, 
was  a layer  of  blood  of  a brownish  red  color,  and  almost  entirely  fluid,  which  gravi- 
tated to  the  posterior  part  of  the  left  hemisphere.  The  quantity  amounted  probably 
to  about  half  an  ounce.  One  small  patch  had  coagulated,  but  was  not  at  all  decolor- 
ized, and  was  adherent  to  the  surface  of  the  hemisphere,  rather  anterior  to  its  middle 
and  very  near  the  median  fissure.  On  slicing  the  brain  there  were  found  more  red 
spots  than  natural  in  the  medullary  portion,  anl  it  was  noticed  that  the  vessels 
near  the  surface  were  unusually  rigid,  several  of  tiiem  standing  out  and  remaining 
open  after  being  cut.  The  substance  of  the  brain  was  somewhat  cedematous.  The 
lateral  ventricles  were  much  dilated.  Each  contained  an  ounce  of  clear  serum.  The 
foramen  of  Monro  was  the  size  of  a sixpence.  W hen  the  brain  was  removed,  it  was 
found  that  the  hemorrhagic  extravasation  on  the  left  side  extended  down  to  the  base, 
where,  in  the  middle  and  posterior  fossae  of  the  skull,  it  formed  a layer  about  an 
eighth  of  an  inch  in  thickness,  and  appeared  rather  inspissated  than  coagulated.  In 
the  anterior  third  of  the  left  hemisphere,  a portion  of  the  grey  matter  of  some  of 
the  convolutions,  and  the  adjacent  white  matter  was  slightly  softened,  and  of  a faint 
yellowish  olor.  On  slicing  the  brain  an  old  apoplectic  cavity  vras  opened  into  at  this 
point.  It  was  of  an  irregularly  crescentic  form,  one  and  a quarter  inches  in  length,  by 
half  an  inch  at  its  broadest  part,  very  shallow,  anl  containing  a soft  matter  of  a russet 
brown  color.  It  was  situated  on  a level  with  the  upper  surface  of  the  corpus  cal- 
losum, and  was  close  to  the  surface  of  the  brain.  The  hemori’hage  had  evidently 
taken  place  from  the  vessels  in  the  grey  matter  of  the  convolutions.  The  cavity 
was  found  to  be  lined  by  a thin  but  tough  membrane.  The  lining  membrane  of  the 
right  lateral  ventricle  was  thickened,  anl  a slight  depression  with  a brownish  yellow 
coloration  of  the  margin  existed  at  the  posterior  part  of  the  optic  thalamus.  On 
cutting  into  this  part,  the  cerebral  matter  did  not  appear  to  be  affected,  but  the 
lining  membrane  of  the  ventricle  was  thickened  there,  and  infiltrated  into  and  below 
it  was  some  yellowish  matter.  On  cutting  into  the  right  corpus  striatum  there  was 
found  in  its  centre  a small  apoplectic  cyst,  about  the  size  of  a field  bean,  having  a 
distinct  lining  membrane,  an  1 containing  a russet  brown  matter.  Other  parts  of  the 
brain  were  natural.  There  was  considerable  athero  ma  of  the  arteries  at  the  base  of 
the  brain.  This  was  especially  the  case  with  the  branches  in  the  fissure  of  Sylvius, 
many  of  which  were  of  an  opaque  color,  having  quite  lost  their  transparency.  Their 
coats  were  thickene  1,  but  contained  no  calcareous  matter. 

Thorax. — The  heart  was  enlarged,  weighing  L5d  ounces.  The  valves  were 
natural,  and  the  hypertrophy  was  entirely  due  to  increased  size  of  the  left  ventricle, 
the  cavity  of  which  was  a little  dilated,  while  its  walls  were  much  thickened.  The 
right  ventricle  was  of  normal  dimensions.  The  aorta  was  atheromatous  and  cal- 
careous just  above  the  semilunar  valves.  The  remainder  of  the  vessel  was  but  slightly 
affected.  There  were  old  adhesions  at  the  apex  of  each  lung  corresponding  to 
puckerings  and  cretaceous  concretions  in  the  pulmonary  ti.ssue,  and  slight  emphysema 


DISEASES  OF  THE  IsEEVOirS  SYSTEM. 


41 G 

cf  the  anterior  margins  of  the  lungs.  The  bronchi  contained  mucopurulent  matter, 
and  the  mucous  membrane  was  much  congested. 

Addomex. — The  liver  weighed  2 lbs.  8 oz.,  the  capsule  was  slightly  thickened,  and 
harder  than  natural.  The  kidneys  were  very  small,  weighing  together  3^  ounces. 
The  capsule  was  removed  with  diihculty.  The  surface  of  the  organs  was  tolerably 
smooth,  but  had  a somewhat  rough  indurated  feeling.  The  vascularity  was  pretty 
regular  and  normal.  Tliere  wei-e  no  opaque  granulations,  but  two  or  three  small 
cysts  v/cre  visible.  On  section  much  fat  was  found  in  the  pelvis  of  each  kidney. 
The  cortical  substance  was  atrophied,  forming  a thin  line  around  the  surface  of  the  organ. 

Microscopic  Examination. — The  contents  of  the  cavity  in  the  left  hemisphere 
were  found  to  consist  of  granular  matter,  yellow  granular  pigment,  and  remarkably 
well-defined  crystals  of  hasraatoidin.  The  lining  membrane  presented  an  obscurely 
fibrous  and  rather  fibrillated  appearance,  having  quite  the  structure  of  an  old  clot. 
Immediately  external  to  the  cavity  was  a patch  of  fawn-colored  softening,  of  the 
size  of  an  almond,  in  which  very  numerous  granular  corpuscles  were  found,  as  well 
as  granular  matter  and  some  blood  globules.  The  softening  of  the  right  optic 
thalamus  presented  exactly  the  same  structure.  The  small  cyst  in  the  right  corpus 
striatum  contained  nothing  but  purely  molecular  matter.  In  the  kidneys  the  amount 
of  fibrous  tissue  was  everywhere  increased.  The  capsules  of  the  Malpighian  bodies 
and  the  coats  of  the  vessels  were  thickened.  Very  numerous  cysts  of  all  sizes  were 
seen,  in  most  of  which  the  lining  of  epithelium  was  distinctly  visible.  The  tubes 
were  contracted  and  seemed  fewer  than  natural.  The  tube-casts  in  the  urine  were 
small.  The  epithelium  also  was  granular,  but  there  was  little  fat. 

Commentary. — This  is  a very  instructive  case  of  cerebral  hemorrhage 
occurring  at  three  distinct  intervals,  causing  characteristic  symptoms  on 
each  occasion,  and  leaving  decided  proofs  of  their  occurrence  after  death. 
Tiie  first  attack  in  May  18G1  was  sudden,  and  he  recovered  with  his 
mind  unimpaired,  but  with  dragging  of  the  left  leg.  This  was  evidently 
dependent  on  circumscribed  hemorrhage  into  the  right  corpus  striatum, 
the  remains  of  which  after  death  exhibited  the  form  of  a small  cyst, 
with  a distinct  lining  membrane,  containing  a brownish  molecular 
matter.  That  is,  the  small  clot  was  transformed  in  the  manner  described 
in  a period  of  ten  months.  The  attack  in  the  following  November  was 
more  severe,  and  on  his  recovery  both  legs  and  arms  were  paralysed. 
H is  mind  also  was  gravely  affected,  and  he  could  not  articulate.  On 
this  occasion  hemorrhage  must  have  occurred  into  the  optic  thalamus 
and  ventricle  on  the  right  side,  and  into  the  anterior  cerebral  lobe  on  the 
left  side,  thus  accounting  for  the  paralysis  on  both  sides  of  the  body,  and 
the  disturbance  of  mind.  The  microscopical  examination  also  proves  that 
both  these  hemorrhages  were  of  the  same  date,  for  though  on  different 
sides  of  the  brain,  they  each  contained  numerous  granule  cells  and  crys- 
tals of  haematoidine.  The  third  and  fatal  attack  was  evidently  caused  by 
the  recent  hemorrhage  into  the  arachnoid  cavity.  Whether  this  was 
caused  by  a fall,  cannot  be  stated  wdth  certainty,  as  no  contusion  could 
be  found;  but  considering  his  state  of  weakness,  and  that  the  mental 
hallucination  under  which  he  labored,  induced  him  to  drag  himself 
seven  miles  from  his  residence,  it  is  by  no  means  improbable.  The 
atheromatous  condition  of  the  cerebral  blood-vessels,  and  condition  of 
the  heart,  lungs,  liver,  and  kidneys,  present  a complication  of  diseases, 
all  of  which  predispose  to  fatal  apoplexy. 

The  predisposing  cause  of  cerebral  hemorrhage  is,  in  the  vast  majority 
of  cases,  previous  disease  and  consequent  brittleness  of  the  arteries.  It 
is  true  there  are  some  rare  instances  in  which  it  cannot  be  traced  to  this 
circumstance,  and  where  its  origin  is  obscure  (Case  XXIV.),  or  where  m 
young  persons,  or  those  of  middle  age,  it  may  originate  from  obstruction 


CEREBRAL  HEMORRHAGE. 


417 


of  the  vessels  by  clots  sent  from  a distance,  as  previously  explained. 
Still,  even  in  these,  and  in  the  great  majority  of  individuals  advanced  in 
life,  among  whom  apoplexy  and  sudden  palsy  are  common,  chronic  cere- 
bral arteritis  may  be  considered  as  the  real  disease,  and  hemorrhage  as 
its  result.  Hence  why  all  those  circumstances  which  induce  increased 
pressure  on  the  internal  surface  of  the  arteries* are  the  proximate  causes 
of  apoplexy  and  sudden  palsy,  such  as  violent  exertion,  constipation, 
straining  at  stool,  strong  drinks,  undue  repletion  at  meals,  mental  emo- 
tions, etc.  etc. 

The  histolocrical  facts  ascertained  in  connection  with  the  hemorrhao;ic 
clot  are  important.  The  colored  blood  corpuscles  at  first  accumulate 
in  groups,  and  some  of  them  are  subsequently  surrounded  by  a colloid 
membrane.  Under  such  circumstances  they  slowly  disintegrate  ; the  red 
color  is  changed  into  a brown,  which  becomes  darker  and  darker,  and  is 
ultimately  converted  into  black.  Not  unfrequently  crystals,  supposed  to 
be  of  hernatine,  are  scattered  among  the  broken-up  clots,  and  have  been 
seen  both  of  a deep-red  and  black  color  even  within  the  membrane  alluded 
to.  That  this  membrane  really  does  form  in  the  manner  described — 
that  is,  secondarily — around  heaps  of  blood  corpuscles,  I am  satisfied — my 
former  assistant.  Dr.  Sanderson,  having  proved  it  by  direct  experiments 
in  my  presence.  He  thrust  a needle  through  the  cranium  into  the  cere- 
bral lobes  of  four  pigeons  which  were  killed,  and  the  brain  inspected, 
successively  on  the  third,  fifth,  and  sixth  days.  There  could  be  observed 
in  one  case,  where  a slight  hemorrhagic  streak  marked  the  track  of  the 
pin,  that  the  cerebral  substance,  seen  under  a magnifying  power  of  250 
diameters  linear,  contained  groups  of  from  five  to  twelve  oval  blood  cor- 
puscles, each  surrounded  by  a delicate  membrane.  (See  Fig.  317,  p.  248.) 
When  the  clot  is  large,  this  process  may  go  on  through  its  entire  sub- 


a b c 


Fig.  410. 

stance,  in  conjunction  with  the  formation  of  compound  granular  cells.  I 
examined  a tumor  the  size  of  a small  hen’s  egg,  brought  to  me  by  Dr. 
Peddie,  in  which  the  external  layer  presented  numerous  fibre  cells  and 
fibres,  in  various  stages  of  development,  whilst  the  interior  was  prin- 
cipally composed  of  numerous  granules  and  compound  granular  cells. 
Here  and  there,  however,  were  patches  of  red  extravasation  more  or  less 

Fig.  410.  Section  of  the  capsule  and  portion  of  the  coagulum,  size  of  an  orange, 
f und  in  the  brain  in  Dr.  Kirkwood’s  case.  External  portion  of  capsule,  consisting 
of  fibrinous  laminae ; h,  internal  portion  of  capsule,  rendered  dark-red,  purple,  and 
opaque,  from  condensed  blood  corpuscles ; c,  broken-down  blood  corpuscles  in  the  in- 
terior, with  crystals  of  cholesteriue.  260  diam. 

27 


418 


DISEASES  OF  THE  NEKVOUS  SYSTEM. 


recent,  containing  large  delicate  vesicles  filled  with  blood  globules.  (See 
Fig.  316,  p.  248.)  In  another  tumor  sent  me  for  examination  by  I)r. 
Kirkwood  of  Berwick, which  was  the  size  of  a large  oi'an^e,  and  im- 
bedded in  the  right  cerebral  hemisphere,  I found  it  to  consist  of  a firm 
resistant  shell  or  capsule,  about  one-eighth  of  an  inch  thick,  containing 
coagula  of  blood  of  a brick-dust  color.  The  capsule,  externally,  was  of  a 
straw  color,  like  that  of  coagulable  lymph;  but  one-third  of  its  thickness, 
internally,  was  dark  red  passing  into  black.  A small  portion  of  the  ex- 
ternal layer  of  the  capsule,  examined  under  the  power  of  250  diameters 
linear,  presented  apparently  a dense  mesh-'work  of  fibres,  running  in 
waved  bundles,  which  in  fact  were  the  edges  of  laminae.  The  thicker  in- 
ternal layer  was  composed  of  simikar  fibres,  mingled  with  masses  of  blood 
corpuscles,  in  various  stages  of  disintegration.  The  internal  coagula 
were  composed  of  numerous  molecules  and  granules,  and  a mass  of  blood 
corpuscles,  diminished  in  size,  and  variously  altered  in  shape,  but  still 
presenting  their  normal  yellow  hue,  mingled  with  numerous  crystals  of 
cholesterine.  These  and  numerous  other  examinations  have  convinced 
me  that  when  the  hemorrhagic  extravasation  is  small,  it  breaks  down  and 
disintegrates  in  a period  varying  from  three  to  six  months.  Even  then 
it  may  leave  traces  of  its  existence,  especially  in  the  form  of  a cyst,  the 
internal  membrane  of  which  is  of  a bright  orange,  or  brick-red  color. 
On  examining  this  membrane,  or  the  colored  softening  in  its  immediate 
neighborhood,  it  may  be  seen  to  consist  of  numerous  molecules  and 
granules,  sometimes  associated  with  fragments  of  the  nerve -tubes.  There 
are  also  granular  corpuscles  and  masses,  variously  tinted,  of  a bright 
orange,  brick-red,  reddish-brown,  or  dark  brown.  The  former  are  evi- 
dently the  celloid  bodies  formerly  described  and  figured  (Fig.  317),  con- 
taining blood  corpuscle  in  diferent  stages 
of  disintegration.  There  are  also  fre- 
quently present  a greater  or  less  number 
of  crystals  of  hematoidine,  of  a deep  red 
or  ruby  tint  (Fig.  349).  If  the  clot  be 
large,  the  period  required  for  absorption 
may  extend  to  years,  and  then  the  ex- 
ternal portions  of  the  clot  are  trans- 
formed into  an  external  fibrous  cyst, 
within  which  the  blood  is  very  slowly 
disintegrated  and  absorbed.  Most  com- 
Fig.  411.  monly,  however,  in  these  cases,  long  be- 

fore absorption  occurs,  secondary  changes  take  place  in  the  surrounding 
nervous  structure,  or  pressure  is  exercised  on  parts  at  the  base  of  the 
cranium,  whereby  oonvulsions,  paralysis,  or  other  symptoms  occur,  and 
life  is  destroyed. 

The  diagnosis  of  cerebral  hemorrhage  from  the  other  lesions  of  the 
brain  is  not  always  easy,  in  consequence  of  the  fact  that  a chronic  cere- 
britis  may  proceed  imperceptibly,  and  then  induce  apoplexy  or  sudden 

* Monthly  Journal,  March  1851. 

Fig.  411.  Granular  corpuscles  and  masses,  of  a bright  orange  and  pale  yellow 
color,  some  of  them  passing  into  brown,  wdth  crystals  of  hematoidine  from  an  old 
apoplectic  clot.  250  diam. 


CEREBKAL  HEMORRHAGE. 


419 


palsy.  It  may  generally  be  observed,  however,  that  a true  exudative 
c.-releral  softening  is  preceded  by  more  or  less  weakness  of  the  intellect, 
and  more  especially  by  slowness  in  receiving  mental  impressions,  or 
framing  replies  to  (questions,  frequently  combined  with  more  or  less 
headache,  confusion  of  ideas,  and  perversion  of  motion.  Much  will  de- 
pend upon  the  seat  of  the  lesion,  the  mind  being  disordered  most  in  pro- 
portion to  the  extent  and  nearness  of  the  disease  to  the  hemispherical 
ganglion — while  motion  is  the  more  influenced,  according  as  the  central 
and  basic  parts  of  the  brain  are  afl’ected.  Then  it  should  not  be  forgot- 
ten that  whilst  a cerebral  softening  may  occasionally  lead  to  or  be  com- 
plicated with  a hemorrhage,  so  a hemorrhage  is  one  of  the  most  common 
causes  of  a softening.  The  distinction  between  the  two  under  such  cir- 
cumstances becomes  very  difficult.  Still  there  can  be  no  question  that 
suddenness  of  attack^  whether  of  apoplexy  or  of  palsy,  is  (excluding  ex- 
ternal injury)  the  characteristic  symotom  of  cerebral  hemorrhage.  Occa- 
sionally, however,  sudden  paralysis  mikes  its  appearance  in  cases  of 
chronic  softening,  a result  which  Dr.  Todd  has  attributed  to  the  rupture 
or  deliquescence  of  tubes  which  had  been  already  softened,  but  not  suffi- 
ciently to  interrupt  their  power  as  conductors  of  the  nervous  force. 
Whether  hemorrhage  be  consecutive  on  diseased  arteries,  or  upon  their 
calibres  being  obstructed  by  clots,  must  be  determined  from  all  the  facts 
of  the  case ; the  former  being  most  likely  in  elderly,  and  the  latter  in 
younger  persons  with  diseased  hearts.  Little,  however,  is  as  yet  under- 
stood of  this  point  diagnostically  in  the  living  subject.  For  what  is 
known  with  regard  to  the  seat  of  cerebral  hemorrhage  and  softening,  I 
must  refer  to  page  152. 

The  influence  of  cerebral  softening  and  hemorrhage  on  the  motor 
function  has  justly  excited  the  attention  of  physicians.  Whilst  by  some 
more  or  less  contraction  and  rigidity  of  the  limbs  have  been  considered 
as  highly  characteristic  of  inflammatory  softening,  others  have  maintained 
that  it  is  altogether  incidental,  that  it  often  exists  when  no  softening 
can  be  found,  and  that  it  is  as  often  absent  when  softening  is  present.  It 
has  also  been  known  to  accompany  hemorrhages,  apparently  unconnected 
with  softening.  The  analysis  of  many  cases  in  reference  to  this  subject 
has  led  me  to  the  conclusion,  that  on  the  whole  muscular  rigidity  or  con- 
traction is  a valuable  sign  of  softening  when  present^  but  that,  as  the 
softening  may  be  permanent,  whilst  the  rigidity  is  only  temporary  and 
indicative  of  the  irritating  effects  of  the  lesion,  the  absence  of  the  one  is 
no  proof  of  the  non-existence  of  the  other.  It  should  be  remembered  that 
much  of  this  discussion  took  place  formerly  when  no  means  were  known 
of  distinguishing  histologically  between  inflammatory,  hemorrhagic,  and 
post-mortem  softenings.  Dr.  Todd  has  especially  drawn  attention  to  the 
state  of  the  muscles  in  palsied  limbs  from  cerebral  disease,*  arranging  the 
cases  into  three  classes  — 1st,  Those  in  which  the  muscles  of  the  paraly- 
tic limbs  are  completely  relaxed;  2d,  Those  in  which  the  paralysed  muscles 
exhibit  rigidity  from  the  moment  of,  or  soon  after,  the  attack;  3d,  Those 
in  which  rigidity  comes  on  long  after  the  paralysis.  The  first  class  of 
cases  he  considers  usually  results  from  hemorrhage,  combined  with 
preyious  softening  of  the  brain  and  rupture  of  the  tubes,  the  clot  of 
^ Clinical  Lectures  on  Paralysis,  etc.  1854. 


420 


DISEASES  OF  THE  XEEYOUS  SYSTEM. 


blood  being  separated  from  healthy  brain.  The  second  class  of  cases 
depends  on  the  clot  of  blood  acting  directly  on  sound  brain  at  the  point 
of  implantation  of  the  nerves  of  the  affected  muscles ; while  the  third 
class  of  cases  are  owing  to  a similar  irritation  from  an  attempt  at  cicatri- 
zation of  the  brain’s  substance.  These  views  of  Dr.  Todd,  though  in- 
genious, must  as  yet  only  be  regarded  as  probable  speculations.  The 
true  generalization  appears  to  me  to  be,  that  complete  paralysis  indicates 
such  pressure  on  or  obstruction  of  cerebral  tissues  as  to  prevent  all  trans- 
mission of  nervous  influence,  whilst  rigidity,  convulsion,  and  pain  show 
that  some  tubes  of  that  tissue  are  preternaturally  excited.  Both  cond^i- 
tions  may  be  occasioned  by  hemorrhage,  exudation,  effusion,  tumors,  or 
any  lesion  that  affects  the  brain. 

The  treatment  of  cerebral  hemorrhage  must  refer  to  the  attack,  and 
to  the  subsequent  management  of  the  case.  At  the  moment  of  attack, 
the  steps  to  be  pursued  must  always  be  a subject  of  anxious  considera- 
tion. Formerly  there  was  little  difficulty — venesection  to  a large  ex- 
tent being  the  established  routine  remedy.  The  advance  of  pathological 
knowledge,  however,  must  have  made  it  apparent,  that  the  same  pro- 
ceeding is  not  likely  to  be  beneficial  in  ail  cases  where  the  nervous 
centres  are  similarly  affected.  We  may  have  sudden  loss  of  conscious- 
ness and  volition  from  syncope,  as  well  as  from  coma,  the  only  supposed 
difference  between  the  two  being,  that  the  same  nervous  phenomena 
commence  in  the  heart,  with  a weak  pulse,  in  the  one  case,  whilst  they 
originate  in  the  brain,  and  have  a strong  pulse,  in  the  other.  But  care- 
ful observation  has  sufficiently  proved  that  there  are  many  cases  of  even 
true  hemorrhagic  apoplexy  which  are  closely  allied  to  syncope,  and 
which  have  recovered  under  the  use  of  stimulants,  rather  than  of  deple- 
tions. It  seems  to  me  also  very  probable  that  many  of  those  individuals 
who  died  under  what  Abercrombie  called  simple  apoplexy,  and  in  whom 
no  trace  of  disease  could  be  found  in  the  brain  after  death,  were  really 
the  victims  of  one  form  of  fatty  degeneration  of  the  heart — an  affection 
in  his  day  altogether  unknown.  The  best  rule,  therefore,  I can  give 
you,  is  to  judge  from  all  the  circumstances  of  the  case.  Whenever  the 
individual  is  of  vigorous  frame  of  body,  if  the  face  be  flushed,  the  attack 
recent,  and  the  pulse  strong  and  full,  a moderate  bleeding  may  be  bene- 
ficial. The  extent  must  be  influenced  by  its  effect  on  the  heart’s  action  ; 
for  as  we  have  seen,  the  object  of  this  measure  is  not  to  draw  blood 
from  the  brain,  which  is  impossible,  but  to  diminish  the  pressure  on  that 
organ,  by  lessening  the  force  with  which  the  heart  propels  the  blood 
through  the  carotid  and  vertebral  arteries.  On  the  other  hand,  if  the 
individual  be  of  spare  habit,  the  face  pale,  the  pulse  weak  and  irregular, 
and  the  usual  symptoms  of  shock  be  present,  wine,  brandy,  stimulants 
generally,  and  restoratives,  are  demanded.  But  it  most  frequently 
happens,  that  when  you  are  called  in,  neither  one  nor  the  other  indica- 
tion presents  itself  It  will  be  most  prudent,  under  such  circumstances, 
simply  to  apply  cold  to  the  head,  administer  an  active  purgative,  and 
above  all  enjoin  quietude.  At  the  same  time  the  patient  should  bb 
placed  in  the  horizontal  position,  with  the  head  slightly  elevated,  whilst 
the  cravat,  stays,  and  all  impediments  to  the  respiratory  and  circulatory 
functions  should  be  removed. 


CANCER  OP  THE  BRAIN. 


421 


Should  the  individual  recover  from  the  attack,  quietude,  mental  and 
boJily,  and  supporting  the  economy  by  good  nourishment,  constitute 
thj  chief  treatment.  Thus  long  conversations,  literary  labor,  business 
transactions,  the  sudden  reception  of  joyful  or  distressing  intelligence, 
etc.,  should  be  carefully  avoided.  Sudden  exertions,  rising  from  bed 
(see  Case  XXYII.),  constipation,  straining  at  stool,  etc.,  must  be 
guarded  against.  Of  all  these  I believe  the  prevention  of  constipation 
to  be  the  most  important,  as  the  straining  at  stool  thereby  occasioned  is 
one  of  the  most  common  causes  of  secondary  attacks.  If  paralysis 
remain,  considerable  caution  must  be  exercised  before  having  recourse 
to  local  stimulants,  such  as  frictions,  galvanism,  or  exercise  of  the 
affected  parts.  These  are  remedies  of  undoubted  utility,  but  never  to 
be  employed  at  the  risk  of  causing  general  excitement,  and  always  very 
gradually  applied,  and  their  increase  well  regulated.  Exactly  the  same 
management  is  required  in  cases  of  chronic  cerebritis,  or  where  there  is 
reason  to  suspect  that  coagula  from  the  heart  constitute  the  cause  of  the 
cerebral  lesion. 


CANCER  OF  THE  BRAIN. 

Case  XXX.^ — Cancer  of  the  Brain^  Spinal  Cord,  Liver,  and  Bones. 

History. — George  Gall,  aet.  29,  a stoker  on  board  a steam-vessel — admitted  July 
1,  1857.  About  the  beginning  of  December  1856,  he  contracted  a cold  with  cough 
and  profuse  expectoration,  and  has  not  since  enjoyed  good  health.  At  the  end  of 
March  1857,  he  began  to  feel  pain  in  the  lumbar  and  sacral  regions,  extending  also 
to  the  neck,  affecting  the  shoulders,  and  spreading  down  to  the  joints  and  muscles 
of  the  arms.  The  knee-joints  were  also  painful.  They  are  reported  to  have  been 
swollen,  but  only  for  a short  time.  At  the  commencement  of  last  April,  he  seemed 
to  labor  under  confusion  of  thought,  with  shortness  of  memory,  and  incapability  of 
carrying  on  a train  of  ideas.  During  the  next  two  months  became  gradually  more 
weak  and  emaciated ; at  length  he  was  unable  to  walk  or  to  rise  unassisted ; passing 
his  urine  in  fair  quantity,  but  involuntarily  during  sleep. 

Symptoms  ox  Admission. — Has  no  headache;  is  very  silent,  but  listens  to  ques- 
tions, and  answers  them  after  a slight  pause  intelligently.  The  questions,  however, 
require  only  monosyllabic  answers.  He  says  little,  and  his  thoughts  are  apparently 
few.  Special  senses  normal.  The  pupils  are  unusually  dilated,  but  contract  on 
stimulus  of  light;  are  equal  and  parallel.  No  paralysis  of  the  muscles  of  the  face  or 
tongue.  Marked  tenderness  over  dorsal,  and  still  more  over  lumbar  vertebrae.  Never 
had  tingling  or  numbness  of  the  extremities.  All  attempts  to  walk  cause  great  pain 
in  the  back,  to  such  a degree  that  he  cries  out.  Great  atrophy  of  the  muscles  ; he 
moves  very  little ; lies  often  in  a cramped  position ; cannot  rise  up  in  bed  without 
assistance.  The  tongue  is  clean ; the  appetite  is  reported  to  be  good  ; but  he  fre* 
queutly  vomits,  sometimes  immediately  after  a meal,  sometimes  an  hour  or  two  after- 
wards. No  increase  in  hepatic  or  splenic  dulness ; abdomen  appears  natural,  except 
in  being  retracted  and  emaciated ; the  bowels  are  habitually  costive.  He  has  at  pre- 
sent no  cough,  sputum,  nor  dyspnoea.  The  respiratory  murmurs  appear  healthy ; the 
cardiac  sounds  are  natural.  Pulse  82,  small  and  weak.  The  urine  is  passed  involun- 
tarily during  sleep,  but  voluntarily  during  the  day.  It  is  of  a light  straw  color, 
sp.  gr.  1005 ; contains  no  albumen  but  abundant  chlorides.  Is  ordered  nutritive 
food,  with  laxative  pills,  and,  if  necessary,  eaemata. 

Progress  of  the  Case. — July  Uh. — Is  growing  weaker;  pulse  96,  small  and 
wiry ; has  a headache,  chiefly  over  the  occipital  region.  July  %th. — The  pain  in  his 
liead  continuing,  the  hair  is  shaved  ; cold  cloths  are  applied  to  the  scalp,  and  a blister 
Vi  put  over  the  nape  of  the  neck.  July  \0th. — Pulse  104,  very  weak;  hot  skin; 
g^'eit  thirst;  little  appetite,  and  frequent  vomiting,  usually  some  time  after  taking 
food.  Is  ordered  a saline  mixture,  and  four  ounces  of  port  wine  daily.  July  12//i. — 


* Reported  by  Mr.  John  R.  Murray,  Clinical  Clerk. 


422 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


On  re-examination,  besides  the  atrophy  common  to  both  lower  cxtrcn  itics,  there 
appears  to  be  almost  total  want  of  sensibility  and  motion  in  the  right  kg;  the  left 
leg  being,  for  one  so  emaciated,  quite  normal.  Pupils  continue  widely  dilated ; there 
is  no  headache  at  present.  July  lAth. — Is  able  to  move  the  right  leg  slightly,  and 
feels  irritants  applied  to  the  sole  of  the  foot,  but  not  to  the  limb  generally.  Again 

complains  of  pain  ditfused  over  the  whole  occiput;  pulse  112,  weak.  July  

Complains  of  his  vision  becoming  impaired;  can  recognise  objects,  and  name  their 
number.  Had  an  evacuation  yesterday  morning,  and  for  two  days  has  not  vomited 
so  much  as  formerly.  Has  headache,  but  it  does  not  seem  severe ; the  application  of 
cold  has  been  continued.  July  \Uh. — Pulse  148,  small,  weak,  and  hard.  Respira' 
tion  22  per  minute.  Ordered  two  additional  ounces  of  wine ; continue  oiutrienis. 
July  ‘list. — Vomiting  recurred  yesterday,  after  being  nearly  absent  for  a week;  is 
observed  to  recur  when  the  bowels  have  been  much  confined,  and  to  disappear  after 
copious  evacuation.  Ordered  two  pills,  and,  if  necessary,  an  injection.  Jtdy  29^/n — 
\ omited  less  after  operation  of  the  laxatives ; is  extremely  weak,  but  little  change 
can  be  noticed  from  day  to  day.  July  30/A. — This  miOrning  he  ivas  found  more  ex- 
hausted ; a cold  sweat  over  the  whole  surface ; the  respirations  short  and  hurried ; 
the  pulse  extremely  feeble,  cardiac  impulse  at  apex  increased.  Wine  was  freely  given, 
but  he  sank,  and  finally  expired  at  2.30  p.m. 

Sectio  Cadaveris. — Forty-eight  hours  after  death. 

Body  moderately  emaciated. 

Head. — On  removing  the  dura  mater,  the  surfaces  of  the  hemispheres  were 
unusually  smooth,  from  flattening  of  the  convolutions.  The  vascularity  of  the 
membranes  was  normal.  On  slicing  the  brain  it  was  seen  to  be  studded  throughout 
with  nodules  varying  in  size  from  a hemp-seed  to  that  of  a large  hazel-nut.  They 
were  of  a grey,  pinkish  color — the  smaller  of  pulpy  consistency,  ihe  larger  more  firm, 
amd  all  capable  of  being  easily  enucleated  from  the  surrounding  brain  substance. 
None  of  them  projected  from  the  surface,  but  they  were  irregularly  distributed,  some 
in  the  grey,  but  most  in  the  white  matter.  Here  and  there  was  slight  softening 
round  some  of  the  masses,  but  there  was  no  extravasation  of  blood.  In  the  right 
hemisphere,  projecting  a little  through  the  roof  of  the  ventricle,  was  a mass  the  size 
of  an  ordinary  marble.  In  the  roof  of  the  left  ventricle  was  another  of  similar  dimen- 
sions. The  left  corpus  striatum  contained  two  of  these  bodies,  one  the  size  of  a small 
cherry,  situated  anteriorly ; another  that  of  a pea,  somewhat  more  posteriorly. 
Around  these  was  no  softening.  The  optic  thalami  were  normal.  Similar  bodies  were 
scattered  through  the  cerebellum,  but  there  were  none  in  the  pons  varolii  and  medulla 
oblongata.  Each  lateral  ventricle  contained  almost  a drachm  and  a half  of  clear  fluid. 
On  removing  any  of  these  bodies,  there  could  readily  be  squeezed  from  them  a creamy 
matter,  leaving  behind  an  apparently  membranous  substance  evidently  very  vascular. 

Spinal  Column. — The  four  upper  dorsal,  and  two  or  three  of  the  lower  dorsal,  and 
the  first  lumbar  vertebrae,  were  soft  and  spongy,  the  osseous  substance  yielding  on  pres- 
sure a copious,  thick,  greyish  juice.  The  membranes  of  the  cord  were  healthy.  On  bi- 
secting the  cord,  a mass  the  size  of  a pea,  exactly  similar  to  those  observed  in  the  brain, 
was  found  in  its  right  half,  opposite  the  junction  of  the  second  and  third  dorsal  vertebrae. 

Chest. — About  the  centre  of  the  sternum  was  a slight  bulging,  of  reddish  color 
and  soft  consistence,  yielding  a dirty  yellow  colored  cancerous  juice  on  pressure. 
Similar  soft  enlargements  were  found  in  the  anterior  portions  of  the  third  and  fourth 
left  ribs.  The  lower  lobe  of  right  lung  contained  an  infiltrated  indurated  mass, 
about  the  size  of  the  fist,  in  some  places  of  a yellow  brown,  and  in  others  of  a dirty 
grey  color.  Some  bronchial  glands  cancerous.  Other  thoracic  organs  healthy. 

Abdomen. — Liver  contained  small,  rounded,  dirty  white  masses,  principally  at  its 
circumference,  varying  in  size  from  a small  pea  to  that  of  a horse  bean,  and  not  pro- 
jecting from  its  surface.  Some  of  the  gastro-colic  glands  were  enlarged  and  cancerous. 
Other  abdominal  organs  healthy. 

Muscular  System,  wherever  examined,  and  especially  in  the  inferior  extremities, 
was  atrophied,  but  presented  its  normal  color. 

Microscopic  Examination. — The  various  encephaloid  masses  scattered  through- 
out the  brain,  consisted  of  a vascular  stroma,  and  a thick  creamy  juice.  A drop  of 
the  latter  contained  numerous  cancer  cells  in  all  stages  of  development,  as  repre- 
sented Fig.  277,  p.  215.  The  stroma  of  the  small  masses  consisted  of  a plexus  of 
vessels  of  various  sizes,  crossing  and  inosculating  with  one  another,  many  forming 
loops  which  were  enlarged  and  crowded  with  blood  corpuscles  as  in  Fig.  151.  In  the 


CANCEK  OE  THE  BRAIN. 


423 


larger  masses  the  vessels  had  undergone  development,  by  pushing  out  from  their 
sides  prolongations,  which,  subsequently  uniting,  formed  a plexus  (as  seen  in  Fig.  • 
302).  During  this  process,  however,  another  change  had  occurred,  viz.,  an  in- 
vestment of  these  prolongations,  which  often  assumed  the  form  of  acini  in  a gland, 
with  a distinct  membrane,  in  the  interior  of  which  was  a vascular  loop.  It  re- 
sulted that  whilst  some  part  of  these  masses  contained  a vascular  plexus,  with 
numerous  cancer  cells  in  a mesh- work,  in  others  it  exhibited  a structure,  now 


. Fig.  412.  Fig.  413. 

villous,  and  now  approaching  towards  that  of  a gland  (Figs.  392,  893).  This  was 
evidently  the  “ Cancer  Stromata,”  so  well  described  by  Rokitanski,  in  some  forms  of 
encephaloma.  The  small  cancerous  nodule  in  the  spinal  cord  presented  the  same 
structure  as  those  in  the  brain.  For  the  most  part  the  nervous  substance  surround- 
ing these  masses  was  quite  healthy ; but  here  and  there,  in  their  immediate  neighbor- 
hood, it  contained  a few  granule  cells.  The  cancer  of  the  lungs  and  bones  presented 
the  usual  structure  of  encephaloma  in  those  organs. 

Commentary. — The  occurrence  of  cancer  in  the  brain  is  exceedingly 
rare ; and  the  form  of  it  above  described  was  seen  by  me  for  the  first 
time,  and  examined  with  the  greatest  care.  Its  structure  histologically 
was  very  interesting,  and  contrasted  in  some  remarkable  particulars 
with  another  well-observed  case  recorded  by  Dr.  Redfern  of  Aberdeen,^ 
in  which  the  stroma  consisted  wholly  of  shreds  of  cell  membranes  and 
granules.  Before  death,  there  were  manifested  both  a cerebral  and 
spinal  disease.  The  former  occasioned  a peculiar  perversion  of  the 
mind,  consisting  of  a certain  confusion  of  thought  and  incapability  of 
carrying  on  ideas,  whilst  he  answered  questions  readily  and  appeared 
perfectly  conscious.  Theoretically  this  is  readily  explained  by  the 
numerous  circumscribed  cancerous  masses  which  may  easily  be  supposed 
to  have  disturbed  that  continuity  of  transmission  along  the  tubes  so 
essential  to  vigor  of  mind.  The  spinal  disease  was  indicated  by  local 
pain  and  incapability  of  supporting  himself  erect,  symptoms  attributable 
* Monthly  Journal  of  Medical  Science,  December  1850. 

Fig.  412.  Peculiar  vascular  stroma  with  villi  in  the  larger  cancerous  masses  of  the 
brain,  acetic  acid  being  added.  The  interstices  were  crowded  with  cancer  cells. 

Fig.  413.  Gland-hke  expansions  of  stroma  in  other  portions  of  the  same  mass.  80  di. 


424 


DISEASES  OF  THE  NEKVOUS  SYSTEM. 


to  the  osseous  disease  and  weakness.  The  paralysis  of  the  right  lower 
extremity  may  be  owing  to  the  nodule  of  cancer  in  the  spinal  cord 
opposite  the  dorsal  vertebrae;  but  this  is  by  no  means  certain.  There 
was  some  difficulty  in  determining  whether  the  indisposition  to  walk 
and  powerlessness  was  owing  to  a^^rophy  of  the  limbs  or  to  a true 
paralysis.  I am  disposed  to  think  that  both  causes  co-operated. 

DROPSY  OF  THE  BRAIN. 

Case  XXXI.'^ — Chronic  Hydrocephalus — Paracentesis  Capitis — No 

Benefit. 

History. — Esther  Little,  ret.  17  months,  was  admitted  June  27,  1857.  Her  birth 
was  natural,  and  nothing  peculiar  in  the  size  or  shape  of  her  head  was  then  ob- 
served. For  two  months  her  health  was  perfect;  she  then  had  convulsions,  vomit- 
ing, and  strabismus ; her  appetite  diminished ; her  abdomen  swelled,  and  there 
were  frequent  green  slimy  stools.  She  was  under  medical  treatment  for  nine  weeks, 
when  she  began  to  improve,  and  from  that  time  her  mother  has  noticed  no  deficiency 
ill  her  appetite.  When  five  months  old  a swelling  appeared  on  left  side  of  neck ; it 
was  lanced,  and  soon  afterwards  healed.  But  about  this  time  also — twelve  months 
c-go — the  size  of  the  head  attracted  the  attention  of  her  parents ; and  from  that  day, 
up  to  admission,  it  has  been  gradually  increasing.  The  child  is  thought  by  her 
parents  to  feel  no  pain  in  her  head,  but  only  inconvenience  from  its  weight.  She 
lias  not  suffered  from  dentition,  and  has  now  cut  ten  teeth.  She  has  not  yet  been 
weaned. 

^ Symptoms  on  Admission. — The  child  is  not  emaciated,  the  arms,  legs,  and  body 
being  well  nourished;  it  often  smiles,  but  the  smile  is  readily  converted  into  a 
querulous  cry.  It  is  fretful  on  the  slightest  change  in  the  position  of  its  head, 
which  is  too  heavy  for  it  to  support.  The  head  is  of  an  irregularly  square  shape, 
the  left  side  appearing  to  bulge  posteriorly  a little  more  than  the  right.  The 
anterior  fontanelle,  4 inches  broad,  and  9 inches  at  its  greatest  length,  gives  a 
distinct  sense  of  fluctuation,  being  at  the  same  time  tense.  The  veins  are  seen 
with  unusual  distinctness  coursing  over  the  head.  There  are  laminated  scabs  of 
chronic  eczema  over  the  scalp.  The  forehead  is  projecting.  The  eyes  appear  to 


Fig.  414.  Fig.  415.  Fig.  416. 

protrude  against  the  inferior  eyelids,  which  cover  the  greater  part  of  their  sur- 
face. The  upper  lids  are  retracted  slightly,  and  leave  the  sclerotic  exposed.  The 
lids  are  somewhat  red.  There  is  no  strabismus ; there  is  intolerance  of  strong 

* Reported  by  Mr.  W.  Guy,  Clinical  Clerk. 

Figs.  414  to  416.  Lateral,  vertical,  and  front  views  of  the  head  of  Esther  Little. 
In  consequence  of  the  well-nourished  face  and  limbs,  the  drawing  does  not  convey  to 
others  an  idea  of  the  comparative  size  of  the  head  so  well  as  usually  occurs  in  these 
cases. 


DROPSY  OF  THE  BRAIN. 


425 


light.  The  features  of  the  face  are  well-proportioned,  and  the  cheeks  bear  a good 
deal  of  color.  The  measurements  of  the  head  were  found  to  be  24  inches  at  the 
greatest  circumference  (the  girth  on  the  left  side  being  12^),  15  inches  across  the 
head  from  ear  to  ear,  and  16  inches  from  the  frontal  sinus  to  the  occipital  pro- 
tuberance. On  examination,  the  cardiac  sounds  are  healthy,  and  the  respiratory 
murmurs  are  natural.  The  tongue  is  moist  and  clean.  The  appetite  is  reported 
good.  The  child  is  not  yet  weaned,  and  is  often  at  the  breast;  it,  however,  also 
gets  milk,  beef-tea,  and  bread.  Its  bowels  are  reported  to  be  regular.  The  urine 
is  passed  in  good  quantity,  but  none  has  been  obtained  for  examination.  The  mother 
has  five  living  healthy  children. 

Progress  op  the  Case. — The  hair  being  clipped  close,  the  tincture  of  iodine 
had  been  painted  over  the  scalp.  July  Uh. — To-day,  about  1 p.m.,  tapping  was 
performed  by  Mr.  Syme.  A small  trochar  being  introduced  to  the  depth  of  about 
one  inch  behind  the  posterior  edge  of  the  right  os  frontis,  one  inch  to  the  right  of 
the  mesial  line,  five  ounces  of  fluid  were  withdrawn.  A compress  was  then  applied 
over  the  puncture  and  secured  by  strapping.  Slips  of  diachylon  plaster  were  also 
applied  from  side  to  side  and  obliquely,  to  effect  gentle  compression,  and  support 
was  further  given  by  a bandage  passed  round  and  across  the  head.  There  was  very 
little  crying  on  the  part  of  the  child.  The  fluid  was  clear  as  water ; alkaline ; sp. 
gr.  1009 ; depositing  slowly,  after  being  heated  and  acidified,  a slight  amount  of 
albumen,  and  giving  also  (under  action  of  sol.  sulph.  cupri,  aqua  potassae  and  heat) 
a trace  of  grape  sugar.  July  IWi. — Since  the  operation  there  have  been  no  symp- 
toms of  nervous  excitement  or  derangement.  On  measurement  of  head  to-day,  was 
found  to  be  the  same  size  as  on  admission.  July  IMh. — Yesterday,  on  again 
measuring  the  head,  the  same  results  were  obtained.  To-day,  Mr.  Syme  again  per- 
formed paracentesis,  removing  twelve  ounces,  the  puncture  being  made  on  the  left 
side  at  a point  corresponding  to  the  previous  one  on  the  right;  the  fluid  exactly 
resembled  that  formerly  drawn,  but  did  not  give  the  grape-sugar  re-action.  The 
head  was  gently  compressed  while  the  fluid  was  flowing  through  the  tube,  and 
until,  by  means  of  strapping  and  bandage,  equable  pressure  was  applied  to  the 
cranium.  The  scalp  was  collapsed  and  puckered  after  the  operation,  and  the  bony 
margins  of  the  fontanelle  had  considerably  approached  one  another.  July  lUh. — 
Child  has  been  more  fretful ; has  passed  less  water : ordered  ten  drops  of  sp.  ether 
nitrici  thrice  a day.  July  Vith. — The  urine  has  increased  in  amount.  The  child  has 
recovered  its  usual  health.  July  21s^. — To-day,  the  seventh  since  the  operation,  the 
bandages  were  removed ; the  coronal  region  felt  full,  and  on  measurement,  the  same 
numbers  were  obtained.  July  24^A. — Paracentesis  was  again  performed ; twelve 
ounces  were  removed,  the  fluid  being  faintly  yellow;  1008  sp.  gr.,  and  otherwise 
identical  in  character  with  the  fluid  formerly  withdrawn.  At  close  of  the  opera- 
tion rigors  occurred,  and  the  child  looked  pallid  and  faint.  It  was  revived  by 
wine  and  warmth;  it  partially  vomited  the  wine;  it  was  then  kept  at  the  breast, 
and  by  the  evening  it  had  regained  its  usual  aspect.  July  2^th. — The  urine  again 
scanty;  slept  well  last  night;  is  exceedingly  fretful,  and  does  not  incline  to  the 
breast.  July  2&th. — The  fontanelle  is  again  tense ; urine  still  scanty ; did  not  sleep 
well  last  night.  July  'ijth. — Slept  better;  urine  slightly  increased,  but  none  can 
be  obtained  for  examination.  Judy  2>%th. — Again  slept  better ; appetite  is  returning ; 
the  child  is  very  fretful;  but  otherwise  has  no  unusual  symptom.  The  mother  is 
anxious  to  return  home,  and  a fourth  paracentesis  is  not  deemed  advisable.  The 
head  was  again  measured,  and  found  to  be  of  the  very  same  size  as  on  admissiom 
Discharged,  July  28^/i,  1857. 

Chemical  Examination  by  Mr,  Turner  of  the  fluid  removed. 

The  fluid  was  especially  examined  with  reference  to  the  question  whether  it  pos- 
sessed the  power  of  deoxidising  the  blue  hydrated  oxide  of  copper  like  grape-sugar. 
This  property  was  possessed  by  the  first  specimen,  the  reduction  to  the  state  of  sub- 
oxide taking  place  after  boiling  for  a few  minutes.  No  such  re-action  could,  however, 
be  obtained  from  the  second  portion,  although  the  experiment  was  tried  several 
times,  both  with  the  fluid  as  received,  and  also  with  it  after  it  had  been  considerably 
concentrated  by  evaporation.  The  third  specimen,  however,  exhibited  the  re  action 
in  a more  decided  manner  than  the  first.  All  three  specimens  contained  albumen 
in  small  quantity.  Heat  and  nitric  acid  causing  it  to  fall  down  as  a white  flocculent 
precipitate.  The  following  inorganic  constituents  were  also  found  in  the  fluid  in 
minute  quantities : — Chloride  of  sodium,  phosphoric  acid,  lime  and  magnesia. 


426 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Commentary. — The  history  of  this  case  indicates  that,  two  months 
after  birth,  the  child  had  probably  an  attack  of  acute  meningitis  at  the 
base,  from  which  she  recovered.  From  this  period  dates  the  commence- 
ment of  the  hydrocephalus,  a circumstance  which  induced  me  to  suppose 
that  the  chronic  exudation  had  in  some  manner  compressed  the  blood- 
vessels, and  caused  dropsy.  I have  previously  pointed  out  that  such  is 
the  pathology  of  effusion  following  acute  meningitis  (p.  372),  and  there 
is  every  reason  to  suppose,  that  such  is  the  explanation  of  the  slow 
accumulation  of  fluid  in  the  present  case.  With  the  exception  of  the 
cerebral  disease,  there  was  no  other  malady.  So  far  as  1 could  discover, 
there  was  especially  no  tubercular  complication,  which  is  generally  so 
much  to  be  dreaded  in  these  cases,  and  all  the  functions  were  performed 
naturally.  On  the  other  hand,  the  mother  assured  me  that  the  head 
was  daily  enlarging,  and  it  was  clear  that,  under  no  circumstances,  if 
left  to  nature,  would  the  child’s  existence  be  an  enviable  one.  Under 
these  circumstances  I determined  to  try  the  effect  of  cautiously  removing 
the  fluid,  and  seeing  whether  the  cause  producing  the  effusion  might  not 
have  ceased  to  operate,  when  assisted  by  diminished  pressure.  The  first 
five  ounces  of  fluid  removed,  produced  no  disturbance  in  the  child  what- 
ever, and,  encouraged  by  this  circumstance,  on  the  next  occasion  twelve 
ounces  were  taken  away.  On  this  occasion  the  head  was  greatly 
diminished,  and  the  scalp  considerably  corrugated  immediately  after  the 
operation.  The  head  subsequently  was  carefully  covered  with  strips  of 
adhesive  plaster  in  the  manner  recommended  by  Mr.  Barnard,  and  the 
whole  supported  by  bandaging.  For  a few  days  afterwards,  the  child 
exhibited  somewhat  more  restlessness,  soon  followed  by  a little  unusual 
stupor.  This  I attributed  to  a re-accumulation  of  the  fluid.  On  re- 
moving the  bandages  the  head  was  found  to  be  of  the  same  size  as  on 
admission.  Subsequently  the  scalp  became  very  tense,  and  another 
twelve  ounces  were  removed,  followed  by  bandaging.  On  this  occasion, 
however,  the  operation  was  followed  by  a rigor,  but  the  child  speedily 
recovered.  The  mother  next  day  informed  me  that  on  this,  as  on  the 
preceding  occasion,  the  urine  was  diminished,  although  I had  endeav- 
ored to  meet  the  possibility  of  this  occurrence  by  the  exhibition  of 
nitric  ether.  This  circumstance,  therefore,  convinced  me  that  no  benefit 
was  to  be  anticipated  from  continuing  the  tappings,  and  the  mother  and 
child  consequently  returned  home.  I have  since  heard  from  Dr. 
Anderson  of  Selkirk,  that,  a few  days  after  returning  to  that  town,  the 
child  died,  but  as  he  was  unfortunately  absent  at  the  time,  he  did  not 
see  her,  and  she  was  buried  before  his  return.  From  an  account  fur- 
nished by  the  parents  of  the  symptoms  which  preceded  death,  it  appears 
that  there  was  no  vomiting,  unusual  restlessness,  strabismus,  convulsions, 
paralysis,  nor  coma.  But  there  was  great  pallor,  disinclination  to  take 
food,  and  exhaustion.  Had  she  remained  in  the  Infirmary,  these  symp- 
toins,  and  the  fatal  results,  might  have  been  delayed  by  the  judicious 
administration  of  nutrients  and  stimulants. 

The  most  satisfactory  proof  of  the  occasional  benefit  of  tapping  the 
head  in  cases  of  chronic  hydrocephalus,  is  to  be  found  in  the  paper  of 
Dr.  Conquest,^'  who  at  that  time  had  operated  in  nineteen  cases,  and  in 
ten  of  these  successfully.  He  tells  us  that  ‘‘  all  the  operations  were 

* Lancet,  vol.  i.  1837-38,  p.  890. 


STEUCTUR.UL  DISEASES  OF  THE  SPINAL  CORD. 


427 


performed  in  the  presence  of  many  medical  gentlemen,  and  most  of 
them  before  large  bodies  of  students  at  St.  Bartholomew’s  Hospital.” 
One  of  these  cases,  that  of  Catherine  Seager,  in  its  general  details  was 
very  like  the  one  now  under  observation.  Two  pints  of  fluid  were 
removed  by  the  operation,  followed  by  a convulsion.  Yet  she  was 
seen  by  Dr.  Conquest,  two  years  and  a half  afterwards,  perfectly  well, 
and  in  complete  possession  of  all  her  intellectual  faculties.  With  such 
facts  before  us,  it  is  clear  that  the  operation  is  warrantable  when,  from  an 
absence  of  complication,  there  is  a reasonable  hope  of  success,  as  existed 
in  the  present  case. 

Should  another  case  present  itself  to  me,  I would  allow  a longer  time 
to  elapse  between  the  tappings.  With  this  exception,  I do  not  know,  on 
a retrospective  view  of  all  the  circumstances,  that  there  was  any  point 
in  its  treatment  that  required  modification.  It  would  be  a matter  of 
great  practical  importance  to  determine,  whether,  as  a rule,  evacuations 
of  the  fluid  are  as  useful  in  advancing  as  in  stationary  cases  of  chronic 
hydrocephalus.  It  is  probable  that  the  good  effects  described  by  Dr. 
Conquest  were  obtained  in  the  latter  kind  of  cases. 

8TRUCTUIIAL  DISEASES  OF  THE  SPINAL  COBD. 

Case  XXXII. — Otorrhcea — ISudden  Lumhar  and  Cervical  Pams— Convul- 
sions— Spinal  Meningitis. 

History. — Martha  Bell,  aet.  19,  servant — admitted  on  the  evening  of  May  29th, 
1863.  She  has  since  childhood  suffered  from  otorrhcea  and  occasional  pains  in  the 
right  ear,  but  in  all  other  respects  has  been  healthy.  After  her  last  menstruation, 
which  terminated  on  the  21st,  the  ear  became  more  painful  than  usual,  and  there 
was  an  increased  discharge  from  it.  The  symptoms  were  followed  by  languor  and 
disinclination  for  work.  On  the  morning  of  the  24th  there  was  nausea,  and  in  the 
evening  vomiting.  During  the  next  two  days  the  vomiting  returned  frequently  at 
irregular  intervals,  the  matters  rendered  being  tinged  with  bile.  On  the  27th  she 
experienced  severe  pains  in  the  neck  and  in  the  lumbar  region,  and  in  the  evening 
there  was  a rigor  followed  by  febrile  symptoms,  which  have  continued  since. 

Symptoms. — May  ZOth. — There  is  no  headache,  but  she  complains  of  severe  pain 
in  the  back  of  the  neck  and  across  the  lumbar  region,  which  is  not  increased  on  pres- 
sure. Intelligence,  sensation,  and  motion  normal ; the  tongue  is  slightly  furred  ; no 
pain  or  swelling  ; no  appetite,  great  thirst ; severe  nausea  , slight  abdominal  tenderness ; 
constipation,  the  bowels  not  having  been  relieved  since  the  24th  ; pulse  120,  of  mode- 
rate strength ; respiration  hurried ; urine  loaded  with  urates  ; a purulent  fluid  flows 
from  the  right  ear,  unaccompanied  by  pain  even  on  pressure ; skin  hot  and  dry ; a warm 
poultice  to  he  applied  to  the  right  ear  and  a domestic  enema  to  he  administered.  May 
31s^. — Passed  a restless  night.  There  has  been  no  recurrence  of  vomiting  although 
she  has  taken  food  tolerably  well.  There  is  still,  however,  nausea,  with  frequent  ex- 
pectoration of  saliva;  pulse  120,  weak, ; bowels  not  relieved  ; great  pains  and  rigidity 
in  the  muscles  of  the  neck.  To  have  §j  of  01.  Ricini.  June  Is^. — Last  night  her 
agony  was  so  great  that  a draught  was  ordered  containing  M.  xv.  of  Sol.  Mur.  Morph, 
and  of  Chlorodyne.  At  midnight,  though  quite  sensible,  she  became  very  restless, 
frequently  endeavoring  to  get  out  of  bed.  During  the  previous  afternoon  the  pain  in 
the  side  and  back  had  considerably  increased.  During  the  night  the  bowels  were 
opened  twice  but  without  giving  her  relief.  On  both  occasions  she  rose  from  bed  to 
go  to  stool.  Towards  morning  the  patient  became  more  quiet,  but  took  her  breakfast 
readily.  At  the  visit  she  was  found  insensible,  lying  on  the  back,  head  resting  on  left 
side,  both  arms  twitching  convulsively,  with  slight  interrupted  moaning.  Skin  hot 
and  covered  with  perspiration.  Pulse  160,  small  and  weak.  No  rigidity  of  muscles 
of  neck.  About  half  past  one  p.m.  a louil  mucous  rattle  was  heard  in  the  throat 
Dyspnoea  came  on,  and  she  died  at  half  past  two  p.m. 

Sectio  Cadaveris. — Twenty-four  hours  after  death. 

The  body  was  well  nourished. 


428 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Head  and  Spinal  Cord. — The  cerebral  membranes  were  congested.  Their  surface 
was  somewhat  dry.  At  the  base  of  the  cranium  there  was  an  abundant  foimation  of 
pus  between  the  arachnoid  and  pia  mater,  reaching  as  far  forwards  as  the  optic  nerves 
and  backwards  over  the  pons  and  medulla  oblongata.  It  extended  to  the  lower  end 
of  the  cord,  but  existed  only  posteriorly  as  far  down  as  the  third  dorsal  vertebra. 
Below  that  point  it  surrounded  the  whole  organ,  and  was  more  dense.  There  was  no 
change  to  be  observed  in  the  substance  of  the  brain  or  the  cord. 

Other  organs  normal. 

Commentary. — This  was  a characteristic  case  of  acute  spiral  meniu- 
gitis,  in  which  both  the  cranial  and  vertebral  portions  of  the  cord  were 
alfected.  It  will  be  observed,  that  with  fever  there  was  no  hcacache, 
but  considerable  nausea  and  vomiting,  pain  and  stiffness  in  the  neck, 
which  extended  to  the  back.  The  pain  in  the  latter  situation  became 
intolerable,  without  paralysis  or  any  symptom  of  mj^elitis.  Lastly,  con- 
vulsions and  death.  The  fatality  of  this  formidable  affection  is  in  pro- 
portion to  the  amount  of  the  cord  involved.  Its  treatment  should  consist 
in  rest,  supporting  the  strength  to  enable  the  pus  to  be  absorbed,  and 
applying  local  warmth  to  relieve  pain.  In  the  early  stage,  local  cold  or 
the  application  of  ice  may  be  supposed  to  be  effective,  but  then  the  symp- 
toms so  closely  resemble  those  of  acute  rheumatism,  that  the  disease  is 
seldom  detected. 

Case  XXXIII.* — Acute  Myelitis  in  the  Cervical  portion  of  the  Cord — 
General  pains  resemhliny  those  of  Rheumatism — Fugitive  Paralysis  in 
the  arms  and  legs — Engorgement  of  the  Lungs — Peath. 

History. — Duncan  M’Lean,  mt.  27,  a laborer,  married — admitted  November  1st, 
1858.  Patient  states  that  on  the  19th  October  he  was  driving  cattle,  and  got  wet 
through.  Having  been  engaged  all  that  night,  he  did  not  change  his  wet  clothes,  but 
drunk  a good  deal  of  whisky.  On  the  following  day  he  went  into  a laihvay  carriage 
while  perspiring  profusely,  fell  asleep,  and  felt  cold  and  stiff  when  he  aw  eke.  Ee  went 
home,  changed  his  clothes,  and  remained  well  until  the  morning  of  the  26lh,  when  he 
experienced  pain  in  the  calves  of  the  legs  as  he  walked  to  his  work.  This  became 
more  severe  during  the  week,  and  extended  upwards  to  the  muscles  of  the  thigh,  and 
thence  to  the  intercostals,  and  to  the  muscles  of  the  shoulder,  arm,  and  k w er  jaw. 
When  he  sat  or  stood  at  rest,  the  pain  was  scarcely  felt,  but  it  was  exciucialirg  duiing 
motion  or  when  firm  pressure  was  made  on  the  affected  muscles.  On  the  £0th  October, 
when  standing  in  the  street — the  evening  being  cold — the  pain  became  exceedingly 
severe,  so  as  to  compel  him  to  return  home.  He  had  at  that  time  also  a sensaticn  cf 
stiffness  over  the  body.  He  remained  in  this  state  till  November  1st,  when  as  he  was 
coming  down  stairs  on  his  way  to  the  Infirmary,  his  strength  failed  him,  and  he  had 
to  be  conveyed  in  a cab. 

Symptoms  on  Admission. — Pulse  70,  of  good  strength.  Eespiraticnnoimal.  Eas 
a slight  cough.  Complains  of  pain  in  almost  all  the  muscles  of  the  body,  and  this  is 
greatly  aggravated  by  pressure  or  movement.  Bending  the  joints  only  causes  ] ain  in 
the  muscles.  He  cannot  put  his  tongue  far  out  on  account  of  the  pain  on  epenirg 
his  jaw.  It  is  slightly  furred,  dark  in  the  centre,  and  trembles  constantly.  Con  plains 
of  great  pain  at  the  back  of  his  throat  in  the  act  of  deglutition.  Appetite  almost 
gone;  considerable  thirst ; bowels  costive.  Urine  strongly  acid — otheiw ise  non  al. 
'J’he  skin  feels  rather  warmer  than  natural,  and  he  sweats  much  at  night.  Le  vos 
ordered  half  drachm  doses  of  bicarbonate  of  potash  thrice  daily,  dissolved  in  j ovr  ovnas 
of  water. 

Progress  of  the  Case. — November  Ath. — The  pains  still  continue  as  severe  as  ever. 
Otherwise  much  in  the  same  state  as  w^hen  he  entered  the  house.  1^  Spt.  Aih.  A 'Arid 
3 ij  ; Aq.  Acet.  Ammon.  3 ij  ; Aqnce  ad  3 iv,  ft.  mist.  A tablespoonful  to  be  ioten 
every  four  hours.  Nov.  &th. — He  speaks  thick,  as  if  his  tongue  were  paialvscd.  Eas 
scarcely  slept  since  he  came  into  the  hospital.  Unable  to  move  his  hands  or  feet. 
He  cannot  shut  his  eyes  fully,  the  left  being  uncovered  when  he  tries  to  do  so,  to  the 

^ Reported  by  Mr.  T.  S.  Clouston,  Clinical  Clerk. 


STEUCTURAL  DISEASES  OF  THE  SPINAL  CORD. 


429 


extent  of  one-eighth  of  an  inch,  and  the  eyes  are  suffused  and  lachrymating.  He  has 
great  thirst,  and  chewing  and  swallowing  are  performed  with  difficulty.  Has  had  reten- 
tion of  urine  for  two  days,  and  required  the  use  of  a catheter.  Retention  has  now  ceased. 
He  passed  his  stools  in  bed  to-day  when  in  a dozing  state.  November  ^th — Counte- 
nance anxious  and  depressed ; eyes  suffused ; pulse  120.  Cannot  move  right  arm  or 
either  leg.  He  has  the  sensation  of  pricking  with  pins  and  needles  in  the  feet,  but 
no  pain  in  any  part  of  the  spine,  except  at  the  back  of  the  neck.  Great  pain  in  tlie 
temporal  region.  Ordered  to  he  cupped  to  the  extent  of  five  ounces  over  the  hack  of  the 
neck^  the  glasses  to  he  applied  along  the  middle  line.  Tinct.  Hgoscyam.  m.  x. 
Aqica  5 j ; //.  haustus,  hora  somni  swnendus.  Nov.  8lh. — Passed  a restless  night. 
Three  glasses  were  applied,  but  only  half  an  ounce  of  blood  extracted.  He  is  not  in 
the  least  relieved.  Complains  to-day  of  a constriction  round  his  chest,  a little  below 
the  level  of  the  nipples.  Eyes  no  longer  suffused,  and  he  can  move  his  right  arm 
readily,  but  not  his  legs.  Tongue  coated  with  a dirty  fur,  pulse  110,  Sweats  a great 
deal  and  the  perspiration  has  a peculiar  mousy  odor.  Bowels  freely  moved  by  cas- 
tor oil.  Ordered  again  to  be  cupped  over  nape  of  neck  to  five  ounces.  Nov.  9^/t. — The 
amount  of  blood  ordered  was  drawn  by  cupping  without  producing  any  relief.  Com- 
plains of  great  pain  in  his  hands  and  feet,  which  had  kept  him  awake  during  the  night. 
The  right  arm  is  again  paralysed,  and  he  cannot  lift  it  from  his  chest.  The  left  arm 
is  now  in  the  same  condition.  B P'-dv.  Ipecac.  Comp.  gr.  x.  To  be  taken  at  bedtime., 
and  that  failing  to  induce  sleep,  to  have  25  minims  of  Sol.  Mur.  Morph.  Nov.  \0th. — 
No  change.  He  slept  for  two  hours  after  getting  the  morphia.  Ijf  ^P-  -TEth.  Nitrici 
3 ij  ; Potass.  Curb.  3 ij  ; Tinct.  Gent.  Co.  § vi ; Infus.  Gent.  Co.  3 v ; ft.  Mist.  Two 
table-spoonfuls  to  be  taken  thrice  daily.  Nov.  Wth. — Feels  the  sense  of  constriction  as 
if  tied  with  a cord  round  the  chest.  He  has  a cough,  but  cannot  expectorate  easily 
on  account  of  the  constriction.  Nov.  \"lth. — Cannot  cough  up  the  rather  viscid  ex- 
pectoration, which  produces  a gurgling  in  his  throat.  There  is  some  harshness  of 
inspiration.  He  can  move  his  arms  better  than  yesterday,  and  the  left  more  than  the 
right.  The  sensibility  of  the  soles  of  his  feet  is  much  diminished,  but  is  more  acute 
in  the  right  than  in  the  left.  Skin,  is  hot ; perspiration  copious.  Urine  is  alkaline 
to-day,  and  throws  down  a copious  deposit  of  phosphates.  Ordered  three  ounces  of 
wine  daily  and  3 ss  0/  Sol.  Mur.  Morph,  at  night.  Nov.  \oih. — Slept  very  little  on 
account  of  the  pain  in  his  legs,  toes,  and  heels.  Pulse  130,  rather  weak.  Feeling  of 
constriction  not  quite  so  troublesome  to-day  as  yesterday.  Appetite  quite  gone. 
Hot  fomentations  to  he  applied  to  the  feet  and  lower  part  of  the  leg,  which  failing  to 
give  relief,  they  are  to  be  painted  over  with  the  tinct.  of  aconite.  Nov.  id/A. — He 
became  much  worse  last  night,  and  to-day  his  face  is  pale  and  expressive  of  great 
suffering;  eyes  sunk,  and  he  can  scarcely  speak.  Respiration  very  quick  and  diffi- 
cult, and  he  is  constantly  pointing  to  his  breast  as  the  seat  of  pain.  Loud  mucous 
rattle  m the  throat ; marked  dulness  all  over  right  side  anteriorly ; feeble  respiration 
and  mucous  rattle  all  over  this  side.  Harsh  respiration  and  very  coarse  mucous 
rattle  all  over  left  side.  He  expectorates  pure  pus.  He  can  move  his  arms  more 
freely  than  yesterday,  and  now  also  his  legs  to  a limited  extent.  H tablespoonfid  of 
wine  every  two  hours.  Vespere. — Skin  covered  with  an  exceedingly  profuse  perspira- 

tion ; respiration  still  more  difficult  than  during  the  day ; pulse  quick  and  feeble ; 
almost  imperceptible.  Abdomen  very  much  distended  with  gas,  impeding  still  more 
the  labored  respiration.  Ordered  a foetid  enema.  Nov.  loth. — Has  ralhed  consider- 
ably to-day.  Respiration  much  easier;  abdomen  less  distended;  pulse  126,  and 
much  stronger ; expectoration  purulent  and  copious.  His  power  of  moving  the  legs 
is  greater  than  yesterday,  but  still  very  limited.  Crack-pot  sound,  and  a great  in- 
crease of  vocal  resonance  over  the  whole  chest  anteriorly.  On  account  of  the  pain 
the  attempt  gave  him,  and  his  weakness,  his  lungs  Could  not  be  examined  posteriorly. 
Urine  has  again  an  acid  reaction;  chlorides  much  diminished.  Nov.  IQth.  Yester- 
day evening  he  vomited  about  three  ounces  of  a thin  yellowish-green  fluid.  Sense 
of  constriction  of  chest  still  remains,  and  the  same  mucous  rales,  etc.,  as  formerly 
mentioned.  Pulse  120,  irregular.  Complains  of  a burning  in  his  throat ; iongue 
covered  with  a dirty-greyish  fur,  and  livid  at  the  tip ; feels  slight  nausea ; can  take 
no  solid  food,  but  only  wine  and  beef-tea.  Sleep  is  very  much  disturbf'd  by  pain  and 
a sensation  of  pricking  in  his  heels  and  ankle-joints,  and  this  is  but  little  relieved  by 
the  warm  opiate  fomentations  applied  over  those  parts.  Nov.  \lth. — Pain  in  his  heels 
not  relieved  by  aconite  or  warm  fomentations  with  opium.  It  distresses  him  exceed- 
ingly. Nov.  \%th.  Voluntary  motion  in  his  arms  is  now  almost  as  perfect  as  in  a 
healthy  individual,  but  is  limited  in  the  legs.  Pulse  130,  small ; sputum  very  copious 


430 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


and  purulent.  Nov.  \9th. — He  has  a depressed  and  pallid  look,  and  is  very  restless. 
Lips  and  tongue  livid;  pulse  1‘26,  weaker  than  yesterday.  Mucous  rattle  heard  all 
over  the  chest  anteriorly  ; respiration  heaving  and  quick  ; expectoration  diminished. 
Died  at  half-past  3 p.m. 

Sectio  Cadaveris. — Forty-seven  hours  after  death. 

Head. — Membranes  of  brain  rather  drier  than  usual,  but  nothing  abnormal  could 
be  detected  in  the  brain  or  its  nerves. 

Spinal  Cord. — Membranes  healthy,  but  on  slitting  up  the  cord,  its  substance  was 
found  to  be  slightly  softened  in  a space  about  an  inch  in  length,  at  the  level  of  the 
third  and  fourth  dorsal  vertebrte.  The  diseased  portion  of  the  cord  presented  its 
healthy  appearance  to  the  naked  eye,  but  the  softening,  though  apparent  to  the  touch, 
was  rendered  evident  by  the  flocculent  surface  produced  on  subjecting  the  section  to 
a slender  stream  of  water. 

Thorax. — The  right  lung  was  found  to  be  strongly  adherent  to  the  thoracic  wall, 
and  there  were  many  puckerings  at  its  apex.  The  anterior  edges  of  both  lungs  were 
emphysematous,  and  on  section,  were  found  to  be  of  a prune  juice  color,  congested 
and  dense  in  patches,  the  parts  between  being  still  crepitant.  This  condition  was 
most  marked  at  the  base  of  both  lungs,  especially  that  of  the  right.  The  bronchi 
contained  a large  quantity  of  pus,  the  mucous  membrane  being  congested,  and  of  a 
mahogany  color.  On  squeezing  a portion  of  the  lung-substance,  bloody  and  purulent 
matter  was  pressed  out.  All  the  other  organs  were  healthy. 

Microscopic  Examination. — The  softened  portion  of  the  cord  contained  some 
granular  exudation  with  a few  granule  cells.  Several  demonstrations  were  made  from 
other  parts  of  the  cord,  but  nothing  abnormal  was  found  in  them. 

Commentary. — Cases  of  acute  myelitis  are  rare,  and  are  almost 
uniformly  fatal.  In  the  present  instance  the  symptoms  commenced  with 
the  usual  signs  of  fever  and  of  general  muscular  rheumatism,  followed 
by  retention  of  urine  and  difficulty  of  deglutition.  The  insomnolence 
and  haggard  expression  of  countenance  led  us  to  fear  that  the  brain 
might  be  implicated;  but  the  total  absence  of  mental  confusion,  the  local 
pain  and  the  appearance  of  paralysis  in  the  arms,  at  once  indicated  the 
cervical  portion  of  the  cord  as  the  seat  of  the  disease.  The  fugitive 
character  of  the  paralysis  was  remarkable,  at  first  appearing  in  the 
right  arm  and  leg;  on  the  following  day  disappearing  in  the  arms,  then 
once  more  returning,  and  again  towards  the  close  of  the  case,  altogether 
disappearing  from  the  limbs.  This  must  have  been  dependent  on  the 
congestion,  which  was  more  intense  at  one  time  than  another,  and 
which  preceded  the  exudation.  The  sense  of  constriction  round  the 
chest  was  harassing,  and  latterly  the  lungs  became  engorged,  one  of 
the  most  common  complications  preceding  death  in  cases  of  myelitis 
at  the  upper  part  of  the  cord.  The  treatment  was  on  his  admission 
directed  to  combat  the  supposed  rheumatism,  at  first  with  alkaline  salts, 
and  secondly  with  Dover’s  powders.  As  soon  as  the  spinal  character 
of  the  disease  was  manifested,  anodynes  were  freely  given  with  cupping 
over  the  seat  of  pain  in  the  neck  as  a palliative.  But  it  is  to  be  ob- 
served that  none  of  these  remedies,  whether  internal  or  external,  gave 
him  the  slightest  relief.  The  disease  took  its  relentless  course,  and  life 
was  only  prolonged  by  assiduous  efforts  to  support  the  system  by  nutri- 
ents and  by  wine. 

Case  XXXIV.* — Slight  Paraplegia. — Recovery. 

History. — William  Maepherson,  ast.  33,  a blacksmith,  a very  muscular  and  appa- 
rently strong  man — admitted  June  1,  1853.  For  two  months  past  he  has  suffered 
from  pain  between  the  shoulders,  in  the  legs,  and  over  the  body  generally,  and  (jluring 
tae  last  three  weeks  he  has  been  very  weak,  frequently  feeling  as  if  the  arms  and  legs 

* Reported  by  Mr.  William  Calder,  Clinical  Clerk. 


STEUCTUEAL  DISEASES  OF  THE  SPINAL  COED. 


431 


were  benumbed.  He  has  been  an  intemperate  man,  but  never  had  delirium  tremens, 
paralysis,  or  other  disease  of  the  nervous  system. 

Symptoms  on  Admission. — There  is  no  tenderness  on  percussion  along  the  spinal 
column,  and  he  only  complains  of  pain  between  the  scapulee,  shooting  into  both 
shoulders,  increased  by  coughing  and  by  motion.  He  says  that  both  arms  are  very 
weak  and  benumbed,  and  that  they  often  tingle,  especially  when  he  coughs.  _ The 
arms  are  muscular,  but  the  grasp  he  takes  of  an  object  is  feeble,  wdiile  the  sensibility 
of  the  skin  is  decidedly  diminished.  Both  arms  are  similarly  affected.  The  legs 
also  are  very  weak,  more  especially  the  left  one,  which  “ shakes  ” when  he  walks, 
especially  if  going  down  a hill.  During  progre.ssioii  the  gate  is  unsteady,  the  left  leg 
beino-  jerked  outwards  in  a semi-circle.  He  cannot  turn  round  rapidly,  and  has  slight 
difficulty  in  standing  with  the  eyes  shut.  The  sensibility  of  the  skin  over  the  inferior 
extremities  as  well  as  over  the  abdomen  and  thorax,  is  diminished  to  the  same  degree 
as  in^  his  arms.  Occasionally  there  are  involuntary  startings  of  the  legs  and  arms, 
especially  at  night,  which  sometimes  prevent  his  sleeping.  In  all  other  respects  the 
functions  are  normal.  Appetite  excellent.  No  constipation.  ^ 01.  Olivar.  3 ss  ; 
01  Crotoni<i  3 ij  M.  ft.  Imimeutum  et  inter  scapulas  appheetnr.  Hydrarg  Proto- 
ioi  gr.  vi-Pxt.  Hyoscyam.:  Ext.  Aloes,  aa  Dj,  M.  et  Jiant  pil.  xij.  Surnat  unam  ter 

in  die.  ^ n i • 

Progress  of  the  Case. — Pune  Qth. — Thinks  himself  somewhat  better.  Complains 
that  his  diet  is  insufficient.  2h  have  lib  of  beef-tea  hi  addition  to  ordinary  diet. 
From  this  time  he  gradually  recovered,  and  was  dismissed  on  the  iHh,  still  a little 
weak,  with  the  perfect  use  of  all  his  limbs,  and  the  sensibility  normal. 

Case  XXX — Paraplegia — Partial  Recovery. 

History. — Benjamin  Robertson,  mt.  42,  a tailor — admitted  July  11, 1853.  States 
that  he  enjoyed  excellent  health,  until  lietween  three  and  four  months  ago,  when  he 
began  to  experienoe  a constant  feeling  of  coldness  in  both  feet  accompanied  with  a 
certain  amount  of  numbness.  The  diminution  of  sensibility  gradually  extended  up 
both  limbs,  and  in  the  course  of  six  weeks  they  were  wholly  affected.  Together  with 
the  numbness,  the  power  of  walking  became  impaired.  This  he  attributes  partly  to 
want  of  muscular  strength,  and  partly  to  the  feeling  of  insecurity  caused  by  the  loss 
of  sensibility.  After  the  lower  limbs  had  become  involved,  the  fingers  of  both  hands 
became  similarly  affected.  Occasionally  he  has  felt  as  if  a belt  were  firmly  bound 
round  the  loins  and  lower  part  of  the  chest.  He  has  never  had  pain  in  the  back,  or 
tenderness  on  percussion  along  the  spine.  For  the  last  ten  years  his  habits  have  been 
temperate,  but  previously  he  was  much  addicted  to  intoxication  and  venereal  excesses. 
The  treatment  hitherto  has  consisted  of  counter-irritation  over  the  back,  and  inter- 
nally iodide  of  potassium. 

Symptoms  on  Admission. — Has  no  pain  anywhere,  but  sensibility  is  dimini.shed  in 
both  lower  extremities,  and  more  especially  in  the  feet.  His  power  of  movement  in 
the  ankle  joints  and  toes  is  unimpaired,  but  he  has  less  command  over  the  knee  and 
hip  joints.  He  is  unable  to  draw  up  the  limbs  in  bed  beyond  a certain  point,  but  the 
left  leg  seems  to  be  a little  stronger  than  the  other.  He  has  no  involuntary  startings 
of  the  limbs,  but  he  has  observed  that  they  move  about  irregularly  when  friction  is 
applied  to  them.  He  has  great  difficulty  in  walking,  feeling  as  if  his  knee  joints  would 
bond  under  him,  and  before  advancing  he  requires  to  steady  himself  on  one  foot  for 
a little.  On  shutting  his  eyes  he  falls  forward  immediately.  The  fingers  are  con- 
stantly benumbed,  but  he  can  move  them  perfectly.  Arms  unaffected.  With  the 
exception  of  defiecation,  all  the  functions  are  normal ; but  on  feeling  an  inclination  to 
evacuate  the  Ijowels,  he  is  obliged  to  comply  instantly,  or  the  faeces  would  pass  invol- 
untarily. ^13^  StryclinicR  gr.  j ; Ext.  Gent.  3 ss.  Micce  Panis.  q.  s.  ft.  massa  in  pil. 
xij.  dividenda.  ^iurnat  unam  ter  indies. 

Progress  of  the  Case. — The  pills  in  the  course  of  eight  days  produced  involun- 
tary startings  of  the  inferior  extremities,  but  the  symptoms  otherwise  remained  the 
same.  IJ  01.  Olivar  ; 01.  Crotonis,  aa  3 ss.  To  he  rubbed  over  the  lower  half  of  the 
spine  morning  and  night.  Jidy  28^/i. — His  general  health  remains  good,  and  he  thinks 
there  is  some  amendment,  although  none  is  very  perceptible.  From  this  time,  repose, 
good  diet,  and  occasional  counter-irritation,  constituted  the  only  treatment,  under 
w’.iich  he  gradually  improved,  so  that  November  Lsif,  when  he  was  dismissed,  he  was 
able  to  walk  considerable  distances  with  the  aid  of  sticks,  and  a little  even  without 
them,  although  unsteadily. 

* Reported  by  Mr.  Alexander  Struthers,  Clinical  Clerk. 


432 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Case  XXX VI.^ — Paraplegia — Incur ahle. 

History. — Maximilian  Saulsen,  let.  35,  perfumer,  native  of  Warsaw— admitted 
January  9,  1851.  States  that  two  and  a half  years  ago  he  first  felt  a priekii.g,  lol- 
lOvved  by  numbness  in  the  toes  of  his  right  foot,  which  gradually  extended,  beii  o- 
accompanied  by  diminution  of  voluntary  power  over  the  parts.  His  left  leg  thtn 
became  similarly  affected.  His  general  health  was  good.  In  1849  he  went  to 
Germany,  where  he  made  use  of  the  baths  of  Weisbaden.  Eeturning  to  England,  he 
applied  to  one  of  the  London  dispensaries,  and  here  he  was  cupped  and  galvanised 
without  benefit.  During  last  summer  he  went  again  to  Germany.  He  savs  he  could 
not  walk  on  board  at  tiiis  time;  but  when  he  lett  for  England  in  October  fast,  he  was 
obliged  to  be  lifted  on  board,  his  legs  being  useless,  while  his  ai  ms  were  unaffected. 
During  the  passage  back  from  Hamburg,  two  months  ago,  his  left  hand  felt  benumbed, 
and  he  could  with  difiiculty  use  the  fingers,  except  the  little  finger,  which  he  says  w as 
unalfected.  The  right  hand  remained  natural,  with  the  exception  of  the  little  finger, 
w hich  felt  numb.  iSince  then,  the  numbness  in  the  feet  and  inability  to  move  have 
increased  very  much. 

Symptoms  on  Admission. — On  admission  his  general  appearance  is  healthy.  He 
is  unable  to  walk  to  any  distance  without  the  assistance  of  a stick.  He  is  unable 
to  direct  the  motions  of  his  right  leg  without  Avatchirg  it.  When  he  stands  without 
support,  great  unsteadiness  is  observed  ; and  when  directed  to  close  his  eyes,  he  loses 
all  control  over  his  movements,  and  would  fall  to  the  gionnd  if  not  prevented.  He 
is  unable  to  use  the  fingers  of  the  left  hand  with  any  precision.  Sensibility  of  the 
skin  unimpaired.  No  headache  ; no  tinnitus  auiium  ; a little  dizziness  occasionally. 
Urine  passed  without  difficulty;  sometimes  invelunlarily  dining  the  night — 10;;3 
sp.  gr.  Complains  of  difficulty  of  defecation.  He  was  oideied  to  be  crpped  ai  d 
blistered.  These  remedies  in  conjunction  with  repose  in  ti  e Infiimary,  product  d 
considerable  amendment,  and  he  was  enabled  to  taf  e krg  walks  with  the  aid  of  a 
stick.  On  Friday  the  10th,  he  passed  a large  limbricus;  and  40 grains  of  Eulv.  Ead- 
Filicis  Maris  ivere  ordered  to  be  taken  night  and  morning.  No  more  wmi ms,  how  ever, 
were  evacuated.  On  February  23d,  he  was  ordered  one-tweltth  of  a giain  of  strycli- 
nine  twice  a day,  which  dose  was  increased  to  one-sixth  on  the  28th.  On  the  1st  ai  d 
2d  of  March,  he  was  awakened  several  times  during  the  night  by  startings  of  the 
limbs  ; and  he  stated  that  their  general  strength  was  dinnnished.  He  evidently  stag- 
gered more  in  walking.  Galvanic  currents  were  then  ordered  to  be  passed  fiomthe 
spine  dowm  both  limbs,  under  which  treatment  he  continued  until  the  31st  of  March, 
when,  being  in  no  way  better,  he  was  discharged  as  incurable. 

Case  XXXVII.f — Paraplegia — Chronic  Myelitis. 

History.— James  Eoy,  »t.  34,  a tailor— admitted  September  20,  _ 184Y.  States 
that  about  three  months  ago,  he  first  observed  slight  unsteadiness  in  his  gait,  with  a 
feeling  of  coldness  in  his  lower  limbs,  wdiich  gradually  increased.  About  a month 
afterwards,  he  became  unusually  constipated,  with  a want  of  power  of  expelling  the 
faeces  and  urine.  On  the  15th,  feeling  unwell,  though  he  had  worked  all  day,  he 
retired  to  rest  earlier  than  usual,  but,  feeling  uncomfortable,  he  got  up  and  found  he 
had  little  power  in  his  legs.  About  twmlve  o’clock  that  night  they  became  completely 
insensible.  Next  morning  he  had  lost  the  functions  of  defaccation  and  micturition. 
A medical  man  bled  him  largely,  removed  ihe  urine  by  catheter,  and^  administered 
purgatives,  which  opened  the  bowels.  He  has  remained  in  the  sam_e  situation  since, 
always  feeling  great  fiiintness  on  assuming  the  erect  posture. 

Symptoms  on  Admission. — All  the  parts  below  a line  drawm  round  the  body  on  a 
line  Avith  the  nipples  appear  to  be  perfectly  paralysed,  deprived  of  all  motility  and 
sensibility.  The  inferior  extremities  present  no  rigidity  whatever.  Only  the  upper 
half  of  the  chest  moves  during  respiration ; the  lower  half  and  the  abdomen  being 
fixed.  There  is  retention  of  urine,  which  requires  to  be  drawn  off  by  catheter  ; and 
his  bowels,  which  are  very  costive,  are  opened  involuntarily  in  bed.  Has  a feeling  of 
constriction  round  the  ehest,  and  still  feels  faint  on  being  placed  in  the  erect  position. 
Temperature  of  the  body  everywhere  natural.  Pulse  90,  of  good  strength.  Other 
functions  normal. 

Progress  of  the  Case. — The  symptoms  underwent  no  change,  but  he  gradually 
became  w'eakcr.  The  treatment  consisted  at  first  of  cupping  over  the  vertebrae,  and 

* Reported  by  Mr.  Sanderson,  Clinical  Clerk. 

•}•  Reported  by  Mr.  James  Struthers,  Clinical  Clerk. 


STRUCTURAL  DISEASES  OF  THE  SPINAL  CORD. 


433 


purgatives,  and  subsequently  of  the  iodide  of  potassium  internally,  and  wine.  Octch 
her  I2th.  Diarrhoea  came  on  yesterday,  and  he  died  this  morning. 

Sectio  Cadaveris. — Twenty-five  hours  after  death. 

Spinal  Cord. — Permission  could  only  be  obtained  for  the  examination  of  this 
organ,  which  was  exposed  from  the  first  cervical  vertebra  downwards.  The  mem- 
branes were  healthy.  Scarcely  any  arachnoid  fluid.  About  seven  inches  of  the 
cord  in  length,  corresponding  to  the  second  and  third  dorsal  vertebrae,  felt  unusually 
soft.  •Externally  the  softening  was  of  a dirty  gray  color,  and  pultaceous  in  con- 
sistence, but  the  centre  was  quite  diffluent,  and  of  a yellow  color,  resembling  pus. 
Above  and  below  the  circumscribed  morbid  portion  the  cord  was  healthy.  No  dis- 
ease of  vertebrae. 

Microscopic  Examination. — The  external  gray  softening  consisted  of  fragments 
of  the  nerve  tubes,  and  globules,  with  double  lines  of  various  sizes  and  forms,  mingled 
with  numerous  granule  cells  and  granules.  The  central  softening  consisted  almost 
wholly  of  numerous  granule  cells  and  fatty  molecules,  fragments  of  tubes  being  com- 
paratively small  in  quantity. 

Commentary. — The  four  preceding  cases  present  the  same  disease  in 
different  stages,  that  disease  being  chronic  myelitis,  by  far  the  most 
common  lesion  of  the  cord  met  with.  Cases  XXXIV.  and  XXXV. 
show  the  occasional  good  effects  which  result  from  rest,  counter-irrita- 
tion, and  supporting  the  nutrition  in  incipient  cases.  Bleeding  and  anti- 
phlogistics  I have  never  seen  beneficial,  but  frequently  injurious ; and 
in  Case  XXXVII.  depletion  evidently  added  to  the  prostration  of  the 
patient.  In  the  more  chronic  or  intense  cases,  nothing  but  palliatives 
are  of  any  service.  I have  tried  galvanism  and  strychnine,  but  have 
never  found  them  of  any  avail  where  the  cord  was  undoubtedly  diseased. 
Indeed,  under  such  circumstances,  it  has  frequently  appeared  to  me  that 
strychnine  renders  the  weakness  of  the  patient  greater,  as  in  Case 
XXXVI.  In  the  last  stages  of  the  disease,  if  chronic,  and  especially  if 
sloughs  have  formed  on  the  back,  our  whole  efforts  should  be  directed 
to  nurse  and  sustain  the  patient’s  strength,  and  alleviate  the  symptoms 
which  arise  from  the  paralysed  condition  of  important  organs.  Hence 
rest,  nourishing  diet,  and  tonics,  are  the  best  remedies,  while  the  hydro- 
static bed  and  every  other  contrivance  should  be  put  in  practice  to 
remove  pressure  from  the  depending  parts  of  the  body.  Mild  aperients 
should  be  employed  from  time  to  time  to  overcome  the  intestinal  torpor, 
while  by  the  catheter  the  urinary  bladder  should  be  evacuated,  so  as  to 
diminish  the  tendency  to  saline  precipitation  in  that  viscus,  and  its  sub- 
sequent disorganization. 

I have  given  phosphorus  in  seven  cases  of  paraplegia  from  chronic 
myelitis,  all  resembling  more  or  less  Case  XXXVI.,  in  the  form  of 
phosphuretted  oil  (4  gr.  of  phosphorus  dissolved  in  of  olive  oil). 
In  none  of  these  cases  have  I been  able  to  satisfy  myself  that  any  im- 
provement was  occasioned.  I commenced  with  three  drops  a day,  which 
were  afterwards  cautiously  increased  to  ten,  and  in  one  case  to  fifteen 
drops.  But  these  large  doses  soon  induced  violent  nausea  and  vomiting, 
and  after  a short  suspension  of  the  remedy,  I have  continued  it  for 
several  weeks  in  doses  of  three  drops.  In  the  case  which  took  fifteen 
drops  thrice  daily  for  two  days,  the  phosphorus  was  excreted  by  tbe 
lungs,  as  the  breath  smelt  strongly  of  the  drug,  but  was  not  phosphor- 
escent at  night — a phenomenon  which  has  been  seen  by  some  physicians 
who  have  employed  it.  In  another  ease,  that  took  ten  drops  thrice  one 
day,  a large  amount  of  phosphate  was  passed  in  the  urine,  presenting, 
28 


434 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


under  the  microscope,  beautiful  feathery  crystals,  which  disappeared  on 
discontinuing  the  drug.  From  the  trial  I made  of  phosphorus,  it 
seemed  to  me  of  little  benefit,  and  that  the  dose  of  phosphuretted  oil 
should  never  exceed  five  drops.  Even  this  amount  cannot  be  adminis- 
tered for  any  length  of  time  without  deranging  the  stomach. 

In  the  spring  of  1859,  I treated  six  cases  of  paraplegia  with  ergot 
of  rye,  5 gr,  three  times  a day.  They  were  all  watched  with  great  care, 
and  in  three  of  them  considerable  amendment  took  place.  At  the  time 
the  trial  of  the  drug  was  considered  favorable.  All  three  cases,  how- 
ever, it  was  ascertained  after  dismissal,  again  became  worse.  Since 
then  I have  given  the  drug  in  the  same  manner  to  thirteen  other  cases 
of  paraplegia — increasing  the  dose  to  ten  grains — and  although  there  has 
been  temporary  relief  in  some  of  them,  it  has  always  appeared  to  me 
attributable  to  the  rest  and  good  nourishment  of  the  hospital.  In  a few 
of  these  cases  the  ergot  was  taken  two  months  without  intermission, 
and  in  two  for  three  months,  not  only  without  symptoms  of  poisoning, 
but  without  any  inconvenience  whatever. 

The  cord  undergoes  the  same  structural  changes  as  the  brain,  and 
after  death,  in  cases  of  true  myelitis,  exudative  softening  may  readily  be 
demonstrated  by  the  microscope.  (See  Fig.  401.)  Softening  from  im- 
bibition of  serum,  however,  is  rare,  whilst  that  from  mechanical  crushing 
with  instruments  after  death  is  exceedingly  common,  and  should  always 
be  carefully  investigated  by  the  pathologist.  Spinal  meningitis  and 
hemorrhage  are  rare  diseases — the  former  generally  resulting  from  an 
extension  downwards  of  cerebral  meningitis.  (See  Case  XXXII.)  I 
have  only  seen  one  case  of  spinal  hemorrhage,  and  that  occurred  in  the 
surgical  ward  of  Mr.  Miller.  It  occurred  in  a woman,  who,  when  tipsy, 
was  kicked  by  her  husband  in  the  neck,  with  the  immediate  result  of 
paralysis  of  all  four  extremities,  and  of  the  trunk.  She  died  in  four  days, 
and,  opening  the  body,  I found  a clot  of  blood  the  size  of  a pea  in  the 
centre  of  the  cord  immediately  below  the  medulla  oblongata,  opposite 
the  second  vertebra.  The  external  portion  of  the  cord,  and  the  vertebral 
bones,  were  unaffected.  On  microscopic  examination,  the  clot  was  com- 
posed of  recently  extravasated  blood  corpuscles,  surrounded  by  mechanical 
softening.^ 

Case  XXXVIII. f — Paraplegia — Tubercular  Caries  of  Dorsal  Vertebrce — 
Myelitis — Pulmonary  Tubercle. 

History. — William  Walker,  set.  42,  mason — admitted  October  17,  1850.  States 
that  for  upwards  of  twelve  years  he  has  suffered  from  occasional  cough,  usually  dry, 
accompanied  in  lower  and  middle  part  of  chest  with  pain,  extending  back  to  the 
dorsal  vertebrae.  The  pain  and  cough  have,  within  the  last  three  months,  become 
more  constant,  and  are  accompanied  by  nightly  perspirations.  About  fourteen  days 
before  admission,  he  felt  a prickling  and  coldness  in  the  feet,  and  an  unsteadiness  in 
walking,  especially  with  the  left  foot.  Two  days  before  admission,  after  a long  walk, 
these  symptoms  were  augmented.  Since  then  they  have  gradually  increased,  so  that 
now  he  has  no  power  over  his  legs  beyond  bending  the  knee  very  slightly.  Sensibility 
of  the  integuments  not  impaired. 

Symptoms  on  Admission. — On  admission,  looks  emaciated  and  anxious.  Com- 
plains of  no  headache,  or  pain  in  spine,  save  between  the  shoulders.  He  cannot 

* An  interesting  case  of  true  spinal  hemorrhage,  with  an  account  of  all  the  then  known 
cases,  is  given  l)y  Dr.  Peddie,  Monthly  Journal  of  Med.  Science,  May  1847,  p.  819. 

I lleported  by  Mr.  Sanderson,  Clinical  Clerk. 


STRUCTURAL  DISEASES  OF  THE  SPINAL  COED. 


435 


stand  without  support,  and  when  he  tries  to  walk  he  staggers,  and  would  fall  if  not 
supported.  He  can  move  his  legs  in  bed  with  tolerable  freedom;  they  often  feel 
cold.  Superior  extremities  unaffected.  There  is  occasional  cough,  with  scanty 
expectoration.  On  percussion  no  dulness  is  perceptible,  on  either  side,  anteriorly. 
On  auscultation,  the  respii  atory  murmurs  are  harsher  and  louder  than  natural  at  apex 
of  both  lungs.  Tlie  urine  not  albuminous,  but  loaded  with  lithates,  and  sometimes 
voided  with  difficulty.  Other  functions  healthy. 

PiiOGRESS  OF  THE  Case. — The  paralysis  in  this  man  gradually  increased.  He  could 
not  stand,  although,  when  in  bed,  he  could  slightly  bend  the  knees  and  toes.  Latterly 
a swelling  formed  over  the  lower  dorsal  and  upper  lumbar  vertebrae,  five  inches  long 
and  tiiree  broad.  The  urine  became  loaded  with  phosphates,  and,  with  the  faeces, 
was  passed  involuntarily.  His  general  health  also  greatly  diminished,  painful  tvvitch- 
ings  occurred  in  the  paralysed  limbs,  emaciation  became  extreme,  the  cough  violent, 
the  expectoration  copious.  Several  sloughs  formed  over  the  left  and  right  hips,  not- 
withstanding he  lay  on  a water  bed,  and  every  care  was  taken  to  prevent  them.  Dur- 
ing the  last  week  in  February,  and  two  first  weeks  in  March,  an  abscess  formed  above 
the  right  clavicle,  which  opened  spontaneously  on  the  loth  of  the  last-mentioned 
month,  and  discharged  about  8 oz.  of  matter.  As  the  respiratory  murmur  was  still 
heard  at  the  apex  of  right  lung,  it  was  concluded  that  the  abscess  originated  in  the 
vertebral  column.  A considerable  quantity  of  pus  was  subsequently  discharged  daily, 
being  forced  out  at  each  inspiration.  March  l^th. — He  was  greatly  exhausted,  pulse 
v/eak  and  irregular ; low  muttering  delirium  at  night,  with  scarcely  strength  to 
expectorate.  Died  the  same  evening.  The  treatment  consisted  at  first  of  a few 
leeches  occasionally  applied  to  the  back,  of  purgatives,  and  latterly  of  remedies 
applicable  to  spinal  symptoms,  which  produced  merely  temporary  relief. 

Sectio  Cadaveris. — March  26^/l — Forty-two  hours  after  death. 

The  body  was  pale,  and  greatly  emaeiated. 

Over  the  left  hip  vvas  a sloughing  sore,  measm-ing  seven  inches  in  its  longest 
diameter  from  above  downwards,  and  six  inches  across.  The  surface  irregular,  in 
some  places  an  inch  below  the  level  of  the  skin,  and  the  whole  covered  with  a dirty 
greenish  ichorous  matter.  Over  the  right  hip  was  a smaller  slough,  of  roundish 
form,  about  two  inches  in  diameter.  Over  the  vertebral  column,  between  and  some- 
what above  these  sloughs,  there  was  a circumscribed  swelling,  of  an  oval  form,  five 
inches  long  and  three  inches  broad.  It  was  firm  and  dense  to  the  feel,  and  on  section 
was  found  to  consist  of  thickening  of  the  dermis  to  the  extent  of  three  quarters  of  an 
inch,  combined  with  oedematous  infiltration  of  the  cellular  tissue.  Opposite  to  the 
seventh  cervical  and  first  and  second  dorsal  vertebrae,  there  was  a slight  angular  cur- 
vature of  the  spinal  column,  in  the  centre  of  whieh  space  externally  the  skin  presented 
a small  purplish  discoloration.  A fistulous  opening,  the  size  of  a fourpenny  piece, 
existed  about  two  inches  above  the  centre  of  the  right  clavicle.  On  tracing  the  open- 
ing inwards,  it  led  into  a cavity  which  passed  behind  the  subclavian  vein,  and  from 
thence  backwards  to  the  tubercle  of  the  first  rib,  which  could  be  felt  carious  and 
rough,  and  from  thence  to  the  first  four  dorsal  vertebrae,  the  bodies  of  wffiich  bones 
were  carious  throughout.  The  periosteum  had  separated  from  the  diseased  bones,  and 
formed  a pouch  anteriorly,  filled  with  pus,  which  communicated  with  the  external 
sinus.  On  examining  the  diseased  bones,  their  cancellated  structure  was  more  or  less 
infiltrated  with  pus,  combined  with  soft  tubercular  exudation.  The  posterior  laminae  of 
the  first  dorsal  vertebrae  especially  were,  from  the  latter  cause,  of  eheesy  consistence. 

Spinal  Cord. — The  membranes  were  healthy.  Externally  the  spinal  cord  pre- 
sented no  appearance  of  disease.  On  making  a longitudinal  section,  however,  it  was 
found  to  be  distinctly  softened  internally  an  inch  of  its  length,  opposite  the  first  dor- 
sal vertebrae.  The  softened  white  structure  encroached  more  on  the  anterior  white 
matter  of  the  cord  than  jiosteriorly,  and  it  was  of  a light  fawn  color. 

Thorax. — The  pleurae  were  united  by  firm  adhesions  at  the  apices  of  both  lungs, 
and  also  over  the  middle  on  the  left  side.  At  the  apex  of  the  right  lung,  the  pleuiTe 
were  also  thickened  in  several  places,  presenting  a white  appearance,  and  the  tissue 
of  the  lung  opposite  was  much  puckered.  On  section,  these  puckerings  were  found 
to  correspond  to  calcareous  concretions,  of  various  sizes,  around  which  numerous  hard 
miliary  tubercles  of  a slate  color  were  grouped.  Throughout  this  lung  were  numerous 
similar  tubercles,  mingled  with  black  pigment  deposits  and  calctireous  masses,  vary- 
ing in  size  from  a millet  seed  to  that  of  a small  pea, — most  abundant,  however,  at  tlie 
apex.  Similar  tubercles  existed  in  the  upper  lobe  of  left  lung  ; but  they  were  not  so 
numerous.  The  bronchial  mucous  membrane  was  much  congested ; and  the  larger 


436 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


bronchi  contained  copious  muco-purulent  fluid.  The  bronchial  glands  were  of  black 
color,  and  here  and  there  loaded  with  calcareous  matter. 

Abdominal  organs  healthy. 

Microscopic  Examination. — The  softened  portion  of  the  spinal  cord  consisted  of 
numerous  molecules  and  granules,  with  the  debris  of  the  varicose  nerve-tubes  of  the 
cord,  forming  globules  of  various  sizes  and  shapes,  of  the  white  substance  of  Schwann. 
Large  numbers  of  compound  granule  cells  and  masses  were  associated  with  the  dis- 
integrated structures. 

Commentary. — The  preceding  case  is  dependent  on  a different  patho- 
logical cause,  and  presents  consequently  marked  variations  in  the 
symptoms  from  the  former  instances  of  paraplegia.  In  it,  pressure  was 
gradually  made  on  the  spinal  cord  from  without,  in  consequence  of 
scrofulous  caries.  The  anterior  columns  of  the  cord,  under  such  circum- 
stances, are  those  which  are  most  injured,  and  loss  of  motion  is  the  lead- 
ing symptom.  In  Cases  XXXIV.  to  XXXVIL,  the  first  symptoms  were 
numbness  or  pricking  of  the  toes,  followed  by  perversion  or  irregularity, 
rather  than  loss  of  motion,  and  not  attended  with  spasms.  This  condi- 
tion is  indicative  of  chronic  inflammation  of  the  cord,  or  myelitis.  Pro- 
fessor Romberg  has  pointed  out  a symptom  in  such  persons,  which  he 
considers  diagnostic  of  softening  of  the  grey  matter  in  the  centre  of  the 
cord,  as  distinguished  from  lesion  of  the  white  matter.  This  consists  in 
ascertaining  that  a man  cannot  stand  steadily  with  his  eyes  shut.  This 
symptom  was  well  marked  in  Cases  XXXV.  and  XXXVL,  and  slightly 
in  Case  XXXIV.,  while  everything  indicated  that  it  was  not  so  much  the 
conducting,  as  the  tonic  power,  which  was  wanting.  These  considera- 
tions induced  me  to  try  the  effects  of  strychnine,  which,  however,  was  of 
no  benefit  in  Case  XXXV.,  and  in  Case  XXXVI.  increased  the  irre- 
gular movements  when  walking,  and  caused  loss  rather  than  increase  of 
power.  The  galvanic  currents,  which  were  subsequently  tiied,  also 
failed  in  producing  any  amendment.  In  case  XXXVIII.  the  caries  of  the 
spinal  column,  but  more  especially  the  discharge  from  the  fistulous  open- 
ing, produced  the  fatal  termination.  The  tubercles  in  the  lung  were  all 
in  a chronic  condition,  and  although  they,  combined  with  the  bronchitis, 
account  for  the  cough  and  physical  signs,  they  also  served  during  life  as 
indications  of  the  kind  of  caries  present  in  the  vertebral  column.  The 
deformity  in  the  dorsal  region  was  only  observable  a few  days  before 
death,  and  became  more  marked  afterwards.  The  swelling  in  the  lumbar 
region  was  a singular  proof  of  the  effects  occasionally  produced  by  deep- 
seated  sloughs  and  cicatrices,  in  causing  local  hypertrophy  and  oedema. 

Scrofulous  or  tubercular  caries  of  the  bones  is  a common  cause  of 
paraplegia,  and  considerable  difference  of  opinion  exists  as  to  its  mode  of 
treatment.  It  has  been  maintained,  for  instance,  that  caries  of  a spongy 
bone  never  heals,  and  that  where  it  can  be  reached,  the  only  remedy  is 
excision.  But  it  has  frequently  happened  that  change  of  air  and  an  im- 
proved diet  have  led  to  the  most  happy  results,  and  that  the  caries  has 
healed  spontaneously.  Every  practitioner  of  experience  must  have  met 
with  cases  where  caries  and  distortion  of  the  vertebrae  have  terminated 
in  anchylosis,  and  the  patient  regained  his  health.  Many  dwarfs  are 
living  examples  of  the  occurrence  of  scrofulous  caries  in  the  vertebral 
bones  having  disappeared,  leaving  them,  although  deformed,  quite 
well.  The  theory,  therefore,  to  which  I have  alluded  is  incorrect ; and 
although  indirectly  it  has  led  to  many  improvements  in  surgery,  by 


STRUCTURAL  DISEASES  OF  THE  SPINAL  CORD. 


437 


causing  excision  of  bones  and  joints,  instead  of  amputation  of  limbs,  or 
allowing  the  patient  to  sink  from  exhaustion,  there  can  be  no  doubt  that, 
notwithstanding,  many  cases  recover  under  a proper  constitutional  treat- 
ment. Thus  I have  seen  some  remarkable  instances  of  caries  and  distor- 
tion of  the  vertebrae,  which  have  produced  perfect  paralysis,  and  reduced 
the  patient  to  a great  state  of  weakness.  Under  such  circumstances,  in- 
stead of  confining  the  patient  to  bed,  under  the  idea  that  the  weight  of 
the  body  would  increase  the  curvature,  I have  recommended  moderate 
exercise,  given  cod-liver  oil  and  nutrients,  and  the  patient  has  ultimately 
recovered.  During  a visit  I paid  to  Germany  in  18-16, 1 saw  in  the  wards 
of  Professor  Heusinger  of  Marburg  three  such  cases  at  once.  They  had 
all  had  paraplegia.  The  one  most  recently  treated  still  had  paralysis, 
the  other  two,  who  had  been  under  treatment  some  months,  had  recovered, 
so  that  they  could  walk  without  difficulty,  and  were  nearly  well.  I saw 
shortly  after,  two  similar  cases  in  the  wards  of  Professor  Jacks  of  Prague. 
Hence  I am  satisfied  that  our  treatment  in  all  such  cases  should  be  from 
the  first  nutritive  and  supporting,  avoiding  depletion  and  lowering 
remedies,  and  insisting  on  exercise  as  far  as  possible  by  walking  or  in  a 
carriage.  In  this  way  not  only  may  a cure  be  effected,  but  in  advanced 
cases  health  may  be  sustained  and  life  prolonged,  while  the  tendency  to 
the  production  of  those  sloughs  on  the  back,  which  so  commonly  hasten 
the  fatal  result,  is  best  prevented. 

Case  XXXIX.* — Paraplegia — Cancer  of  Vertebral  bones — Softening  of 
the  Cord  fi'om  Pressure — Cancer  of  Lung ^ Liver ^ and  Lumbar  Glands 
— Ulceration  of  Urinary  Bladder. 

History. — Agnes  M‘Guire,  aet.  60 — admitted  January  12th,  1849.  With  the 
exception  of  two  attacks  of  fever,  had  always  enjoyed  good  health  until  three  months 
ago,  when  she  was  seized  during  the  night  with  nausea,  vomiting,  and  purging. 
These  symptoms  continued  more  or  less  until  a fortnight  since,  when  she  first  be-came 
aware  of  a feeling  of  coldness  in  the  lower  extremities,  especially  in  the  feet  and  toes. 
Six  days  ago,  on  waking  in  the  morning,  she  found  that  she  had  completely  lost  all 
power  over  the  lower  extremities,  and  had  a feeling  of  great  weight  in  the  haunches 
and  lumbar  region. 

Symptoms  on  Admission. — There  is  great  emaciation.  The  countenance  is  expres- 
sive of  pain  and  anxiety.  Face  and  lips  pale  and  sallow.  Skin  cold  and  harsh. 
There  is  a black  slough  about  three  inches  in  diameter  over  the  sacrum.  She  com- 
plains of  pain  in  the  breast,  chest,  and  back,  and  there  is  tenderness  over  the  abdomen 
and  sides,  with  tympanitic  distension.  There  is  total  loss  of  motor  power,  and  of 
sensibility  from  the  haunches  downwards ; but  on  pricking  the  soles  of  the  feet, 
slight  spasmodic  muscular  movements  occur.  All  attempts  to  move  the  body,  even 
by  others,  cause  great  pain,  especially  in  the  lumbar  regions.  No  cough  nor  expec- 
toration. Percussion  and  auscultation  over  the  anterior  surface  of  the  chest  elicit 
nothing  abnormal ; the  posterior  surface  cannot  be  examined  in  consequence  of  the 
difficulty  of  moving  her.  Heart  healthy;  tongue  furred;  appetite  irregular;  con- 
siderable thirst  and  occasional  nausea.  Has  passed  urine  and  fseces  involuntarily 
since  admission,  but  says  she  is  generally  costive.  Urine  abundant,  and  when  re- 
moved by  catheter,  is  of  a brick  color,  with  a dark  sediment,  composed  of  amorphous 
urates,  triple  phosphates,  epithelial  cells,  and  blood  corpuscles.  It  is  readily  decom- 
posed, and  has  an  ammoniacal  odor. 

Progress  of  the  Case. — This  woman  gradually  became  more  and  more  ex- 
hausted. The  slough  on  the  back  became  enlarged,  the  tympanitic  condition  of  the 
abdomen,  with  pain  there  and  in  the  back,  underwent  occasional  remissions,  but  on 
the  whole  never  left  her.  The  urine  could  never  be  passed  voluntarily,  and  gradu- 
ally became  more  loaded  with  phosphates,  blood,  and  epithelial  cells,  and  emitted 
an  intolerably  foetid  odor.  The  bowels  for  some  time  were  constipated,  but  diar- 

'*  Reported  by  Mr.  J.  N.  Fanning,  Clinical  Clerk. 


438 


DISEASES  OP  THE  JfERVOUS  SYSTEIil. 


rhoea  ensued  shortly  before  death,  which  took  place  February  5th.  Tlie  treatment 
consisted  at  first  of  the  occasional  application  of  leeches  to  the  painful  portion  of  the 
vertebral  column,  but  they  never  caused  even  the  slightest  relief.  The  constipation 
was  overcome  by  laxatives,  and  the  urine  frequently  drawn  off  by  catheter.  The 
slough  was  constantly  dressed  with  turpentine,  and  balsamic  ointments  and  poultices, 
and  pressure  removed  from  it  as  much  as  possible.  Warm  bottles  were  frequently 
applied  to  the  feet  and  lower  extremities,  but  they  could  never  overcome  the  feeling 
of  cold  which  prevailed.  Internally,  nutrients  with  wine,  and  latterly  brandy,  wera 
given. 

Sectio  Cadaveris. — Tioenhj-jive  hours  after  death. 

Head. — Brain  and  membranes  healthy. 

Spinal  Column. — The  bodies  of  the  eighth  and  ninth  dorsal  vertebrae  were  much 
thickened,  presenting  an  abrupt  swelling,  and  on  section  were  soft  from  infiltration  of 
encephaloma.  The  left  psoas  muscle  was  adherent  to  the  bodies  of  the  diseased 
vertebrae,  and  formed  with  these  a pultaceous  disorganised  mass,  consisting  of  fatty 
softened  muscle,  and  broken-down  cancerous  bone.  The  body  of  the  third  lumbar 
vertebra  was  also  infiltrated  with  encephaloma. 

Spinal  Cord. — The  diseased  dorsal  vertebral  bones  had  encroached  considerably 
on  the  spinal  canal,  and  formed  somewhat  of  an  acute  angle  compressing  the  cord, 
which,  for  the  space  of  one  inch  opposite  them,  was  reduced  throughout  to  a pulta- 
ceous consistence.  The  softening  was  white,  and  the  membranes  surrounding  it  were 
healthy. 

Chest. — In  the  left  auricle  of  the  heart  was  a hemispherical,  flattened,  earthy 
concretion,  the  size  of  an  almond,  embedded  in  the  muscular  wall.  Heart  otherwise 
healthy.  Lungs  anteriorly  emphysematous.  The  left  lung  adherent  at  the  apex 
posteriorly,  on  separating  which,  half  of  the  upper  lobe  posteriorly  was  seen  to  be  in- 
filtrated with  encephalomatous  exudation  of  a dirty  white,  and  in  some  places  a light 
pink  color.  Throughout  other  portions  of  both  lungs,  nodules  of  similar  encephaloma 
were  disseminated,  varying  in  size  from  a pea  to  that  of  a walnut,  and  separated  by 
perfectly  healthy  lung  tissue.  Bronchial  glands  of  a blackish  color,  from  deposition 
of  pigment,  but  not  cancerous. 

Abdomen. — The  liver,  kidneys,  and  lumbar  glands  were  studded  with  masses  of 
soft  cancer,  varying  in  size  in  the  first-named  organ  from  a hazel-nut  to  that  of  a 
pigeon’s  egg.  The  urinary  bladder  was  much  contracted  and  corrugated.  The  inner 
surface  was  rough,  in  consequence  of  red  bloody  projections  from  it,  varying  in  size 
from  a millet-seed  to  that  of  a pea.  In  other  places  there  were  injected  rugae, 
with  cracks  and  ulcerations  in  the  depressions,  and  considerable  depositions  of  phos- 
phatic  salts.  The  spleen  and  other  organs  healthy.  Considerable  flatus  in  the  large 
intestines. 

Microscopic  Examination. — The  softened  spinal  cord  consisted  of  the  nerve 
tubes  broken  up  into  minute  fragments  of  various  shapes,  round,  oval,  flask-.shaped, 
etc.,  with  double  outlines,  mingled  with  a multitude  of  fatty  molecules  and  granules. 
A few  granule  cells  were  also  visible.  The  cancerous  masses  in  the  lung  presented 
broken-up  cancer  cells,  intermixed  wfith  numerous  granule  cells  and  granular  matter, 
as  in  the  Cancer  reticulare  of  Muller.  In  the  liver,  more  characteristic  cell  structures 
were  found ; still,  however,  here  and  there  mixed  with  retrograde  cancerous  masses 
of  a yellowish  color.  In  the  bones  the  cancer-cells  were  large,  many  of  them  con- 
taining two  or  three  nuclei  undergoing  development. 

Commentary. — In  this  case,  encephaloma  of  various  internal  organs 
came  on  slowly,  without  causing  any  distinctive  symptoms,  until  the  en- 
largement of  the  eighth  and  ninth  dorsal  vertebrae  from  cancerous  in- 
filtration, by  pressing  on  the  spinal  cord,  occasioned  incipient  symptoms 
of  paraplegia.  The  two  softened  vertebral  bones,  however,  sunk  suddenly 
inwards,  compressed  the  cord,  and  occasioned  in  the  night  complete  para- 
lysis, followed  sometime  afterwards  by  ulceration  of  the  bladder  and 
sloughs  on  the  sacrum,  which  caused  her  death.  On  dissection,  the 
bodies  of  the  two  vertebrie  were  seen  to  form  an  angle,  compressing  the 
cord,  which  was  aftei  wards  reduced  to  a pulpy  consistence,  and  entirely 
disorganised. 


STRUCTURAL  DISEASES  OF  THE  SPINAL  CORD. 


439 


The  importance  of  rightly  understanding  the  pathology  of  structural 
disease  of  the  spinal  cord  will  be  appreciated  on  reflecting  that  it  gener- 
ally induces  incurable  paralysis.  Its  extent  will  be  greater  or  less,  ac- 
cording as  the  lesion  involves  the  origin  of  a greater  or  smaller  number 
of  nerves,  or  what  amounts  to  the  same  thing,  cuts  off  their  intercourse 
with  the  brain.  The  recent  views  of  the  structure  of  the  cord  (pp,  144, 
145)  further  point  out  to  us,  that  disorganization  of  the  grey  matter  not 
only  diminishes  the  evolution  of  nervous  force,  but  acts  directly  on  the 
fibres  which  transmit  it  to  the  brain.  There  is  every  reason  to  believe  that 
these  fibres  not  only  decussate  in  the  medulla  oblongata,  but  do  so  all 
the  way  down  the  cord.  So  small,  however,  is  this  latter  organ,  that 
diseases  of  its  texture  usually  affect  both  halves,  and  occasion  effects  on 
both  sides  of  the  body,  whereas  it  has  long  been  a matter  of  observation, 
that  a lesion  on  one  side  of  the  brain  causes  paralysis  only  on  the  oppo- 
site side  of  the  body.  Hence,  in  cases  of  hemiplegia,  the  disease  in  the 
vast  majority  of  cases  is  referable  to  the  opposite  hemisphere  of  the  brain, 
more  especially  to  the  cranial  portion  of  the  spinal  cord  above  the  de- 
cussation in  the  medulla  oblongata ; whereas  paraplegia  is  as  frequently 
found  to  depend  on  disease  of  the  vertebral  portion  of  the  cord  below 
that  decussation. 

A very  few  cases  have  been  recorded,  however,  in  which  hemiplegia 
has  occurred  on  the  same  side  as  a lesion  found  in  the  brain  after  death, 
and  which  has  been  supposed  to  occasion  it.  Mr.  Hilton,  indeed,  in  a 
paper  read  before  the  Royal  Society  in  1837-’38,  described  a disposition 
of  fibres  which  he  thought  capable  of  explaining  such  exceptional  cases. 
These,  however,  are  so  rare,  that  it  can  scarcely  be  supposed  to  arise 
from  a permanent  anatomical  arrangement,  and  it  is  far  from  probable 
that  even  in  them  there  is,  in  fact,  no  exception  to  the  general  law. 
Thus,  numerous  instances  have  occurred  of  abscesses  softening  and  other 
morbid  changes  having  been  found  after  death,  but  in  which  there  was 
no  paralysis  during  life ; and  a still  greater  number  are  on  record,  in 
which  there  was  well-marked  paralysis  during  life,  but  no  appreciable 
change  in  the  structures  after  death.  It  is  by  no  means  improbable, 
therefore,  as  paralysis  may  be  induced  without  leaving  any  traces,  that  in 
these  few  cases  it  was  caused  by  unknown  changes  in  the  opposite  hemi- 
sphere of  the  brain  ; and,  as  is  sometimes  the  case,  that  the  lesion  found 
in  the  hemisphere  of  the  paralysed  side  had  produced  no  effect.  Such, 
we  think,  is  the  most  probable  explanation  of  these  exceptional  cases. 

In  the  vertebral  portion  of  the  cord,  although  the  general  rule  is, 
that  all  those  parts  are  paralysed,  furnished  by  nerves  coming  off  below 
the  seat  of  disorganization,  exceptional  cases  also  have  been  recorded.  In 
these  it  has  been  said  that  individuals  have  retained  the  power  not  only 
of  moving  the  lower  limbs,  but  of  walking,  notwithstanding  that  the 
spinal  cord  has  been  disorganized  throughout  its  entire  thickness.  Every 
one  accustomed  to  pathological  examinations  must  receive  with  distrust 
accounts  of  such  observations,  knowing  how  soon  this  portion  of  the 
nervous  system  may,  in  certain  cases,  become  softened  after  death,  as  well 
as  the  injuries  it  is  likely  to  receive  in  opening  the  vertebral  canal. 
Several  years  ago,  I took  the  trouble  to  analyse  the  more  remarkable  of 
these  cases,  and  satisfied  myself  that  there  was  no  absolute  proof  that  in 
any  of  them  the  cord  was  wholly  destroyed  during  life. 


440 


DISExlSES  OF  THE  NERVOUS  SYSTEM. 


Thus,  in  the  celebrated  case  of  Desault  (Journ.  de  Chir.  de  Desavlt^ 
tom.  iv.  p.  437),  the  appearance  of  the  parts  is  not  described  : it  is 
merely  stated,  “ the  spinal  marrow  was  totally  divided  ; ” and  the  move- 
ments which  took  place  are  thus  narrated  : — “ He  was  in  a continual 
agitation,  and  moved  the  pelvis  and  inferior  extremities  even  to  the  last.” 
In  all  this  there  is  nothing  decided.  May  not  the  movements  have  been 
excito-motory  ? Was  the  altered  structure  well  observed  ? The  case  of 
M.  Rullier  {Journ.  de  Physiol.^  1823)  has  been  also  frequently  alluded  to 
in  connection  with  this  question.  It  was  that  of  a gentleman  who  had 
complete  and  perfect  paralysis  of  the  arms,  without  loss  of  sensibility  and 
motion  in  the  inferior  extremities ; he  remained  in  this  state  six  years, 
and  died  of  pectoral  complaints.  Dr.  Abercrombie,  alluding  to  the  case, 
states  that  a portion  of  the  cord,  six  inches  in  length,  occupying  two- 
thirds  of  the  cervical  portion  and  part  of  the  dorsal,  was  entirely  diffluent ; 
so  that,  before  the  membranes  were  opened,  it  moved  upwards  and  down- 
wards like  a fluid.  The  posterior  roots  of  the  nerves  of  this  portion 
preserved  their  nervous  matter  to  their  junction  to  the  membranes  of  the 
cord  ; but  in  the  anterior  roots  it  was  destroyed,  and  they  were  reduced 
to  an  empty  neurilemma.  (Abercrombie,  p.  350,  3d  edit.)  This  writer 
mentions  that  the  anterior  columns  were  completely  destroyed,  and  others 
in  alluding  to  the  case  have  thought  a portion  of  the  cord  was  entirely 
disorganized.  The  case  itself  is  headed  Disappearance  (Disparation)  of 
the  Nervous  Substance  of  the  Spinal  Marrow  in  the  Superior  Third  of  the 
Dorsal  Portion  (Ollivier,  3d  edit,  vol.  ii.  p,  368),  and  yet,  in  the  details 
of  the  dissection  it  is  stated,  “ On  voyait  a peine,  vers  la  partie  anterieure 
de  cette  portion  alteree,  les  cordons  medullaires  en  rapport  avec  les 
racines  correspondantes  des  nerfs  spinaux;  ” and  again,  “ Cette  alteration 
etait  beaucoup  moins  sensible  lorsqu’on  regardait  la  moelle  par  sa  face 
anterieure,”  etc.  From  this  it  would  appear  that  certain  continuous 
fibres  still  existed  in  the  anterior  columns,  although  they  were  seen  with 
difficulty,  but  that  there  could  be  no  doubt  many  existed  in  the  posterior. 
The  persistence  of  voluntary  motion  and  sensibility  in  the  inferior  ex- 
tremities under  such  circumstances,  when  the  disease  too  was  chronic,  is 
in  no  way  surprising. 

Instances  have  also  been  recorded,  in  which  balls  have  traversed  the 
vertebral  column ; or  swords  have  been  thrust  into  the  neck,  which  are 
said  to  have  entirely  cut  across  the  spinal  cord,  without  being  followed 
by  paralysis.  We  cannot  here  enter  into  the  analysis  of  these  cases,  but 
those  who  choose  to  do  so  will  readily  come  to  the  conclusion,  that  no 
positive  proof  exists  that  the  cord  was  wholly  destroyed  during  life.  On 
the  other  hand,  without  throwing  any  doubts  on  the  accuracy  of  the 
observations  which  have  been  made,  may  we  not  consider  that  the  com- 
plete destruction  which  has  been  described,  is  in  some  degree  a post- 
mortem appearance  caused  by  partial  softening  of  the  cord,  mixing  after 
death,  perhaps,  with  the  serous  fluid  always  present  ? Is  it  not  probable 
that  the  necessary  violence  in  opening  the  vertebral  canal  may  have 
broken  across  the  fibres,  which  during  life  were  entire  ? Again,  may 
not  the  movements  described  in  many  cases  have  been  excito-motory  ? 

At  all  events  we  consider  that,  in  the  present  state  of  science,  such 
views  are  much  more  rational  than  to  suppose  that  the  influence  of  voli- 
tion can  leap  over  four  or  five  inches  of  disorganized  spinal  cord  in  order 


STjEiUCTUKAL  DISEASES  OF  THE  SPINAL  CORD. 


441 


to  reach  the  inferior  extremities,  or  that  impressions  made  on  the  latter 
can  be  communicated  to  the  brain  by  other  channels  than  the  nervous 
system.* 

Case  XL.f — Neuralgia  of  the  Salorhital  Nerve  and  subsequent  Irritation 
and  Paralysis  of  various  Nerves  at  the  Base  of  the  Cranium,  from  Can- 
cerous Disease  of  the  Bones — Catarrhal  Pneumonia, 

History. — Mary  Stephenson,  set.  32,  wife  of  a shoemaker,  admitted  January  21st, 
1861.  Six  months  ago  she  received  a blow,  immediately  below  the  inner  canthus  of 
the  left  eye,  directly  over  the  course  of  the  infra-orbital  nerve.  The  injury  was  fol- 
lowed by  a discharge  from  the  left  nostril,  which  has  continued  up  to  the  present  time. 
Three  months  ago  she  first  experienced  pain  in  the  gums  of  the  left  side,  which  was 
attributed  to  a decayed  tooth,  and  supposed  by  her  to  be  excited  by  exposure  to  cold, 
whilst  carrying  water  from  a distance  to  her  home.  The  tooth  was  extracted  without 
causing  any  relief.  A month  after,  two  other  teeth  were  extracted — one  of  which  was 
decayed — without  any  benefit.  At  this  lime  she  experienced  pricking  sensations  be- 
low the  left  eye,  with  a feeling  as  of  cold  water  running  over  the  same  place,  with 
diminution  of  sensibility,  and  ringing  noises  in  the  left  ear.  Blisters  and  stimulating 
applications  to  the  part  only  produced  temporary  relief.  About  three  weeks  ago  the 
pupil  of  the  left  eye  became  contracted  and  the  vision  dim,  the  left  cheek  also  became 
swollen.  Extract  of  belladonna  was  applied  round  the  eye,  which  caused  the  pupil  to 
enlarge,  and  she  took  three  powders  daily  for  five  days,  which  produced  salivation. 
She  was  also  ordered  to  wean  her  child,  which  was  now  sixteen  months  old.  Expe- 
riencing no  relief,  she  entered  the  Infirmary.  Her  diet  has  always  been  good,  and  her 
general  health  excellent. 

Symptoms  on  Admission. — She  complains  of  a pricking  sensation,  often  amounting 
to  great  pain,  and  even  agony,  in  the  left  cheek,  darting  along  the  course  of  the  infra- 
orbital nerve,  constant  pain  below  inner  canthus.  Has  paroxysms,  consisting  of  dart- 
ing pain  over  the  cheek,  extending  down  to  the  chin  and  arm.  The  sensibility  of  the 
skin  is  diminished,  over  a space  extending  from  the  mesial  line  of  the  face  to  the  ear 
laterally,  extending  upwards,  so  as  to  include  the  inferior  eyelid,  and  below  to  the 
margin  of  the  lower  jaw.  There  is  partial  ptosis  of  the  left  upper  eyelid,  but  the  lids 
can  be  closed  perfectly.  The  pupil  of  left  eye  much  smaller  than  the  other,  and 
readily  contracts  on  the  applieation  of  light.  The  left  ala  nasi  remains  open  on  sniflf- 
ing.  There  is  a slight  swelling  over  the  left  malar  bone.  The  masseter  and  temporal 
muscles  act  normally. 

The  tongue  is  clean,  and,  when  protruded,  appears  to  diverge  slightly  to  the  left. 
This  is  in  consequence  of  the  mouth  being  slightly  dragged  to  the  right  when  in 
motion ; no  sensibility  to  touch  on  left  side  of  tongue,  teeth  perfect  on  both  sides. 
Cannot  masticate  her  food  on  the  left  side  of  the  mouth ; obliged  to  support  her 
chin  with  her  hand,  or  the  food  eollects  between  the  cheek  and  dental  arches.  The 
food  and  saliva  occasionally  escape  from  the  left  comer  of  the  mouth.  Tears  never 
produced.  On  endeavoring  to  spit,  the  saliva  falls  on  her  elothes,  from  want  of  power 
to  project  it.  In  drinking  she  feels  the  cup  more  distinctly  with  the  right  half  of  the 
lips,  and  the  water  feels  colder  on  the  left  side.  The  speech  is  occasionally  thick. 
Headache  during  strong  attacks.  Appetite  good.  Bowels  regular.  Other  funetions 
normal. 

Progress  of  the  Case. — On  the  2Uh  of  January,  the  patient  experienced  ago- 
nising pain  in  the  left  cheek  and  left  half  of  the  tongue.  A blister  was  ordered  to  be 
applied  behind  the  left  ear.  January  26/A. — The  pain  continues,  the  blister  having 
caused  no  relief.  The  pupil  of  the  left  eye  is  much  diminished  in  size  and  not 
movable.  Warm  fomentations  with  laudanum  to  be  applied  to  the  cheek.  January 
2^lh. — The  pain  continuing,  having  in  no  way  been  lessened  by  the  laudanum  fomen- 
tations, 20  drops  of  a solution,  containing  bi-meconate  of  morphia,  gr.  ix.  to  ^ j of  water, 
were  injected  into  the  eellular  tissue  of  the  cheek,  below  the  eyelid.  January  28^A. — • 
The  injection  caused  considerable  stupor,  which  continued  two  hours.  The  head 
pain  has  been  diminished,  she  having  experienced  only  two  twinges  since  the 
operation.  January  30</i. — Yesterday  the  pain  returned  as  violently  as  ever.  To 

* See  the  Author’s  Article  on  Paralysis,  Library  of  Medicine,  vol.  ii. 

j-  Reported  by  Messrs.  W.  Turner,  W.  Spalding,  J.  Nicholson,  and  R.  Davy,  Clini- 
cal Clerks. 


442 


DISEASES  OF  THE  NERVOUS  SA^STEM. 


repeat  the  injection  of  bi-meconate  of  morphia.  To  take  Quinice  Sulph.  gr.  v.  three 
times  daily.  February  \'2th. — The  symptoms  have  undergone  no  permanent  change  ; 
the  injections  have  been  repeated  eight  times,  causing  only  tempoi’ary  relief.  Various 
remedies  were  now  tried  in  succession,  including  the  internal  use  of  strychnine, 
belladonna,  iodide  of  potassium,  corrosive  subhmate,  and  anodyne  draughts  of  morphia 
and  chloric  ether  at  night ; and,  externally,  tr.  aconiti,  mixed  with  seven  parts  of  gly« 
cerine,  the  endermic  absorption  of  muriate  of  morphia  from  a blistered  surface  over 
the  cheek,  leeches  and  galvanism,  with  only  temporary  relief.  She  passed  sleepless 
nights,  the  discharge  from  the  left  nostril  was  increased,  and,  between  the  paroxysms, 
a constant  dull  aching  pain  below  the  left  eye  was  complained  of.  On  the  23d  March 
she  was  dismissed  at  her  own  request  in  no  way  relieved. 

She  was  re-admitted  April  3d,  the  symptoms  having  undergone  in  the  interval  little 
change.  Ext.  belladonnae  was  applied  round  the  orbit  to  dilate  the  pupil.  She  was 
then  ordered  Sol.  liydr.  hichlor.  § ij,  a teaspoonful  twice  daily.,  with  m.  xxx  sol.  mur. 
morph,  in  the  form  of  draught  at  bed  time.  April  \*lth. — Was  ordered  gum.  opii  gr. 
ij  at  bedtime,  which,  on  April  23d,  had  been  gradually  increased  to  5 grains.  On  the 
24th  ordered  4 grains,  which  she  took  until  the  case  fell  again  under  my  charge  on  the 
1st  of  May.  The  solution  of  bichloride  of  mercury  was  then  discontinued,  and  quinine 
followed  by  bebeerine  in  the  form  of  mixture,  were  again  taken,  and  Fleming’s  tr.  of 
aconite  once  more  applied  locally,  but  with  only  temporary  relief.  On  the  .27th  of 
May,  the  patient  was  dismissed  in  no  way  better. 

She  was  again  admitted  into  the  Infirmary,  December  19th,  1861.  After  leaving 
the  house  she  had  in  succession  converging  strabismus  of  the  left  eye,  which  was  much 
bloodshot ; partial  deafness  in  left  ear  ; loss  of  sensibility  and  motion  of  left  side  of 
face  ; and  dragging  of  the  features  towards  the  right  side.  Four  months  ago  the  sight 
of  the  left  eye  was  completely  gone,  and  there  was  permanent  ptosis ; hearing  on  the 
left  side  had  become  worse,  with  constant  whirring  sounds  and  throbbing  pain  in  the 
ear.  On  assuming  the  erect  posture  there  has  been  lately  a bloody  discharge  from  the 
left  nostril.  Five  weeks  ago  the  right  eye  became  affected,  and  dimness  of  sight  in 
it  lias  been  progressive.  Her  mind  has  also  become  weak  and  irritable.  On  admission 
the  features  express  great  pain  and  anxiety.  There  is  still  slight  sensibility  on  the 
left  cheek,  but  she  can  pass  a piece  of  paper  into  the  left  nostril  without  causing  any 
tendency  to  sneeze.  The  left  eyeball  is  protruded  and  apparently  enlarged.  Conjunc- 
tiva injected.  Dense  opacity  of  the  cornea,  the  lower  half  of  which  is  ulcerated.  Fupil 
dilated.  Cannot  raise  the  upper  eyelid,  but  can  slightly  evert  the  eyeball.  Great 
deafness  in  left  ear,  which  is  the  seat  of  constant  throbbing  and  singing.  Muscles  of 
left  side  of  the  face  are  flaccid,  smooth,  and  apparently  swollen,  with  complete  loss 
of  motor  power,  still  necessitating  introduction  of  the  finger  to  remove  the  food  from 
beyond  the  dental  arches.  No  smell  in  left  nostril.  Occasional  giddiness.  Sleep 
disturbed.  Left  side  of  palate  flaccid,  and  uvula  drawn  to  the  right  side.  Articulation 
so  much  imj^aired  that  her  words  are  scarcely  intelligible.  Occasional  excrucia- 
ting pain.  Other  functions  not  affected.  January  2,  1862. — Since  last  repoit, 
complains  of  violent  pain  in  the  left  eye,  occasional’ y darting  into  the  tongue, 
over  the  left  temple,  and  through  the  parotid.  To  have  2 grains  of  codeine  in  a 
a pill  three  times  daily.  She  has  subsequently  had  draughts  of  chlorodyne  at  night, 
and  occasionally  had  chloroform  administered  to  relieve  her  excessive  pain.  February 
1st. — Again  took  charge  of  this  case.  She  was  then  taking  4 pills  daily,  each  contain- 
ing a grain  of  opium,  and  at  night  half  a drachm  of  chlorodyne.  February  20th. — 
The  left  cheek  has  been  occasionally  painted  with  Fleming’s  tr.  of  aconite,  but  without 
causing  any  relief.  There  has  also  been  slight  diarrhoea  for  a few  days,  and  violent 
vomiting  on  the  night  of  the  10th.  The  appetite  has  diminished,  and  the  nourish- 
ment taken  greatly  lessened  in  quantity.  Fulse  100,  weak.  February  22d. — Less 
discharge  from  the  nostrils  externally,  and  she  complains  of  its  passing  backwards 
and  trickling  down  the  throat.  From  this  time  she  took  less  and  less  nourishment. 
The  amount  of  chlorodyne  at  night  was  increased  in  consequence  of  the  restlessness 
and  great  pain.  She  gradually  became  weaker,  and  expired  at  1 p.m.,  February  27, 
conscious  nearly  to  the  last. 

Sectio  Cadaveris,— Twenty-four  hours  after  death. 

Head. — The  brain  and  its  membranes  were  healthy,  with  the  exception  of  the  latter 
over  the  orbital  plate  of  the  ethmoid  bone,  where  they  wei'e  firmly  adherent  and  united 
to  the  osseous  tissue.  The  soft  spongy  tissue  of  the  body  of  the  sphenoid  bone,  and 
of  the  basilar  process  of  the  occipital  bone,  was  completely  infiltrated  with  a soft  grey- 
ish substance,  which  presented  to  the  naked  eye  the  appearance  of  medullary  cancer. 


NEURALGIA. 


443 


The  compact  outer  shell  of  these  bones  was  so  softened  that  a knife  could  readily  be 
passed  through  it.  The  sphenoidal  and  ethmoidal  sinuses  were  filled  with  a similar 
substance.  The  left  side  of  the  body  of  the  sphenoid  was  completely  destroyed,  so 
tliat  the  cancerous  mass  projected  into  the  middle  and  posterior  cranial  fossae.  In  the 
former  of  these  it  had  contracted  adhesion  to  the  apex  of  the  middle  cerebral  lobe.  In 
Its  growth  it  had  involved  the  third,  fourth,  fifth,  and  sixth  left  cerebral  nerves  as  thej 
passed  along  the  sides  of  the  cavernous  sinus.  They  were  all  surrounded  by  the  can- 
cerous material,  softened  in  texture,  and  evidently  infiltrated  by  it.  The  fifth  nerve 
was  especially  included  in  the  diseased  mass,  so  that  it  was  impossible  to  dissect  out 
its  fibres — the  nerve  before  it  entered  the  gasserian  ganglion,  the  ganglion  itself,  and 
the  three  large  branches  proceeding  from  it,  being  involved.  The  internal  carotid 
artery  lying  in  relation  to  the  inner  wall  of  the  cavernous  sinus  was  also  included  in 
the  tumor,  but  its  canal  was  pervious.  The  sympathetic  nerves  accompanying  the 
artery  and  forming  the  cavernous  plexus  were  necessarily  involved.  The  part  of  the 
tumor  which  projected  into  the  posterior  cranial  fossa  was  about  the  size  of  a hazel-nut. 
It  had  extended  along  the  posterior  surface  of  the  petrous  part  of  the  temporal  bone, 
and  surrounded  the  seventh  left  cranial  nerves  as  they  entered  the  internal  auditory 
meatus,  a small  portion  passing  in  along  with  them.  The  superior  surface  of  the  petrous 
bone  was  blackened.  In  places  it  was  so  soft  as  to  be  easily  cut  with  the  knife.  The 
tumor  had  grown  forwards  into  the  left  orbit,  and  had  surrounded  all  the  muscles  and 
nerves  which  lie  in  the  posterior  third  of  that  cavity.  The  posterior  part  of  the  orbital 
plate  of  the  frontal  bone  was  thickened,  softened,  and  partially  destroyed.  The  tumor 
projected  also  into  the  left  nostril,  and  had  pushed  to  the  right  side  the  nasal  septum. 
The  bones  forming  the  septum  were  in  great  part  softened  and  destroyed.  The  mucous 
membrane  of  the  right  side  of  the  septum  was  entire,  although  commencing  to  lose 
its  normal  appearance.  A quantity  of  dark  green,  almost  black,  mucus  covered  the 
mucous  membrane,  which  extended  from  the  back  of  the  nostrils  into  the  pharynx. 
The  eighth  and  ninth  cranial  nerves  were  not  affected.  Although  the  growth  of  the 
tumor  was  chiefly  to  the  left  side,  yet  it  had  in  part  also  projected  to  the  right  side. 
The  right  internal  carotid  and  its  accompanying  sixth  nerve  were  surrounded  by  it. 
The  gasserian  ganglion  of  the  fifth  on  this  side,  together  with  its  ophthalmic  and  supe- 
rior maxillary  branches,  were  distinctly  involved,  but  the  inferior  maxillary  branch 
was  very  slightly  affected.  Tlie  second,  third,  and  fourth  could  be  dissected  out,  and 
no  adhesion  between  them  and  the  tumor  was  observed.^ 

I'noRAX. — Heart  and  pericardium  natural.  There  was  a moderate  quantity  of  a 
gelatinous  matter  in  the  bronchi,  the  lining  membrane  of  which  was  somewhat  congested. 
Both  lungs  had  interiorly  a some.vhat  knotty  irregular  feeling;  on  being  cut  into  this 
was  found  owing  to  the  existence  of  numerous  little  patches  of  catarrhal  pneumonia. 
The  affected  patches  were  of  a pale  yellowish-pink  color,  slightly  granular  appearance, 
softish  consistence,  and  on  being  squeezed,  a small  quantity  of  fluid,  resembling  pus 
mixed  with  air,  escaped. 

Abdomex. — There  was  no  abdominal  lesion. 

Microscopic  Examination. — Portions  of  the  tumor  selected  from  the  following 
parts — from  the  sphenoidal  sinus,  from  within  the  body  of  the  sphenoid,  from  the  sella 
turcica,  and  from  the  part  projecting  into  the  posterior  cranial  fossa,  all  presented 
those  cell-forms  which  are  characteristic  of  soft  cancer.  The  indurated  patches  of 
pulmonary  tissue  were  found  to  consist  of  epithelial  cells  and  nuclei,  mixed  with 
some  pus  globules. 

Commentary . — This  case,  which  was  under  observation  for  more  than 
a twelvemonth,  exhibits  remarkably  well  the  progress  of  a cancerous 
growth  in  the  osseous  substance  at  tlie  base  of  the  cranium.  At  first 
the  symptoms  of  a neuralgia  of  the  suborbital  nerve  only  were  present, 
but  as  the  disease  spread,  its  direction  could  be  accurately  followed  by  its 
effects  on  the  various  nerves  it  involved.  Thus  the  ptosis,  loss  of  contrac- 
tility in  the  iris,  and  impaired  mobility  of  the  eye-ball  in  some  directions, 
were  owing  to  lesion  of  the  third  nerve,  while  loss  of  movement  in  other 
directions  was  owing  to  the  disease  having  attacked  the  fourth  and  sixth 
nerves.  Pressure  upon  the  first  and  second  division  of  the  fifth  nerve 
was  indicated  by  the  neuralgia,  impaired  nutrition  of  the  eyeball,  and 

* The  morbid  parts  were  carefully  dissected  by  Mr.  Turner,  to  whom  I am  indebted 
for  the  above  facts.  They  may  be  seen  in  the  University  Museum. 


444 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


insensibility  of  the  nasal  mucous  membrane  That  the  inferior  maxillary 
was  involved  was  proved  by  paralysis  of  the  muscles  of  mastication, 
while  the  deafness  and  facial  paralysis  demonstrated  that  both  divisions 
of  the  seventh  nerve  were  affected.  In  a note  concerning  this  case 
which  Mr.  Turner  was  good  enough  to  give  me,  he  says,  “ The  paralysis 
of  the  soft  palate  may  be  difficult  to  find  a reason  for,  seeing  that  the 
vagus  nerve,  which  through  its  pharyngeal  branches  is  its  principal 
motor-nerve,  was  unaffected.  But  one  of  the  muscles  of  the  soft  palate — 
viz.  the  tensor  palati — receives  a branch  from  the  otic  ganglion,  which 
ganglion  again  receives  its  motor-root  from  the  third  division  of  the  fifth, 
which  was  included  in  the  tumor.  It  may  be  also,  that  the  soft  palate 
receives  a branch  from  the  portio  dura,  for  that  nerve  gives  off  a branch, 
the  greater  superficial  petrosal,  to  Meckel’s  ganglion,  from  which  the 
descending  palatine  nerves  pass  to  the  soft  palate.  From  the  fact  of 
both  the  sympathetic  nerve  and  the  ophthalmic  division  of  the  fifth  being 
involved  in  the  disease,  the  case  throws  additional  light  on  the  question, 
whether  the  sympathetic  or  the  ophthalmic  division  of  the  fifth  regulates 
the  nutrition  of  the  eyeball.” 

The  phenomena  may  further  be  grouped,  as  they  were  connected,  with 
special  nerve  functions  : — 1st,  The  increase  or  loss  of  common  sensibility, 
of  which  it  may  be  observed  that  while  the  skin  was  insensible  to  touch, 
it  was  the  seat  of  great  pain,  a circumstance  by  no  means  uncommon  in 
paralysed  parts.  I have  seen  the  skin  also  insensible  to  cold,  while 
morbidly  sensitive  to  beat,  so  that  the  numerous  tubes  which  enter  a 
compound  nerve  may  be  excited  by  varied  impressions.  It  is  even 
possible  that  while  some  are  capable  of  being  excited  by  motor,  and 
others  by  sensitive  impression,  a third  class  may  be  stimulated  by  heat, 
and  a fourth  by  cold,  and  others  by  a variety  of  peculiar  stimuli  we  have 
not  yet  discriminated.  2d,  The  complete  loss  of  the  special  sensibility, 
on  the  affected  side,  of  smell,  sight,  hearing,  and  taste — all  the  special 
nerves  having  been  involved  in  the  cancerous  growth  in  the  bone.  3d, 
The  paralysis  of  motion  in  the  fibres  of  the  iris,  in  those  of  the  levator 
palpebrae  superioris,  buccinator,  and  tongue,  from  injury  to  motor-nerves. 
4th,  The  increased  secretion  from  the  nostrils  and  from  the  salivary 
glands,  but  not  from  the  lachrymal  gland.  5th,  The  influence  on  the 
vaso-motor  nerves,  as  observed  in  the  redness,  increased  heat,  and  even 
swelling  of  the  left  side  of  the  face,  especially  during  a paroxysm  of  pain. 
Several  of  these  symptoms  even  were  latterly  observable  on  the  right 
side.  And  6th,  the  effect  on  nutrition,  as  observable  in  the  destruction 
of  the  eyeball,  and  progressive  emaciation  of  the  tissues  of  the  face  on 
the  left  side. 

The  multitude  of  remedies  tried  in  this  case  not  only  failed  to  arrest 
the  disease,  which  from  its  nature  was  scarcely  to  be  expected,  but  did 
little  to  relieve  the  symptoms.  Narcotics,  whether  employed  locally  or 
internally,  if  in  sufficient  doses  to  affect  the  brain,  caused  stupefaction 
and  only  temporary  ease. 

The  pathology  of  neuralgia,  when  dependent  upon  a structural  dis- 
ease, such  as  the  one  just  related,  is  clear  enough,  and  consists  of  pres- 
sure on  the  nerve  causing  irritation  and  excitement,  in  the  first  instance, 
and  loss  of  function  in  the  second.  The  same  results  may  be  caused  by 
liestruction  of  the  nerve  (see  p.  152)  ; and  according  to  the  amount  of 
pressure  or  disease  even  in  the  same  nerve,  may  the  functions  of  its  vaid- 


rUNCTIONAIi  DISOKDEES  OF  TEE  NERYOES  SYSTEM. 


445 


ous  tubules  be  excited,  perverted,  or  destroyed.  In  a case  I watched  with 
great  care  at  the  Salpetriere  in  1839,  under  M.  Cruvelhier,  it  was  observed 
that,  whilst  the  first  and  third  divisions  of  the  fifth  nerve  were  paralysed, 
the  parts  supplied  by  the  second  division  were  the  seat  of  excruciating 
neuralgia.  On  dissection,  considerable  thickening  of  the  dura  mater 
existed,  where  the  main  trunk  of  the  nerve  made  its  exit  from  the 
cranium;  and  it  appeared  evident  that,  whilst  the  more  external  tubules 
were  so  compressed  as  to  cause  loss  of  function,  the  more  internal  were 
less  acted  upon,  so  as  to  induce  excitement.  When,  however,  neuralgia 
is  functional,  great  discussion  has  taken  place  as  to  the  nature  of  the 
change  producing  it.  Thus,  it  may  depend  upon  the  temporary  conges- 
tion of  some  nerve-centre,  irritating  the  root  of  a nerve,  or  upon  an 
irritation  applied  to  any  part  of  its  course,  or  even  to  its  extremities. 
Again,  it  may  be  caused  by  a change  in  the  nutrition  of  the  nerves, 
in  what  Du  Bois  Raymond  calls  their  electro-tonic  state.  For  anything 
positive  as  to  this  last  condition,  we  must  wait  for  the  further  progress 
of  electro-magnetic  pathology. 

In  the  treatment  of  functional  neuralgia,  all  the  remedies  which  were 
given  in  the  case  of  Stephenson  have  been  tried  with  varying  success. 
It  should  never  be  forgotten  that  the  pain  is  most  variable  and  capri- 
cious in  its  attacks,  with  intervals  more  or  less  long — a circumstance 
which  favors  fallacies  as  to  the  value  of  particular  drugs.  The  disorder 
also  often  goes  away  of  itself.  Notwithstanding,  whenever  it  exhibits  a 
periodic  tendency,  which  it  frequently  does,  antiperiodic  remedies  are 
very  beneficial.  Of  these,  I have  found  bebeerine  most  valuable.  All 
local  anodyne  remedies  should  be  tried  as  palliatives,  the  best  being 
Fleming’s  tincture  of  aconite,  and  injection  of  the  cutaneous  cellular 
tissue  with  a watery  solution  of  bi-meconate  of  morphia.  The  applica- 
tion of  narcotic  vapor,  as  recommended  by  Dr.  Downing,  I have  also 
seen  give  great  relief. 

FUNCTIONAL  DISORDERS  OF  THE  NERVOUS  SYSTEM. 

Case  XLI.^ — Partial  Amaurosis — Spectral  Illusions — Perversions  of 
Hearing^  Smell,  and  Touch — Spinal  Irritation, 

History. — Mrs.  M’Kenzie,  set.  35 — admitted  December  30,  1850. — Has  been 
travelling  companion  to  a lady,  and  always  been  a delicate  and  highly  nervous  person. 
Nine  years  ago  she  had  rheumatic  fever,  and  twelve  months  afterwards  her  sight 
became  impaired,  owing,  she  supposes,  to  too  much  reading  at  night  with  gas-light. 
For  this  she  was  freely  bled  and  blistered,  and  was  subjected  to  a long  antiphlogistic 
treatment  by  an  oculist,  without  benefit.  About  the  same  period  the  menses  became 
irregular,  leucorrhoea  was  established,  and  there  was  great  spinal  irritation.  For 
these  latter  complaints  I prescribed  for  her  several  times,  an  1 getting  better,  she  went 
to  Canada.  From  thence  she  returned  four  months  ago,  and  feeling  weak,  the 
menstrual  discharge  also  having  been  excessive  during  the  last  four  months,  she 
entered  the  Infirmary. 

Symptoms  on  Admission. — On  admission,  she  complains  of  headache  and  pain  in 
the  epigastrium,  darting  round  the  left  side,  and  extending  to  the  back.  Pressure 
over  the  fourth  and  fifth  dorsal  vertebrae,  corresponding  to  the  painful  part,  causes 
acute  pain.  There  is  also  slight  tenderness  over  the  lower  lumbar  vertebrae.  The  left 
pupil  is  slightly  dilated,  and  vision  is  much  impaired.  She  does  not  look  straight 

* Reported  by  Mr.  Henry  Thom,  Clinical  Clerk. 


446 


DISEASES  OF  THE  NERYOES  SYSTEM. 


forward  at  any  object  placed  before  her ; both  eyes  being  turned  to  the  left  of  it,  almost 
at  light  angles.  She  is  much  troubled  with  ocular  spectra.  She  thinks  she  sees  wild 
animals,  flower-gardens,  oil  paintings,  and  children  dancing  before  her,  dressed  in 
clothes  of  various  colors.  She  frequently  experiences  noises  in  the  ears,  and  especially 
one  like  the  ringing  of  a small  hand-bell.  The  sense  of  smell  is  also  perverted  ; a box 
of  strong  snuff,  for  instance,  when  placed  below  her  nose,  having  apparently  the  odor 
of  tea.  The  sense  of  taste  is  not  altered.  The  sense  of  touch  is  capable  of  being 
perverted  by  suggestive  ideas.  On  placing  a cold  piece  of  metal  in  her  hand,  and 
telling  her  it  was  warm,  she  declared  that  it  was  so.  V oluntary  motion  is  also  impaired. 
On  being  addressed  suddenly  she  starts  ; and  on  endeavoring  to  grasp  an  object,  makes 
several  ineffectual  efforts  to  do  so.  At  the  same  time,  there  is  considerable  tremor 
and  twitchings  of  the  muscles  of  both  arms.  There  is  also  great  difficulty  in  walking, 
from  a sense  of  being  pressed  down  by  a heavy  weight  placed  on  her  shoulders.  The 
tongue  is  pale,  furred,  and  cracked ; there  is  an  acid  taste  in  the  mouth,  frequent  slight 
difficulty  of  deglutition,  and  occasional  vomiting  about  half  an  hour  after  taking  solid, 
but  not  liquid,  food.  The  bowels  are  opened  very  irregularly,  and  there  is  in  eneral 
constipation.  The  urine  has  a specific  gravity  of  1005 — not  coagulable.  The  men- 
struation is  irregular,  and  has  been  latterly  profuse.  During  the  last  six  months  it  has 
appeared  five  times.  In  the  intervals,  there  is  abundant  leucorrhoea.  On  examination 
with  the  speculum,  the  os  and  cervix  uteri  were  found  tumefied.  There  was  no  ulce- 
ration, but  copious  discharge  of  purulent  matter  from  the  os  uteri.  The  sounds  of  the 
heart  are  natural.  Pulse  60,  soft.  Other  organs  healthy.  A tepid  hath  was  ordered 
every  morning.  T ? use  also  a vaginal  injection  of  one  drachm  of  alum  to  eight  ounces 
of  water  ; and  to  have  the  following  mixture:  Ferri  Citratis^  3 ss  ; TV.  Card.-Comp. 

5 j ; Tr.  Aurantii  | ss ; Inf  us.  Columb.  3 ivss ; M. ; | ss  to  he  taken  three  times  a day. 

Progress  op  the  Case. — Under  this  treatment,  and  with  an  occasional  laxative, 
her  general  health  greatly  improved.  The  menorrhagia  ceased.  The  headache  dimin- 
ished; the  appetite  improved.  The  spectral  and  aural  illusions  ceased  to  appear, 
and  on  the  19th  of  February  she  insisted  on  going  out. 

Commentary. — In  this  case,  conjoined  with  spinal  irritation,  there 
was  imperfect  amaurosis,  one  point  of  each  retina  only  retaining  its  sen- 
sibility to  light,  which  point  she  brought  into  the  axis  of  vision,  by 
directing  both  eyes  to  the  left  of,  and  at  right  angles  with,  the  object 
examined.  With  the  exception  of  taste  also,  all  the  other  senses  were 
more  or  less  perverted.  At  the  same  time,  the  digestive  and  uterine 
functions  were  much  disordered ; and  it  was  observed  in  this,  as  it  has 
been  in  numerous  similar  cases,  that,  as  her  general  strength  improved 
and  the  dyspnoea  and  menorrhagia  diminished,  so  did  the  spectral  and 
aural  illusions  and  other  perversions  of  the  nervous  system  disappear. 
This  fact  points  out  how  cautiously  the  treatment  of  these  cases  should 
be  conducted  in  the  first  instance,  and  how  dangerous  the  bleedings, 
cuppings,  purgings,  mercurials,  etc.  etc.,  must  be  in  certain  cases  of  in- 
cipient amaurosis,  when  these  are  practised  (as  they  too  often  are) 
without  discrimination  or  reference  to  the  constitutional  powers  of  the 
patient. 

Another  curious  phenomenon  was  observed  in  this  case — namely, 
that  her  sensations  were  capable  of  being  governed  to  a certain  extent 
by  suggestive  ideas.  That  is  to  say,  on  calling  attention  to  a particular 
object  placed  in  her  hand,  and  asserting  that  it  was  hot  or  cold  (although 
in  reality  it  was  neither),  corresponding  sensations  were  produced  in  her 
mind.  This  peculiar  condition  of  the  nervous  system  is  one  which,  it 
appears  to  me,  is  more  deserving  the  attention  of  medical  men  than  they 
have  hitherto  paid  to  it.  It  is  well  known  to  numerous  charlatans,  who 
have  ascribed  the  phenomena  so  produced  to  an  external  jwwer  or  force, 
which  they  could  wield  at  pleasure.  Such  ideas  have  done  much  to 
shock  the  minds  of  physiologists  and  medical  men,  and  prevent  the 


FUNCTIONAL  DISOKDERS  OF  THE  NERVOUS  SYSTEM.  44) 

proper  appreciation  of  many  important  facts.  Believing,  however,  that 
these  facts  are  capable  of  being  explained  on  physiological  principles,  and 
are  capable  of  being  rendered  serviceable  in  practical  medicine,  I would 
direct  your  attention  to  them  in  a special  manner.  (See  p.  285,  et  seq.) 
In  no  case  I ever  saw  was  the  inutility  of  antiphlogistics,  mercury,  and 
other  modes  of  active  treatment,  better  demonstrated,  even  to  relieve  the 
amaurosis,  for  which  they  were  used.  In  fact,  not  only  the  disorder  of 
the  retina  increased,  but  so  much  was  the  weakness  augmented,  as  ap- 
parently to  induce  almost  every  other  form  of  nervous  disorder.  On 
admission  to  the  house  her  condition  was  pitiable,  and  from  this  she 
was  restored  by  rest,  good  diet,  chalybeates,  cheerful  conversation,  and 
confident  predictions  of  her  recovery,  which  evidently  had  a powerful 
influence  in  calming  her  mind  and  diminishing  the  nervous  symptoms. 

The  functional  derangements  of  the  nervous  system  are  capable  of 
assuming  at  various  times  every  conceivable  disorder  of  intelligence, 
sensation,  and  motion,  so  that  not  only  may  all  kinds  of  diseases  which 
have  received  names  be  simulated,  but  the  symptoms  may  be  so  curi- 
ously combined  as  to  set  all  arbitrary  nosological  classification  at  defiance. 
If  it  be  farther  remembered  that  through  the  brain,  spinal  cord,  and 
nerves,  the  functions  of  every  organ  in  the  body  may  be  more  or  less 
influenced,  the  endless  variety  of  local  as  well  as  of  general  ‘derange- 
ments will  readily  be  imagined.  To  illustrate  each  of  these  numerous 
forms  of  disease  by  cases  is,  in  a clinical  course,  impossible ; although 
the  wards  always  present  a variety  of  examples  of  perverted  nervous 
function.  I shall  content  myself,  therefore,  with  giving  a classified 
enumeration  of  these  disorders,  and  then  dwelling  more  especially  on 
their  pathology  and  treatment. 

The  functional  disorders  of  the  nervous  system  may  be  classified 
into — 1st,  Cerebral;  2d,  Spinal;  3d,  Cerebro-spinal ; 4th,  Neural;  and 
5th,  Neuro-spinal ; according  as  the  brain,  spinal  cord,  or  nerves  are 
affected  alone,  or  in  combination.  Aberrations  of  intellect  always  de- 
pend on  cerebral  disturbance  ; while  perversions  of  motion  and  sensi- 
bility, if  extensive,  indicate  spinal ; and  if  local,  neural  disorder.  Thus 
insanity  and  apoplexy  are  cerebral ; tetanus  and  chorea,  spinal ; epilepsy 
and  catalepsy  are  cerebro-spinal ; neuralgia  and  local  paralysis  are  neural ; 
and  all  combined  spasms,  dependent  on  diastaltic  or  reflex  actions,  are 
neuro-spinal.  The  following  enumeration  of  nervous  disorders,  with  the 
meanings  that  ought  to  be  attached  to  them,  will  at  the  same  time  serve 
the  purposes  of  definition  and  of  nosological  distinctions. 


Classification  of  Functional  JYervous  Disorders. 

I. — Cerebral  Disorders,  in  wTiicTi  the  cerebral  lobes  {or  brain  'proper') 
are  affected. 

1.  Insanity^  or  mental  aberration  in  its  various  forms,  not  organic, 

including  delirium. 

2.  Headache  and  other  uneasy  sensations  within  the  cranium,  such 

as  lightness,  heaviness,  vertigo,  etc.  etc. 


448 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


3.  Apoplexy,  Sudden  loss  of  consciousness  and  of  voluntary  motion 

commencing  in  the  brain.  The  absence  of  consciousness 
necessarily  involves  that  of  sensation.  The  same  condition 
as  regards  nervous  phenomena  exists  in  syncope  and  asphyxia,^ 
but  the  first  of  these  commences  in  the  heart,  and  the  second 
in  the  lungs.  Allied  to  apoplexy  is  coma  or  stupor,  arising 
from  various  causes  affecting  the  brain,  such  as  pressure,  or 
poisonous  agents  like  alcohol,  chloroform,  opium,  etc.  etc. 

4.  Trance,,  or  prolonged  somnolence,  either  with  or  without  perver- 

sion of  sensation  or  motion.  To  this  state  is  allied  ecstasy,,  or 
unconsciousness  with  mental  excitement. 

6.  Irregular  motions,  spasms,  etc.,  originating  in  excited  or  diminished 
voluntary  power,  as  in  certain  cases  of  dominant  ideas,  som- 
namhulism,  saltatory  movements,  tremors,  etc.,  or  on  the  other 
hand  incapahility  of  movement  from  languor,  surprise,  mental 
agitation,  etc.  etc. 

[T. — Spinal  Disorders,  in  which  the  cranial  and  vertehral  portions  of  the 
spinal  cord  are  affected. 

1.  Spinal  irritation.  Pain  in  the  spinal  column,  induced  or  increased 

by  pressure  or  percussion,  often  associated  with  a variety  of 
neuralgic,  convulsive,  spasmodic,  or  paralytic  disorders,  affect- 
ing in  different  cases  all  the  organs  and  viscera  of  the  body, 
and  so  giving  rise  to  an  endless  number  of  morbid  states, 
especially  muscular  pain,  as  shown  by  Dr.  Tuman. 

2.  Tetanus.  Tonic  contraction  of  the  voluntary  muscles.  Trismus, 

if  confined  to  the  muscles  of  the  jaws.  Opisthotonos,  if  affect- 
ing the  muscles  of  the  back,  so  as  to  draw  the  body  backwards. 
Emprosthotonos,  if  affecting  the  muscles  of  the  neck  and 
abdomen,  so  as  to  draw  the  body  forwards;  and  Pleurosthotonos 
if  affecting  the  muscles  of  the  body,  laterally,  so  as  to  draw  the 
body  sideways. 

3.  Chorea.  Irregular  action  of  the  voluntary  muscles,  when  stimu- 

lated by  the  will. 

4.  Hysteria.  Any  kind  of  perverted  nervous  function,  connected 

with  uterine  derangement.  Nothing  can  be  more  vague  than 
this  term. 

5.  Hydrophohia.  Spasms  of  the  muscles  of  the  pharynx  and  chest, 

with  difficulty  in  drinking  and  dread  of  fluids. 

6.  Spasms  and  convulsions.  Tonic  and  clonic  contractions  of  the 

muscles  of  every  kind  and  degree,  not  included  in  the  above, 
originating  in  the  cord  (centric  spinal  diseases  of  Marshall 
Hall). 

7.  Hemiplegia.  Paralysis  of  a lateral  half  of  the  body,  generally 

dependent  on  disorders  of  the  cranial  portion  of  the  spinal  cord 
above  the  decussation  in  the  medulla  oblongata. 

8.  Paraplegia.  Paralysis  on  both  sides  of  the  body,  generally  the 

lower  half,  in  consequence  of  disorder  of  the  vertebral  portion 
of  the  spinal  cord,  below  the  decussation  in  the  medulla  ob* 
longata. 


FUNCTIONAL  DISORDERS  OF  THE  NERVOUS  SYSTEM. 


449 


III.  — Cerebro-Spinal  Disorders,  in  which  the  cerebral  lobes  and  spinal 

cord  are  both  affected. 

1.  iEpilepsy.  Loss  of  consciousness,  with  spasms  or  convulsion 

occurring  in  paroxysms.  Apoplexy  vnth  convulsion  or  paralysis 
is  also  cerebro-spinal,  though  generally  organic. 

2.  Catalepsy.  Loss  of  consciousness,  with  peculiar  rigidity  of 

muscles,  so  that  when  the  body  or  a limb  is  placed  in  any 
position  it  becomes  fixed. 

3.  Eclampsia.  Tonic  spasms,  with  loss  of  consciousness  in  infants. 

The  acute  epilepsy  of  some  writers. 

IV.  — Neural  Disorders,  in  which  the  nerves  are  affected  during  their 

course  or  at  their  extremities. 

1.  Neuralgia.  Pain  in  the  course  of  a nerve,  although  in  fact  all 

kind  of  pain  whatever  is  owing  to  irritation  of  the  nerves. 
Thus  the  sympathetic  system  of  nerves  and  its  ganglia,  though 
ordinarily  giving  rise  to  no  sensation,  may  occasionally  do  so, 
as  in  angina  pedorisj  colic^  irritable  testicle  and  uterus^  and  other 
■ agonising  sensations,  referred  to  various  organs. 

2.  Irritation  of  the  nerves  of  speeial  sense.  Of  the  optic,  causing 

flashes  of  lights  ocular  spectra,  muscce  volitantes,  color-blindness, 
etc. ; of  the  auditory,  causing  tinnitus  aurium  ; of  the  olfactory, 
causing  unusual  sensitiveness  to  odors;  and  of  the  gustatory, 
causing  perverted  tastes  in  the  mouth.  Itching,  formication,  and 
other  sensations  referable  to  the  peripheral  nerves,  also  belong 
to  this  class. 

3.  Irritation  of' special  nerves  of  motion,  as  in  local  spasms  of  one  or 

more  muscles,  or  of  the  hollow  viscera. 

4.  Local  Paralysis.  Loss  of  motion  or  sensibility  in  a limited  part 

of  the  body,  or  confined  to  a special  sense,  as  in  lead  palsy,  or 
in  amaurosis,  cophosis,  anosmia,  ageustia,  anccsthesia. 

V.  — Neuro-S  PINAL  Disorders,  in  which  both  the  nerves  and  spinal  cord 

are  affected. 

1.  Piastaltic  or  reflex  actions.  To  this  class  belong  all  diseases  de- 
pending on  irritation  of  the  extremity  of  a sensitive  nerve, 
acting  through  the  cord  and  motor  nerves  on  the  muscular 
system,  and  producing  a variety  of  spasmodic  disorders,  local 
or  general,  far  too  numerous  to  mention, — which  can  only  be 
understood  by  a thorough  knowledge  of  the  physiology  of  the 
diastaltic  or  excito-motory  system  of  nerves. 


Pathology  of  Functional  Nervous  disorders. 

By  the  term  functional  disorder  of  the  nervous  system,  I understand 
one  which  may  produce  the  greatest  pain,  spasm,  paralysis,  and  even 
death,  and  yet,  on  the  most  careful  examination  afterwards,  assisted  by 
the  most  minute  researches  with  the  aid  of  the  microscope,  not  the 
slightest  change  from  the  normal  structure  of  the  nervous  tissue  can  be 
29 


450 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


observed.  Sucli  is  wliat  occurs  in  all  the  disorders  we  have  named, 
some  of  them  moreover  almost  always  fatal,  such  as  tetanus  and  hydro- 
phobia. At  the  same  time  it  must  not  be  forgotten,  that  similar  phe- 
nomena may  be  the  result  of  structural  disease  of  the  nervous  system. 
Thus  tetanic  rigidity  may  depend  on  a spinal  arachnitis,  as  well  as  on 
the  irritation  from  a wound,  or  poisoning  by  strychnine,  and  delirium 
and  coma  may  be  caused  by  cerebral  meningitis,  as  well  as  by  moral  in- 
sanity, starvation,  or  poisoning  by  chloroform  or  opium.  Whether  in 
these  cases  there  be  in  fact  only  one  cause  common  to  the  whole,  it  is 
difficult  to  say,  certainly  it  cannot  be  demonstrated.  It  might  be  con- 
tended that  in  every  instance  there  is  a certain  amount  of  congestion  pro- 
ducing unaccustomed  pressure,  or  that  a peculiar  state  of  nutrition  of  the 
part  is  momentarily  produced  here  or  there  in  the  nervous  mass.  But 
as  neither  theory  appears  to  us  applicable  to  all  cases,  we  shall  consider 
the  pathological  causes  of  functional  nervous  disorders  as  of  three  kinds 
— 1st,  Congestive  ; 2d,  Diastaltic ; 3d,  Toxic. 

Congestive  disorders  of  the  nervous  system. — I have  previously  pointed 
out  the  peculiar  nature  of  the  circulation  within  the  cranium  and  verte- 
bral canal,  and  shown  that,  although  well  defended  under  ordinary  cir- 
cumstances against  any  mischievous  change,  still  when  an  alteration  does 
occur  it  operates  in  a peculiar  manner.  (See  p.  148,  et  seq.)  In  other 
words,  so  long  as  the  bones  are  capable  of  resisting  atmospheric  pressure, 
although  the  amount  of  fluid  within  these  cavities  cannot  change  as  a 
whole,  yet  the  distribution  of  that  amount  may  vary  infinitely.  Thus, 
by  its  being  accumulated  sometimes  in  the  arteries,  at  other  times  in  the 
veins,  or  now  in  one  place  and  then  in  another,  unaccustomed  pressure 
may  be  exercised  on  different  parts  of  the  nervous  centres.  This,  accord- 
ing to  its  amount,  may  either  irritate  or  suspend  the  functions  of  the 
parts,  a fact  proved  by  direct  experiment,  as  well  as  by  innumerable  in- 
stances, where  depression  of  bone  has  caused  nervous  phenomena,  which 
have  disappeared  on  removal  of  the  exciting  cause.  That  congestion 
does  frequently  occur  in  the  brain  and  spinal  cord,  there  can  be  no 
doubt,  although  it  cannot  always  be  demonstrated  after  death.  The 
tonic  contraction  of  the  arteries  is  alone  sufficient  to  empty  them  of  their 
contents,  and  turgidity  of  the  veins  may  or  may  not  remain  according  to 
the  symptoms  immediatel}"  preceding  death,  and  the  position  in  which 
the  body  is  placed.  But  it  is  observable  that  all  causes  which  excite  or 
diminish  the  action  of  the  heart  and  general  powers  of  the  body,  induce, 
at  the  same  time,  nervous  disturbance,  by  occasioning  a change  of  cir- 
culation in  the  cerebro-spinal  centres — such  as  the  emotions  and  passions, 
plethora  and  anemia,  uterine  derangement,  etc.  etc. 

It  is  only  by  this  theory  that  we  can  understand  how  such  various 
results  occasionally  occur  from  apparently  the  same  cause,  and  again  how 
what  appear  to  be  different  causes  produce  similar  effects.  Thus  violent 
anger  or  an  unaccustomed  stimulus  may,  in  a healthy  person,  induce  a 
flushed  countenance,  increased  action  of  the  heart,  a bounding  pulse,  and 
sudden  loss  of  consciousness.  Again,  fear  or  exhaustion  may  occasion 
a pallid  face,  depressed  or  scarcely  perceptible  heart’s  action,  feeble  pulse, 
and  also  loss  of  consciousness.  In  the  first  case,  or  coma,  there  is  an 
accumulation  of  blood  in  the  arteries  an-d  arterial  capillaries,  and  a corre- 


rUXCTlOJ^AL  DISORDERS  OE  THE  NERVOUS  SYSTEM. 


451 


spoiicling  compression  of  the  veins ; in  the  second  case,  or  syncope^  there 
is  distension  of  the  veins  and  venous  capillaries,  with  proportionate  di- 
minution of  the  calibre  of  the  arteries.  In  either  case,  owing  to  the  pecu- 
liarity of  the  circulation  within  the  cranium,  pressure  is  exerted  on  the 
brain.  Hence  syncope  differs  from  coma  only  in  the  extreme  feebleness 
of  the  heart’s  action — the  cause,  producing  loss  of  consciousness,  sensa- 
tion, and  voluntary  motion,  being  the  same  in  both.  Indeed,  it  is  some- 
times difficult  to  distinguish  these  states  from  each  other,  and  that  they 
have  frequently  been  confounded  does  not  admit  of  doubt. 

In  the  same  manner,  partial  congestions  from  either  cause  may  occur 
in  one  hemisphere,  or  part  of  a hemisphere,  in  the  brain,  or  in  any  par- 
ticular portion  or  segment  of  the  spinal  cord.  The  pressure  so  occasioned 
may  irritate  and  excite  function,  or  may  paralyse  or  suspend  it ; nay,  it 
may  so  operate  as  to  suspend  the  function  of  one  part  of  the  nervous 
system,  while  it  exalts  that  of  another.  Thus  all  the  phenomena  of 
epilepsy  are  eminently  congestive,  the  individual  frequently  enjoying  the 
most  perfect  health  in  the  intervals  of  the  attack,  although  the  effects 
are  for  the  time  terrible,  causing  such  pressure,  that,  while  the  cerebral 
functions  are  for  the  time  annihilated,  the  spinal  ones  are  violently  ex- 
cited. In  the  same  manner  are  explained  all  the  varied  phenomena  of 
hysteria  and  spinal  irritation,  for  inasmuch  as  the  spinal  cord  furnishes, 
directly  or  indirectly,  nerves  to  every  organ  of  the  body,  so  congestion 
of  this  or  that  portion  of  it  may  increase,  pervert,  or  diminish  the  functions 
of  the  nerves  it  gives  off,  and  the  organs  which  they  supply.  Congestion, 
therefore,  we  conceive  to  be  the  chief  cause  of  functional  nervous  dis- 
orders originating  in  the  great  cerebro-spinal  centre. 

Biastaltic  or  Reflex  Disorders  of  the  Nervous  System. — We  have  pre- 
viously seen  that  recent  researches  render  it  probable  that  the  actions 
hitherto  denominated  I'eflex  are  in  fact  direct  (p.  145),  only  that  the  im- 
pression which  is  conveyed  commences  in  the  circumference  of  the  body, 
instead  of  in  the  nervous  centres.  There  is  every  reason  to  believe  that 
such  impressions  pass  throuyh  the  cord  by  means  of  conducting  nerve- 
fibres,  which  cross  from  one  side  of  that  organ  to  the  other,  and  that 
histology  will  yet  demonstrate  that  all  these  apparently  confused  actions 
are  dependent  on  the  existence  of  certain  uniform  conducting  media. 
Indeed,  already  we  can  judge  with  tolerable  exactitude,  from  the  effects, 
what  are  the  particular  nerves  and  segments  of  the  cord  which  are  in- 
fluenced during  a variety  of  actions  ; and  notwithstanding  the  immense 
difficulties  of  the  inquiry,  we  have  every  hope  that  the  period  is  not  dis- 
tant when  the  diagnosis  of  many  more  reflex  acts  will  also  be  rendered 
certain.  The  principle  involved  in  all  these  acts  is,  that  the  irritation 
which  produces  them  is  to  be  sought  for  in  the  nervous  extremities 
rather  than  in  lesions  of  the  centres;  and  the  great  importance  of  this 
principle  in  pathology  and  in  practice  cannot  be  too  highly  estimated, 
although  for  the  numerous  details  which  illustrate  it,  I must  refer  to 
physiological  works,  and  especially  to  those  of  Dr.  Marshall  Hall.  I 
would  point  to  traumatic  tetanus  and  to  the  convulsions  resulting  from 
teething  and  gastric  derangements  in  children,  as  good  examples  of  dia- 
staltic  functional  disorders. 


452 


DISEASES  OF  TUE  NERVOUS  SYSTEM. 


In  addition  to  important  diseases  of  this  kind,  numerous  symptoms 
which  accompany  organic  changes  belong  to  the  same  category.  In  other 
words,  the  structural  lesion  constitutes  the  irritant,  or  cause,  while  the 
effect  is  functional.  Thus  I have  seen  epileptic  opisthotonos,  after  resist- 
ing for  years  every  kind  of  remedy,  at  once  removed  on  extracting  a 
decayed  tooth.  In  the  case  of  Joanna  M’Grregor,  admitted  Dec.  4th, 
1856,  there  was  hysterical  epilepsy,  which  resisted  all  treatment,  and 
among  the  rest,  a long-continued  use  of  the  bromide  of  potassium,  recently 
recommended  by  Sir  Charles  Locock  in  such  cases.  The  attacks  of  uni- 
versal rigidity,  with  tremor  and  complete  unconsciousness,  usually  lasted 
from  three  to  four  hours.  It  was  observed,  however,  that  immediately 
before  coming  out  of  the  attack  she  was  seized  with  suffocative  cough, 
accompanied  by  great  turgidity  and  redness  of  the  face.  It  was  thought 
that  by  exciting  such  cough  artificially,  the  attacks  might  be  shortened. 
Galvanism  was  in  consequence  applied  to  the  larynx  the  moment  she 
was  seized,  with  the  eti'ect  of  at  once  exciting  cough,  flushing  of  the  face, 
and  immediate  recovery.  In  this  case,  the  spasm  of  the  larynx,  which 
was  an  excito-motory  act,  by  producing  a change  in  the  circulation  within 
the  cranium,  dispelled  the  congestion  causing  the  epileptic  paroxysm. 

Again,  those  compound  effects  which  require  the  conjunction  of  voli- 
tion with  diastaltic  acts  are  most  interesting  to  the  scientific  practitioner 
— such,  for  instance,  as  coughing,  yawning,  laughing,  hiccough,  and  sneez- 
ing. Cough  more  especially  is  a frequent  and  most  distressing  symptom, 
and,  as  we  shall  subsequently  see,  requires  for  its  successful  treatment  a 
thorough  knowledge  of  the  causes  producing  it.  If,  for  instance,  it  ori- 
ginates in  irritating  disease  of  the  larynx,  what  permanent  benefit  can 
be  produced  by  giving  opiates  which  act  upon  the  brain  ? 

Toxic  Disorders  of  the  Nervous  System. — The  influence  exercised  by 
certain  drugs  is  of  a kind  which  causes  a close  resemblance  to  various 
diseases  of  the  nervous  system.  These  influences,  if  carried  to  excess, 
are  toxic,  and  dangerous  to  life ; if  employed  moderately  and  with 
caution,  they  constitute  the  basis  of  our  therapeutic  knowledge  in  a vast 
variety  of  diseases.  Why  one  drug  should  possess  one  power,  and 
another  a different  one,  or  why  some  should  influence  the  brain,  and 
others  the  spinal  cord  or  nerves,  we  are  ignorant.  Such  facts  are  as 
much  ultimate  facts  in  therapeutics  as  are  the  separate  endowments  of 
contractility  and  sensibility  in  physiology.  (See  p.  344,  et  seq.)  As 
pathological  causes  of  functional  disorders  of  the  nervous  system,  their 
power  is  undoubted.  By  their  means  the  five  classes  of  nervous  disor- 
ders may  be  occasioned  in  different  ways,  producing  altogether  distinct 
and  peculiar  effects.  Thus — 

Cerebral  Toxic  Disorders  are  occasioned  by  opium  and  most  of  the 
pure  narcotics,  which  first  excite  and  then  depress  or  destroy  the  mental 
faculties.  According  to  Flourens,  opium  acts  on  the  cerebral  lobes,  while 
belladonna  operates  on  the  corpora  quadrigemina.  The  first  causes  con- 
traction, and  the  last  dilatation  of  the  pupils.  Tea  and  coffee  are  pure 
exciters  of  the  cerebral  functions,  and  cause  sleeplessness.  Alcoholic 
drinks,  ether,  chloroform,  and  similar  stimulants,  first  excite  and  then 
suspend  the  mental  faculties,  like  opium.  The  modern  practice  of  de* 


FUNCriOXAL  DISOEDEES  OF  THE  NEEVOUS  SYSTEM. 


453 


priving  persons  of  consciousness,  in  order,  for  a time,  to  destroy  sensation, 
has  been  very  much  misunderstood,  in  consequence  of  such  remedies 
having  been  erroneously  and  unscientifically  denominated  anaesthetics. 
The  fact  is,  they  scarcely  influence  local  sensibility,  or  the  sense  of  touch. 
Their  action  is  cerebral,  and  hence  the  danger  which  occasionally  attends 
their  administration. 

Spinal  Toxic  Disorders. — Strychnine  acts  especially  as  an  excitor  of 
the  motor  filaments  of  the  spinal  cord,  causing  tonic  muscular  contrac- 
tions, as  in  tetanus  from  spinal  arachnitis,  or  from  the  diastaltic  action 
of  a wound.  Woorari  produces  exactly  an  opposite  effect,  causing  para- 
lysis and  resolution  of  the  same  parts.  Coniuni  paralyses  the  motor  and 
sensitive  spinal  nerves,  producing  paraplegia,  commencing  at  the  feet  and 
creeping  upwards.  (See  case  of  Gow,  p.  460.)  Picrotoxine.^  according  to 
Dr.  Mortimer  Glover,  causes  the  animal  to  stagger  backwards,  as  in  the 
experiments  of  Magendie  on  the  Crura  Cerebelli. 

Cerehro-Spinal  Toxic  Disorders. — Of  these  the  poisonous  effects  of 
hydrocyanic  acid  offer  a good  example.  All  the  animals  I have  seen 
killed  by  this  agent  utter  a scream,  lose  their  consciousness,  and  are  con- 
vulsed. These  are  the  symptoms  of  epilepsy.  Cold  is  at  first  an  excitor 
of  the  spinal  functions,  and  is  a strong  stimulant  to  diastaltic  activity, 
but,  if  long  continued,  produces  drowsiness  and  stupor. 

Neural  and  Near o- Spinal  Toxic  Disorders  are  especially  occasioned  by 
the  action  of  certain  metallic  poisons,  such  as  mercury.,  which  occasions 
irregular  muscular  action  with  weakness,  and  lead^  which  causes  numb- 
ness and  palsy,  most  common  in  the  hands.  On  the  other  hand,  can- 
tharides  stimulates  the  contractions  of  the  neck  of  the  urinary  bladder, 
and  secale  cornutum  those  of  the  pregnant  uterus.  Stramonium  acts  as 
a sedative  to  the  nerves  of  the  bronchi,  while  aconite  operates  powerfully 
in  paralysing  the  action  of  the  heart. 


Treatment  of  Functional  Nervous  Disorders. 

The  great  principle  in  the  treatment  of  congestive  disorders  of  the 
nervous  system  a2>pears  to  be,  the  necessity  of  increasing  the  strength 
and  nutrition  of  the  body  by  all  practicable  means.  Such,  indeed,  has 
been  the  general  practice — the  mineral  tonics,  and  more  especially  chaly- 
beates,  being  the  chief  remedies  administered  in  such  cases,  conjoined 
with  the  various  preparations  of  quinine,  bark,  and  the  vegetable  bit- 
ters. Stimulants  of  all  kinds,  and  especially  the  anti-spasmodics,  have 
also  been  liberally  administered.  It  must  be  confessed,  however,  that 
not  unfrequently  antiphlogistics,  with  general  and  local  bleedings,  espe- 
cially the  latter,  have  occasionally  been  employed.  Formerly  it  was 
supposed,  and  I shared  in  the  opinion,  that  functional  nervous  disorders 
might  depend  upon  both  an  increased  and  a diminished  vital  power  of 
the  economy,  and  that  for  the  former  a lowering,  and  for  the  latter  a 
supporting  plan  of  treatment  would  be  necessary.  Experience,  how- 
ever, has  satisfied  me,  that  if  the  former  cause  ever  operates  at  all,  it  is 
extremely  seldom,  and  that  nervous  disorder  is  almost  always  a symptom 
of  exhaustion. 

The  relief  of  pain,  more  especially  in  cephalalgia  and  spinal  irritation, 


454 


DISEASES  OF  THE  NERVOUS  SYSTEil. 


appears  to  follow  laws  which  have  by  no  means  been  determined. 
Thus  two  or  three  leeches  applied  over  the  part  often  effect  this  object, 
under  circumstances  where  it  is  impossible  to  imagine  that  they  can 
have  diminished  the  congestion.  How,  for  instance  in  cases  of  head- 
ache, if  it  be  dependent  upon  congestion  of  the  brain,  can  an  ounce  of 
blood,  drawn  by  leeches  from  the  vessels  of  the  scalp,  act  in  this  way  ? 
It  has  often  appeared  to  me,  that  the  warm  fomentations,  usually 
applied  to  the  leech-bites  afterwards,  are  more  effectual  than  the  loss 
of  blood,  and  that  the  therapeutic  action  is  really  reflex  in  its  character. 
For  the  same  reason,  dry  is  often  as  efiectual  as  wet  cupping. 

The  influence  of  heat  and  cold  is  most  important  in  relieving  all 
kinds  of  nervous  pain,  and  has  been  previously  referred  to.  (See 
p.  327.) 

As  a true  anaesthetic,  or  destroyer  of  local  sensibility,  congelation 
has  been  shown  by  Dr.  James  Arnott  to  be  a most  successful  and 
manageable  remedy.  I have  used  it  in  the  way  he  has  recommended 
with  excellent  effect  in  a variety  of  local  painful  affections,  and  join 
him  in  condemning  the  use  of  chloroform  in  cases  where  this  safer  pro- 
ceeding can  be  employed.  Why  remove  the  consciousness  of  an  indi- 
vidual by  deep  intoxication,  with  all  its  attendant  risks,  when  the 
same  effect  can  be  produced  by  immersing  the  parts  in  a mixture  of 
powdered  ice  and  salt,  without  any  risk  at  all  ? 

Counter-irritation  is  also  most  useful  in  the  relief  of  chronic  con- 
gestive nervous  disorders,  and  not  unfrequently  produces  a cure.  Tliis 
is  well  observed  in  certain  cases  of  spinal  irritation,  in  which  the  local 
pain  is  often  made  to  shift  its  position,  and  if  followed  by  other  blisters, 
is  at  length  got  rid  of.  I once  ordered  a blister  to  be  applied  over 
some  painful  dorsal  vertebrae,  in  a young  lady,  who  had  long  suffered 
from  dyspnoea,  cough,  and  supposed  phthisis.  Next  day  I found  her 
breathing  easily,  with  no  pain  in  the  back,  which,  however,  had  shifted 
to  the  occiput,  and  occasioned  trismus.  Another  blister  applied  to  her 
neck  perfected  the  cure.  On  other  occasions,  the  disappearance  of  pain 
in  one  part  of  the  back  will  bring  on  sudden  aphonia,  palpitation, 
colic,  or  other  symptoms,  which  in  their  turn  yield  to  further  counter- 
irritation. 

The  great  principle  in  the  treatment  of  diastaltic  disorders  of  the 
nervous  system  is  to  remove  the  peripheral  source  of  irritation  from 
which  they  arise.  Thus,  cutting  the  gums,  diminishing  acidity  in  the 
stomach,  or  removing  undue  accumulations  in  the  intestines,  are  the 
appropriate  means  for  combating  the  convulsive  disorders  of  infancy 
and  childhood.  Attacks  of  hydrophobia,  epilepsy,  and  tetanus,  may 
frequently  be  prevented  by  attention  to  the  local  causes  which  induce 
these  disorders.  Hysteria  is  always  associated  with  uterine  derange- 
ment, to  which  the  practitioner’s  attention  should  chiefly  be  directed, 
whilst  innumerable  spasms  and  convulsions  may  be  traced  to  carious 
teeth,  disease  of  the  larynx  or  pharynx,  indigestible  food,  worms,  pecu- 
liar habits  and  occupations,  etc.  etc.,  on  the  removal  of  which  the  cure 
depends. 

The  ready  metliod  of  applying  numerous  remedies  for  the  cure  of 
morbid  states  or  particular  symptoms  is  dictated  by  our  knowledge  of 
excito-niotory  actions,  and  owes  all  its  importance  to  the  labors  of  Dr. 


FUNCTIONAL  DISORDERS  OF  THE  NERVOUS  SYSTEil. 


455 


Marshall  Hall.  Thus  dashing  cold  water  on  the  face  and  general  sur- 
face in  syncope,  or  in  the  suspended  animation  of  the  new-born ; the 
irritation  of  the  fauces  to  excite  vomiting;  the  avoidance  of  this  irrita- 
tion, by  pushing  the  bolus  rapidly  into  the  pharynx  when  our  object  is 
to  excite  deglutition ; and  the  series  of  operations  lately  proposed  to 
recover  asphyxiated  persons,  are  all  of  this  character. 

In  1856, 1 observed  in  a young  woman  with  strong  epileptic  attacks, 
that  on  passing  a galvanic  shock  through  the  larynx,  the  paroxysms 
ceased  immediately.  I have  repeated  this  practice  frequently  since,  but 
have  only  found  it  to  succeed  in  hysterical  women.  Such  is  its  marked 
effect,  however,  in  this  class  of  cases,  that  I have  no  hesitation  in 
recommending  it  as  highly  useful,  at  once  arresting  the  convulsion  or 
spasm,  preventing  exhaustion,  and  thereby  more  rapidly  causing  recovery. 
This  result,  however,  is  by  no  means  invariable;  and  in  one  case  where 
it  failed,  the  spasms  (complete  opisthotonos)  were  immediately  stopped 
by  dashing  cold  water  freely  over  the  face  and  chest.  Whichever 
stimulant  be  applied,  there  can  be  no  question  that,  whenever  the  con- 
vulsion can  be  controlled,  its  employment  is  highly  conducive  to 
recovery. 

The  great  principle  in  the  treatment  of  toxic  disorders  of  the 
nervous  system  is  to  support  and  stimulate  the  strength  of  the  patient, 
until  the  action  of  the  poison  is  exhausted.  This  subject  will  be  best 
illustrated  by  examples  : — 

Case  XLII.^ — Delirium  Tremem— Recovery. 

History. — Peter  Fraser,  eet.  56,  an  engraver — admitted  September  22,  1851.  He 
has  generally  enjoyed  good  health.  For  some  time  his  habits  have  been  very  intem- 
perate, and  he  has  had  much  domestic  annoyance.  A year  ago  he  had  an  attack  of 
delirium  tremens.  During  the  last  few  weeks  he  has  been  drinking  considerably, 
although  he  says  not  to  excess.  Fourteen  days  ago  he  began  to  feel  very  restless  and 
uneasy  while  at  work,  and  his  sleep  during  the  night  became  disturbed,  but  he  has 
had  no  tremors  or  spectral  illusions  of  any  kind. 

Symptoms  on  Admission. — He  now  complains  of  severe  pain  in  the  head,  referred 
principally  to  the  frontal  region.  No  pains  in  any  other  part  of  the  body.  His 
hands  when  put  out  have  a trembling  fidgety  motion,  but  when  kept  by  his  side  are 
steady.  Tongue  is  moderately  dry,  and  covered  with  a whitish  fur.  Bowels  are 
generally  costive,  but  were  open  yesterday.  Action  of  the  heart  hurried,  and  occa- 
sionally irregular ; impulse  strong.  Pulse  96,  full  and  strong.  Other  functions 
normal.  8ol.  Mur.  Morph.  Dij;  Vin.  Antimon.  3j;  Tinct.  Aurantii^  3 j ; 
Aquce  3 j-  Ft.  haustus  hora  somni  sumendus. 

Progress  op  the  Case. — September  23. — Notwithstanding  the  draught,  passed 
a restless  night.  Bowels  not  open  since  admission.  Pulse  90,  of  moderate  strength. 

Pidv.  Rhei.  Co.  Dj  ; Aq.  Menthce.  Pip.  § j ; Ft.  haustus  statim  sumendus.  Sep- 
tember 24. — Passed  a more  quiet  night.  Bowels  open.  From  this  time  all  tremor 
in  the  hands  and  cephalalgia  left  him.  He  was  dismissed  quite  well,  September 
27. 

Case  XLIII.f — Delirium  Tremens  with  Ocular  Spectra— Recovery. 

History. — Elizabeth  Banks,  aet.  34,  married — admitted  April  7,  1851.  She 
states  that  a fortnight  ago  she  was  suddenly  seized  with  pain  in  the  head,  trembling 
and  dizziness,  so  that  she  was  obliged  to  be  supported.  She  ascribes  the  attack  to 
the  receipt  of  unpleasant  intelligence.  There  have  been  several  of  these  attacks 

* Keported  by  Mr.  Scott  Sanderson,  Clinical  Clerk, 
f Reported  by  Mr.  W.  H.  Pearce,  Clinical  Clerk. 


456 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


since,  during  some  of  which,  her  husband  says,  she  has  been  very  violent  in  her 
attempts  to  escape  from  imaginary  enemies.  She  confesses  to  have  been  for  some 
time  addicted  to  spirit-drinking,  and  states  that  up  to  the  time  of  this  illness  she  has 
enjoyed  good  health. 

Symptoms  on  Admission. — She  has  a healthy  but  somewhat  restless  appearance. 
She  answers  questions  rationally  and  is  quite  calm,  remembering  everything  that 
has  occurred,  except  during  the  sudden  attacks  of  trembling,  etc.  She  has  pain  over 
the  whole  head  ; there  is,  however,  no  heat  of  scalp  or  suffusion  of  the  eyes.  The 
pupil  is  natural,  and  the  iris  contracts  readily.  She  sees  various  things  before  her, 
especially  different  kinds  of  animals  running  about,  which  are  most  numerous  and 
vivid  at  night.  She  feels  also  at  times  as  if  persons  were  making  attempts  upon  her 
life.  For  the  last  three  nights  she  has  had  no  sleep,  in  consequence  of  these  ocular 
appearances.  Her  hands  are  very  unsteady,  and  the  fingers  are  constantly  playing 
with  the  bed-clothes.  Pulse  90,  of  good  strength.  Tongue  furred,  and  rather  dry. 
Bowels  habitually  constipated,  and  unrelieved  for  three  days.  Other  functions  nor- 
mal. ^ Elaterii  gr.  ss.  ; Pidv.  Gamb.  gr.  ij  ; Potass.  Bitart.  gr.  x ; Ft.  pulvis 
statim  sumendus.  Sol.  Mar.  Morphies  3 j ; Aquos  3 vij  ; Ft.  haustus  hora  somni 
sumendus. 

Progress  of  the  Case. — April  8. — Has  slept  tolerably  during  the  night.  Is  not 
so  restless,  and  has  seen  few  ocular  spectra.  The  hands  and  her  whole  appearance 
calm.  The  purgative  powder  only  occasioned  one  stool.  From  this  time  she  gradu- 
ally recovered,  and  was  discharged  quite  well  on  the  24th. 

Case  XLIV."^ — Delirium  Tremens  with  Convulsion  and  Coma — Recovery. 

History. — David  Seaton,  set.  25,  a chimney-sweep — admitted  on  the  evening  of 
September  10,  1849.  His  friends  state  that  he  has  been  greatly  addicted  to  the  use 
of  spirits,  and  that  during  the  last  three  months  he  has  had  several  apoplectic 
attacks.  He  has,  notwithstanding,  continued  to  indulge  in  drink  ; was  this  morning 
extremely  violent,  and  during  the  afternoon  became  insensible. 

Symptoms  on  Admission. — On  admission  the  countenance  is  bloated  and  flushed, 
and  his  short  stout  figure  gives  evidence  of  great  strength.  He  is  now  comatose, 
breathes  stertorously  ; pulse  60,  full  and  strong.  The  head  to  he  shaved,  12  leeches  to 
he  applied,  a drop  of  croton  oil  to  he  placed  on  the  hack  of  the  tongue  with  sugar,  so  as 
to  ensure  deglutition,  and  to  he  repeated  in  an  hour  if  necessary. 

Progress  of  the  Case. — September  11. — During  the  night  he  several  times  par- 
tially recovered  his  senses,  and  again  relapsed.  To-day  is  much  better,  and  can 
answer  questions  in  a confused  way.  Four  drops  of  croton  oil  have  been  given,  and 
operated  once.  To  have  one  drachm  of  sol.  of  muriate  of  morphia  at  niglu.  Sep- 
tember 12. — Violent  delirium  during  the  night,  with  insomnolence.  It  became  neces- 
sary to  employ  the  strait  waistcoat.  Pulse  quick  and  feeble.  Ice-water  to  be  applied 
to  the  head.  One  drachm  of  sol.  of  muriate  of  morphia  to  he  repeated  at  night.  To 
have  a turpentine  enema.  September  13  and  14. — No  improvement.  September  15. — 
Is  somewhat  sensible ; pulse  rapid  and  feeble.  To  discontinue  the  morphia.  To 
have of  whisky  every  two  hours.  September  16. — Slept  a little  last  night.  To-day 
talks  sensibly.  Pulse  80,  stronger.  Bowels  opened  by  means  of  an  injection.  From 
this  time  he  gradually  recovered,  and  was  dismissed  well,  September  27. 

Case  XLV.f — Coma  and  Death  from  Excessive  Drinking — Opacity  of 
Arachnoid — Subarachnoid  Effusion — Fluid  Blood. 

History. — James  Dick,  set.  48,  a joiner — admitted  on  the  evening  of  January  31, 
1851,  in  a moribund  condition.  He  has  been  habitually  intemperate  for  many  years. 
For  the  last  week  has  been  in  a constant  state  of  intoxication.  This  evening  became 
suddenly  ill,  and  lost  his  consciousness.  Shortly  afterwards  he  was  conveyed  to  the 
Infirmary. 

Appearance  on  Admission. — On  admission  he  presented  all  the  appearance  of 
a corpse.  No  breathing  was  perceptible ; no  beating  of  the  heart  could  be  heard 
with  the  stethoscope.  The  countenance  pale  ; head  thrown  back  ; mouth  open  and 
frothy ; eyes  turned  up,  and  pupils  dilated.  All  efforts  at  re-animation  were  of  no 
avail ; he  was  dead. 


* Reported  by  Mr.  Alexander  Christison,  Clinical  Clerk, 
f Reported  by  Mr.  Sanderson,  Clinical  Clerk. 


FUNCTIOJ^’AL  DISORDERS  OF  THE  NERVOUS  SYSTEM. 


457 


Sectio  Cadaveris. — Thirty-eight  hours  after  death. 

Body  well  formed  and  strong,  not  emaciated.  A little  tumidity  of  depending  parts. 

Head. — On  removing  the  calvarium,  the  subarachnoid  tissue  was  seen  to  be  in- 
filtrated with  fluid,  raising  the  arachnoid  to  the  level  of  the  convolutions.  The  sinuses 
were  distended  with  fluid  blood.  The  cerebral  arachnoid  presented  considerable 
opacity  all  over  the  hemisphere,  in  some  places  diffused,  in  others  exhibiting  minute 
points  closely  aggregated  together.  The  ventricles  contained  a small  amount  ^of  fluid, 
and  several  simple  cysts  in  the  choroid  plexuses.  Cerebral  arteries  and  other  portions 
of  the  brain  perfectly  healthy. 

Chest. — Both  pleur®  contained  several  ounces  of  serum,  and  were  slightly  adherent 
at  the  apices.  Both  lungs  were  healthy,  with  the  exception  of  unusual  engorgement, 
posteriorly  and  inferiorly.  A cretaceous  concretion,  the  size  of  a barley-corn,  in  apex 
of  right  lung.  Bronchi  contained  a moderate  quantity  of  frothy  mucus,  which  was 
more  abundant  in  trachea  and  larynx.  Pericardium  contained  one  drachm  of  serum. 
Heart  healthy.  The  blood  in  the  cavities  and  large  vessels  remarkably  fluid. 

Abdomen. — The  liver  pale  in  color,  and  very  soft,  weighed  3 lbs.  14  oz.  A few 
serous  cysts  in  the  kidney.  Other  abdominal  organs  healthy. 

Microscopic  Examination. — The  cells  of  the  liver  were  loaded  with  oil  granules 
of  large  size.  The  tubercles  of  the  kidney  here  and  there  also  contained  several  fatty 
granules.  Cerebral  substance  healthy. 

Commentary. — Various  opinions  as  to  the  nature  of  delirium  tre- 
mens have  been  held  by  medical  men,  who  have  successively  placed  it 
among  the  neuroses,  the  phlegmasiae,  and  the  pyrexim.  Until  recently, 
it  was  held  that  whilst  drinking  was  its  predisposing  cause,  the  sudden 
abstraction  of  the  accustomed  stimulus  brought  on  the  attack.  This 
theory  was  successfully  combated  by  Dr.  Peddie,*  who  has  shown  that 
the  disease  is  seldom  observed  in  our  prisons,  notwithstanding  the  large 
number  of  confirmed  drunkards  admitted  there  and  immediately  placed 
upon  low  diet.  The  view  of  its  pathology  now  prevalent  is,  that 
alcohol,  a poison  dangerous  to  life  in  large  doses,  is  also  cumulative 
taken  habitually  in  small  quantities.  Like  many  others,  it  is  one  which 
especially  affects  the  nervous  system,  and  more  particularly  the  brain, 
as  shown  by  Percy,  Huss,  and  other  writers.  Hence  those  effects  deno- 
minated intoxication,  delirium  tremens,  etc.  Formerly  the  treatment 
used  to  consist  of  supplying  the  accustomed  stimulus;  but  theoretically 
it  is  clear  that  this  is  tantamount  to  adding  coals  to  fire,  and  practically 
it  has  been  shown  that  patients  more  rapidly  recover  under  the  use  of 
nutrients.  In  the  vast  majority  of  cases  of  delirium  tremens,  the  poison 
Decomes  eliminated  from  the  system  in  a certain  time;  whether  anti- 
mony, in  half  or  quarter  grain  doses,  assists  this  process,  as  was  at  one 
time  supposed,  is  very  doubtful.  Generally  speaking,  if  a good  sleep 
can  be  obtained,  it  is  critical,  and  the  patient  at  once  recovers.  Opium 
has  been  largely  given  to  obtain  this  result,  but  its  supposed  beneficial 
action  is  generally  coincident  with  the  muscular  fatigue,  exhaustion,  and 
tendency  to  repose  which  accompany  the  elimination  of  the  alcoholic 
poison.  I have  been  so  struck  with  the  increase,  rather  than  the  dimi- 
nution of  the  symptoms,  by  all  attempts  at  medication,  in  the  early 
stage  of  the  disorder — a circumstance  observable  in  the  cases  recorded 
— that  for  the  last  ten  years  I have  given  little  but  nutrients,  and  every 
case  has  recovered.  During  the  summer  of  1864  I strongly  pointed 
this  out;  and  every  case  admitted  during  May,  June,  and  July  of 
that  year  was  carefully  recorded.  They  all  recovered  as  follows : — 

* Monthly  Journal  of  Med.  Science,  June,  1864. 


458 


DISEASES  OF  THE  XERVOUS  SYSTEM. 


I 

No. 

Name. 

Sex. 

Age. 

Admitted. 

Symptoms. 

Treatment, 

1 

Dismissed. 

1 

T.  Eadie 

M. 

49 

5th  May. 

Mild. 

Good  diet— rest. 

12th  Mav. 

2 

J.  Bortliwick. 

M. 

49 

19th  May. 

Well  marked— 4th 
attack. 

Do.  do. 

24th  May. 

3 

F.  llastie. 

M. 

44 

19th  May. 

Mild. 

Do.  do. 

24th  May. 

4 

J.  C alder. 

M. 

7 

24th  M:iy. 

Mild. 

Do.  do. 

27th  May. 

5 

G.  Gillis. 

M. 

33 

25th  May. 

Violent. 

Tied  down  in  bed— beef 
tea  and  nutrients. 

31st  May. 

6 

J.  Adair. 

M. 

40 

28th  May. 

Mild— 3d  attack. 

Beef  tea  and  nutrients. 

1st  June. 

7 

W.  Gordon. 

M. 

47 

29th  May. 

Mild— 2d  attack. 

Do.  do. 

1st  June. 

8 

R.  H.  Whitten. 

M. 

54 

9th  June. 

Well  marked— had 
other  attacks. 

Tied  in  bed— good  diet. 

16th  June. 

9 

Thos.  Robb. 

M. 

55 

11th  June. 

Well  marked. 

Do.  do. 

16th  June. 

10 

T.  Dickson. 

M. 

48 

12tli  June. 

Mild. 

Good  diet— rest. 

15th  June. 

11 

W.  M'Donald. 

M. 

43 

17th  June. 

Comatose  on  ad- 
mission. 

Emetic  first— good  diet. 

20lh  June, 

12 

B.  M'Giiitie. 

M. 

50 

19th  June. 

Mild. 

Good  diet — rest. 

28th  June. 

13 

W.  Simpson. 

M. 

44 

20th  June. 

Severe. 

Emetic  first — good  diet. 

1st  July. 

14 

M.  Bell. 

F. 

24 

21st  June. 

Severe. 

Tied  in  bed — emetic — 
good  diet — rest. 

5th  July, 

15 

M.  Coverdale. 

F. 

40 

3d  July. 

Mild. 

Good  diet — rest. 

13th  July. 

16 

D.  Davies. 

M. 

44 

4th  July. 

Mild. 

Tied  in  bed — rest— good 
diet. 

12th  July. 

17 

D.  Wallace. 

M. 

47 

6th  July. 

Severe. 

Do.  do.  do. 

12th  July. 

18 

M.  A.  Smith. 

F. 

34 

ISth  Ju'ly. 

Severe, 

Do.  do.  do. 

28th  July. 

19 

P.  Forrest. 

M. 

30 

20th  July. 

Mild. 

Good  diet — rest. 

22d  July. 

20 

J.  Bi’own. 

M. 

52 

21st  July.  jMild. 

Do.  do. 

30th  July. 

1 

1 hold,  therefore,  that  delirium  tremens  is  one  of  those  diseases  that 
only  requires  a dietetic  treatment,  and  that  the  sooner  nutrients  can  be 
taken,  the  more  rapid  is  the  recovery.  It  is  of  great  importance  that 
the  windows  and  doors  of  the  room  in  which  patients  with  delirium 
tremens  are  should  be  well  closed,  because,  although  there  is  no  violence, 
a tendency  to  escape  from  imaginary  enemies  has  led  to  some  deplorable 
accidents.  Personal  restraint  should  be  avoided  as  much  as  possible. 

Case  XLVI.^ — Poisoning  by  Opium — Recovery. 

History. — Helen  M'Dermott  or  Cuthbertson,  set.  33,  but  looking  ten  years  older, 
residing  in  the  Cowgate  as  the  wife  of  a cooper,  was  admitted  at  3 p.m.  May  25,  1857. 
She  has  not  unfrequently  been  drunk,  and  had  a quarrel  lately  with  her  husband. 
On  the  preceding  day  she  had  gone  out  and  purchased  two  ounces  of  laudanum, 
namely,  one  ounce  at  two  different  druggists’  shops,  and  bad  swallowed  them  (it  is 
said)  half  an  hour  before  admission. 

Symptoms  ox  Admission. — On  admission,  contracted  pupils,  great  drowsiness,  re- 
laxation of  muscles,  and  tendency  to  cold  ; with  lividity  of  face  and  extremities.  The 
stomach-pump  was  employed  to  wash  out  the  stomach  ; this  was  first  done  with  warm 
water,  and  twice  subsequently  with  mustard  and  water.  The  first  vomited  matters 
smelled  of  laudanum.  The  patient  was  stimulated  to  walk  about  until  toward  4.30 
P.M.  By  that  time  her  limbs  became  so  relaxed  that  she  sank  to  the  ground  ; and 
she  was  so  drowsy  as  to  fall  avsleep  unless  pushed  or  pricked.  The  galvanic  battery 
was  then  applied  to  the  popliteal  spaces,  and  to  the  hands,  breast,  and  neck — 
(Kemp’s  battery  being  the  instrument  employed).  Meanwhile,  as  patient  was  in  bed, 
warmth  was  maintained  by  clothes  and  hot  bottles.  Under  stimulus  of  the  battery, 
patient  was  also  induced  to  swallow  some  coffee.  At  6.30  p.m.  she  was  so  easily 
roused  by  galvanism — the  skin  warm,  the  pulse  (small  and  weak  before)  becoming 
more  perceptible  and  strong — that  the  stimulus  was  more  rarely  applied,  merely  to 
prevent  the  sleep  into  which  from  time  to  time  she  fell  from  becoming  profound.  At 
8 P.M.  a drachm  of  brandy,  and  half  a drachm  of  Sp.  Ammon.  Aromat.  were  admini- 
stered, to  be  repeated  every  hour.  During  the  first  three  administriitions  of  this 
stimulant  vomiting  occurred,  the  vomited  matter  consisting  of  the  coffee  that  had 
previously  been  swallowed.  At  ten,  eleven,  and  twelve,  she  was  seen  dozing  slightly, 
but  was  easily  roused.  Next  morning  complained  of  sickness,  and  of  not  having  been 

* Reported  by  Dr.  John  Glen,  Resident  Pliysician. 


FUNCTIONAL  DISOKDERS  OF  THE  NERVOUS  STSTEil. 


459 


able  to  sleep  during  the  night;  was  quite  conscious  and  thankful  for  her  recovery. 
Slept  during  the  day,  taking  tea  and  beef  tea.  On  the  2'7th,  having  fully  recovered, 
she  was  discharged. 

Case  XLVII.'^ — Poisoning  by  Opium — Recovery. 

History. — Robert  Cooper,  aet.  47,  admitted  June  24th,  1864,  a laborer,  in  the 
habit  of  drinking  to  excess.  After  leaving  off  work  on  the  evening  of  the  20th,  he 
commenced  drinking,  and  continued  to  do  so  until  the  evening  of  the  24th,  when  he 
was  brought  to  the  Infirmary  by  some  men,  one  of  whom  said  he  had  seen  him  go  into 
three  druggists’  shops.  Two  hours  before  admission  he  was  found  fast  asleep  in  the 
street,  and  as  he  could  not  be  awakened,  was  brought  to  the  Infirmary.  In  his  pockets 
were  two  bottles,  one  capable  of  holding  5 j,  the  other  § vi,  both  strongly  smelling 
of  laudanum. 

Symptoms  ox  Admission. — Pupils  contracted  to  the  sixteenth  of  an  inch  in 
diameter,  insensible  to  light.  There  is  profound  coma,  face  pale,  pulse  weak.  A 
stomach-pump  was  immediately  procured,  and  the  stomach  emptied  of  its  contents, 
which  smelt  of  laudanum.  It  was  filled  four  times  with  water,  and  again  emptied. 
Then  a strong  infusion  of  coffee  was  administered.  Three-quarters  of  an  hour  after- 
wards he  appeared  to  be  slightly  conscious,  and  answered  questions  indistinctly.  On 
the  following  morning  the  surface  was  bathed  in  perspiration,  pupils  still  contracted, 
but  slightly  sensitive  to  light.  Answers  questions,  but  is  oblivious  of  everything  that 
happened  since  the  22d.  Easily  relapses  into  drowsiness  and  sleep.  To  have  beef 
tea  and  nutrients.  From  this  time  slowly  recovered,  and  was  dismissed  on  the  28th. 
The  matter  pumped  out  from  the  stomach,  on  being  analysed  by  Dr.  Duckworth,  was 
found  to  contain  muriate  of  morphia  in  large  quantity. 

Commentary. — The  symptoms  of  poisoning  by  opium  are  first  cere- 
bral, and  secondly  spinal,  the  danger  to  be  apprehended  being  great 
depression  of  the  vital  powers.  Our  first  efforts  should  be  directed  to 
removing  as  rapidly  as  possible  the  poison  from  the  stomach,  and  to  this 
end  the  pump  should  be  employed,  in  preference  to  emetics.  Indeed,  in 
most  cases,  coma  renders  deglutition  difficult.  After  this  it  was  formerly 
the  habit  of  trying  to  rouse  the  patient  by  walking  him  about,  shaking 
him,  or  administering  galvanic  shocks.  All  these  processes,  as  they  tend 
to  produce  exhaustion  of  the  vital  powers,  cannot  be  regarded  as  judi- 
cious. Our  object  ought  to  be  to  support  the  strength  and.  action  of  the 
heart  as  long  as  possible,  with  a view  of  permitting  the  poison  to  be 
eliminated.  Accordingly,  it  will  be  observed  that  the  second  case  recov- 
ered rapidly,  without  having  recourse  to  any  such  expedients.  Another 
idea  is  that  some  antidote  should  be  administered,  supposed  to  be  capa- 
ble of  rousing  the  brain.  Thus,  in  both  cases  recorded,  a strong  infu’ 
sion  of  coffee  was  administered.  In  1859,  my  then  resident  physician, 
Dr.  Carter,  now  of  Leamington,  injected  a solution  of  atropine  into  the 
cellular  tissue,  as  a supposed  corrective  to  the  effects  of  opium.  Coffee 
or  tea  can  do  no  harm,  but  it  is  much  to  be  doubted  whether  theoreti- 
cally their  employment  can  be  defended  (see  p.  345)  as  being  useful. 
Experience  and  careful  experiments  up  to  this  time  have  failed  to  give 
us  any  positive  information  on  the  subject. 


Case  XLVIII.f — Poisoning  by  Hemlock — Death. 

History. — On  Monday,  April  21st,  1845,  about  seven  o’clock  in  the  evening,  a 
man,  called  Duncan  Govv,  was  brought  into  the  Infirmary  by  two  policemen.  It  was 


* Reported  by  Mr.  D.  Thomas,  Clinical  Clerk. 

\ Published  by  me  in  the  Edin.  Med.  and  Surg.  Journal,  No.  164.  1845. 


460 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Stated  that  he  had  been  found  Ijdng  in  the  street,  apparently  in  a state  of  intoxication, 
or  in  a fit.  On  being  taken  into  the  waiting-room,  he  was  found  to  be  dead. 

I subsequently  learnt  from  his  wife  that  the  man,  forty-three  years  of  age,  a tailor 
by  trade,  was  in  such  reduced  circumstances  that  he  had  not  eaten  anything  on  Mon- 
da}q  until  he  took  the  substance  which  caused  his  death.  Two  of  his  children,  a boy 
and  a girl,  aged  respectively  ten  and  six  years  of  age,  found  what  they  took  for  parsley 
growing  on  the  bank  under  Sir  Walter  Scott’s  Monument  (which  was  then  building), 
and  knowing  that  their  father  was  very  fond  of  this,  as  well  as  of  other  green  vegeta- 
bles, they  gathered  some  to  take  to  him.  On  visiting  the  place  with  the  boy,  four 
days  afterwards,  I found  that  the  spot  from  whence  the  plants  were  gathered  had  been 
covered  over  with  fresh  rubbish.  But  on  the  uncovered  part  of  the  bank,  eighty  yards 
westwards,  the  Comum  maculatum  could  be  seen  growing  in  considerable  quantity. 
The  children  returned  home  between  three  and  four  o’clock  p.m.  The  father,  who  had 
fasted  the  whole  day,  greedily  ate  the  vegetables,  together  with  a piece  of  bread,  and 
said  more  than  once  how  good  they  were.  The  quantity  consumed  could  not  be  ascer- 
tained, for  he  ate  nearly  all  that  was  brought.  On  finishing  his  meal,  he  rose,  saying 
he  would  endeavor  to  get  some  money,  in  order  to  procure  food  for  his  children.  At 
this  time  he  was  in  perfect  health. 

From  his  own  house,  at  the  head  of  the  Canongate,  Gow  walked  about  half  a mile 
to  the  house  of  one  Wright,  in  the  West  Port,  with  a view  of  selling  him  some  small 
matter.  Wright,  on  his  entering  the  room,  thought  at  first  that  he  was  intoxicated, 
because  he  staggered  in  walking.  On  passing  through  the  door  also,  which  was  nar- 
row, he  faltered  in  his  gait,  and  afterwards  sat  down  hastily.  He  stayed  ten  minutes, 
during  which  time  he  conversed  readily,  drove  a hard  bargain,  and  obtained  fourpence 
for  what  he  sold.  He  did  not  complain  of  pain  or  uneasiness,  was  not  excited  in  man- 
ner or  speech,  and  his  face  was  pale  and  wan.  On  rising  from  his  chair,  he  was  ob- 
served by  Wright’s  boy  to  fall  back  again,  as  if  he  had  some  difficulty  in  idsing.  On 
making  a second  effort  he  got  up,  and  was  seen  by  Wright’s  wife  to  stagger  out  of  the 
house  and  down  the  steps.  This  was  a little  after  four  o’clock. 

On  leaving  Wright’s  house,  he  was  next  seen  standing  with  his  back  against  the 
corner  of  the  street,  by  Andrew  Me’ All,  a meal-dealer  in  the  Grassmarket,  about  200 
yards  from  Wright’s  house.  Me’ All  saw  him  leave  the  corner  he  was  leaning  against, 
and  stagger  to  a lamp-post  a few  yards  further  on.  Here  he  again  paused  for  a few 
minutes,  and  then  again  went  forward  in  the  same  vacillating  manner,  passed  Me’ All’s 
shop,  and  sat  down  at  the  opening  of  the  common  stair  next  to  it.  Me’ All’s  words  are, 
“ He  could  not  walk  rightly,  and  was  staggering  as  a man  in  liquor.”  His  mode  of  pro- 
gression attracted  a number  of  boys  and  girls,  who  laughed  at  him.  believing  him  to 
be  intoxicated.  He  was  heard  to  speak  to  them,  but  what  he  said  is  not  known.  He 
was  also  seen  by  two  women,  who  told  a policeman  to  take  him  away. 

The  policeman  (James  Mitcliell,  No.  161)  told  me  that,  on  finding  Gow  sitting  at 
the  foot  of  the  common  stair,  he  thought  he  was  drunk.  He  spoke  to  him,  and  in 
reply  Gow  desired  to  be  taken  to  his  own  house,  at  the  top  of  the  Canongate.  He 
also  said  that  he  had  completely  lost  his  sight,  and  had  not  the  perfect  use  of  his 
limbs,  but  expressed  his  willingness  to  walk  forwards,  until  the  policeman  could  obtain 
the  assistance  of  his  comrade  in  the  Cowgate.  He  was  then  raised  up  and  supported 
by  one  arm,  but,  after  moving  with  great  difficulty  past  four  or  five  shops,  his  legs 
bent  under  him,  and  he  fell  upon  his  knees.  Mitchell  then  gave  him  some  water  to 
drink,  which  he  was  incapable  of  swallowing,  and  left  him  to  get  a barrow.  On  his 
return  he  found  him  surrounded  by  women,  who  were  pouring  cold  water  on  his  head, 
and  sprinkliug  his  forehead.  With  the  assistance  of  another  policeman  (James  Hastie, 
No.  Ill),  he  was  then  placed  on  a barrow.  One  of  the  women,  Mrs.  Anderson,  on  his 
being  raised,  saw  that  he  made  no  attempt  to  walk,  but  that,  as  he  was  pulled  away  by 
the  policeman,  his  legs  were  dragged  or  trailed  after  him. 

The  second  policeman,  Hastie,  on  first  seeing  him,  told  Mitchell  that  it  was  not 
drink,  but  a fit,  that  was  the  matter  with  him.  He  lifted  up  his  eyelids  and  found 
the  eyes  dull.  He  seemed  sensible,  and  endeavored  to  say  something,  but  could  not 
artic-ulate.  He  was  now  slowly  conveyed  to  the  main  police-office  in  the  High  Street, 
where  he  arrived  about  six  o’clock.  Mitchell  told  the  police-lieutenant  on  duty,  that 
from  the  manner  in  which  the  man  was  lying,  and  from  the  loss  of  power  in  the  legs, 
he  now  thought  he  was  not  intoxicated.  At  this  period  it  would  seem  that,  although 
the  limbs  were  completely  paralysed,  the  intelligence  was  still  perfect,  for  he  told  the 
turnkey  his  exact  address  in  the  Canongate,  in  reply  to  a question. 


FUNCTIONAL  DISORDERS  OF  THE  NERVOUS  SYSTEM. 


461 


Dr.  Tait,  surgeon  to  the  police  force  was  now  sent  for,  and  saw  him  about  quartet 
past  six.  In  reply  to  a note  which  I addressed  to  him  on  the  subject,  he  says : — 

“ The  first  impression  produced  on  my  mind  from  his  appearance  was,  that  he  was 
in  a state  of  intoxication ; he  was  then  lying  on  his  back,  with  his  head  and  shoulders 
elevated  upon  a board  we  have  in  the  office  for  that  purpose.  He  was  sensible  when 
I spoke  to  him,  and  tried  to  turn  his  face  toward  me,  and  slightly  raised  his  eyelids, 
but  appeared  unable  to  speak.  His  power  of  motion  appeared  completely  prostrated, 
for  when  I lifted  his  arm  and  laid  it  down,  it  lay  where  it  was  put ; and  Avhen  his  arm 
pits  were  tickled,  he  seemed  to  manifest  a little  sensibility,  but  could  make  no  exertion 
to  rid  himself  of  the  annoyance.  There  were  occasional  movements  of  the  left  leg, 
but  they  appeared  rather  to  be  spasmodic  than  voluntary.  Several  efforts  were  made 
to  vomit,  but  these  were  ineffectual.  His  pulse  and  breathing  were  perfectly  natural. 
He  had  spoken  to  the  turnkey  a few  minutes  before  I arrived.  Heat  of  skin  natural.  I 
visited  him  again,  about  ten  minutes  before  seven  o’clock,  at  which  time  all  motion  of 
the  chest  appeared  to  have  ceased ; the  action  of  the  heart  was  very  feeble,  and  the  coun- 
tenance had  a cadaveric  expression ; pupils  fixed.  He  was  then  sent  to  the  Infirmary.” 

He  was  conveyed  to  tlie  Infirmary  by  Hastie  and  another  policeman,  MTherson. 
After  being  put  on  the  stretcher,  Hastie  saw  him  draw  the  legs  gently  upwards,  as  if 
to  prevent  their  hanging  over  the  iron  at  its  extremity.  This  was  the  last  movement 
he  was  seen  to  make.  On  being  carried  into  the  waiting-room  of  the  Infirmary,  he  was 
visited  by  the  house-clerk  on  duty,  who  found  him  pulseless,  and  declared  him,  as 
previously  stated,  to  be  dead.  This  was  shortly  after  seven  o’clock  p.m. 

Seciio  Cadaveris. — Sixty-three  hours  after  death. 

The  body  was  well  formed  and  muscular.  There  were  no  external  marks  of  vio- 
lence. The  back  and  depending  portions  were  livid  from  sugillation. 

Head. — An  unusual  quantity  of  fluid  blood  flowed  from  the  scalp  and  longitudinal 
sinus  when  divided.  There  was  slight  serous  effusion  below  the  arachnoid  membrane, 
and  about  two  drachms  of  clear  serum  in  the  lateral  ventricles.  The  substance  of  the 
brain  was  soft  throughout ; on  section  presented  numerous  bloody  points,  but  was 
otherwise  healthy.  No  fracture  could  be  discovered  in  any  part  of  the  cranium. 

Chest. — There  were  slight  adhesions  between  the  pleurae  on  both  sides  superiorly. 
The  apices  of  both  lungs  were  strongly  puckered.  On  the  right  side  below  the  puck- 
ering were  two  cretaceous  concretions,  the  size  of  peas,  surrounded  by  chronic  pneu- 
monia and  pigmentary  deposit.  On  the  left  side  only  induration,  with  hard,  black, 
gritty  particles,  existed  below  the  puckering.  The  structure  of  the  lungs  otherwise 
was  healthy,  although  they  were  throughout  intensely  engorged  with  dark-red  fluid 
blood.  The  heart  was  healthy  in  structure,  but  soft  and  flabby.  The  blood  in  the 
cavities  was  mostly  fluid,  presenting  only  here  and  there  a few  small  grumous  clots. 

Abdomen. — The  liver  was  healthy  ; the  spleen  soft,  readily  breaking  down  under 
the  fingers.  The  kidneys  were  of  a brownish-red  color  throughout,  owing  to  venous 
congestion,  but  healthy  in  structure.  The  stomach  contained  a pultaceous  mass, 
formed  of  some  raw  green  vegetable  resembling  parsley.  Its  contents  weighed  eleven 
ounces,  and  had  an  acid  and  slightly  spirituous  odor.  The  mucous  coat  was  much 
congested,  especially  at  its  cardiac  extremity.  Here  there  were  numerous  extravasa- 
tions of  dark-red  blood,  below  the  epithelium,  over  a space  about  the  size  of  the  hand. 
The  intestines  were  healthy,  here  and  there  presenting  patches  of  congestion  in  the 
mucous  coat.  The  bladder  was  healthy  ; its  inner  surface  much  congested  from  venous 
obstruction. 

The  Blood  throughout  the  body  was  of  a dark  color  and  fluid,  even  in  the  heart 
and  large  vessels. 

Commentary. — From  the  absence  of  structural  lesion,  and  the  general 
fluidity  of  the  blood,  I was  induced  to  suspect  that  the  vegetable  matter 
found  in  the  stomach  was  of  a poisonous  nature.  On  examining  this 
more  minutely,  it  was  seen  to  be  composed  chiefly  of  fragments  of  green 
leaves  and  leaf-stalks.  Although  much  was  reduced  to  a pulp,  a con- 
siderable quantity  of  both  had  escaped  the  action  of  the  teeth.  The 
same  afternoon,  I carried  as  perfect  a specimen  of  the  fragments  as  could 
be  found  to  Dr.  Christison,  who  pointed  out  that  they  could  scarcely  be 


462 


DISEASES  OF  THE  HEEYOUS  SYSTEM. 


anything  else  than  the  lacinice  of  the  Conium  maculatum^  or  common 
hemlock.  Next  day  I bruised  some  of  the  leaves  in  a mortar,  with  a 
solution  of  potash,  when  the  peculiar  mousy  odor  of  conia  was  evolved 
so  strongly  that  Dr.  Douglas  Maclagan  and  others,  although  previously 
unacquainted  with  its  nature,  at  once  pronounced  it  to  be  hemlock.  Dr. 
Christison  also  procured  a recent  specimen  of  the  Conium  maculatum 
from  Salisbury  Crags,  the  botanical  characters  of  which,  on  being  com- 
pared with  the  fragments  found  in  the  stomach,  were  proved  to  be  iden- 
tical. No  doubt  could  exist,  therefore,  that  the  man  died  from  having 
eaten  hemlock. 

Few  cases  of  poisoning  with  this  plant  have  hitherto  been  published, 
and  none  have  been  minutely  detailed.  The  effects  imputed  to  it  in  the 
notices  given  of  prior  cases  are  very  contradictory.  In  some  it  is  said 
to  have  caused  death,  like  opium,  by  stupor  and  coma.  In  others,  con- 
vulsions of  the  frantic  kind  are  symptoms  stated  to  have  been  present. 
But  the  effects  observed  by  Dr,  Christison  in  the  lower  animals,  in  his 
experiments  with  extract  of  hemlock  and  its  alkaloid  conia,  are  totally 
different,  viz.,  “ palsy,  first  of  the  voluntary  muscles,  next  of  the  chest, 
lastly  of  the  diaphragm  ; asphyxia,  in  short,  from  paralysis,  without  in- 
sensibility, and  with  slight  occasional  twitches  only  of  the  limbs.”*  On 
this  account,  as  well  as  from  the  circumstance  that  considerable  interest 
is  connected  with  the  question,  as  to  whether  the  hemlock  of  modern 
times  be  the  Kcovecov,  or  state  poison  of  the  Athenians,  great  pains  were 
taken  to  obtain  a perfect  history  of  the  case.  In  preparing  it  I endeav- 
ored to  insure  accuracy,  by  carefully  interrogating  all  who  saw  him  from 
the  time  of  his  eating  the  hemlock  until  the  period  when  he  was  brought 
into  the  Infirmary.  Fortunately,  he  was  seen  by  many  persons,  and 
their  several  accounts  are,  on  the  whole,  consistent,  and  render  the  case 
tolerably  perfect. 

The  time  of  day  mentioned  by  the  different  narrators  shows  that  the 
poison,  shortly  after  it  was  taken,  produced  want  of  power  in  the  inferior 
extremities,  without  causing  any  pain.  This  is  proved  by  what  took 
place  ill  Wright’s  house.  His  gait,  which  at  that  time  was  faltering 
afterwards  became  vacillating ; he  staggered  as  one  drunk — at  length 
his  limbs  refused  to  support  him,  and  he  fell.  On  being  raised,  his  legs 
dragged  after  him ; and  lastly,  when  the  arms  were  lifted,  they  fell  like 
inert  masses  and  remained  immovable.  Perfect  paralysis  of  the  inferior 
extremities  was  ascertained  to  exist  one  hour  and  a half  after  the  poison 
was  taken,  and  that  of  the  arms  half  an  hour  later. 

As  regards  the  existence  of  sensibility,  we  have  only  the  evidence 
afforded  by  tickling  the  arm-pits,  which,  according  to  Dr.  Tait,  seemed 
to  excite  it  a little.  The  amaurosis,  however,  is  a proof  that  one  nerve 
of  sensibility,  at  all  events,  was  paralysed.  This  seems  to  have  happened 
when  perfect  paralysis  of  the  inferior  extremities  was  manifested. 

The  excito-motory  functions  seemed  also  paralysed.  Tickling  the 
arm-pits  failed  in  producing  movements.  He  lost  the  power  of  degluti- 
tion. Dr.  Tait  says  his  efibrts  to  vomit  were  ineffectual.  There  were 
no  convulsions,  only  slight  occasional  movements  of  the  left  leg ; and 
lastly,  both  inferior  extremities  were  slowly  drawn  upwards,  when  placed 
* Treatise  on  Poisons,  p.  885  1846. 


FUNCTIONAL  DISORDERS  OF  THE  NERVOUS  SYSTEM. 


463 


over  the  iron  of  the  stretcher.  Three  hours  after  taking  the  poison,  the 
respiratory  movements  had  ceased ; the  pupils  were  fixed.  At  this  time, 
the  heart’s  action  was  felt  very  feeble.  These  also  ceased  about  ten 
minutes  afterwards. 

The  intelligence  remained  perfect  up  to  a very  late  period.  When 
his  movements  were  vacillating,  he  was  seen  to  direct  his  steps  from  one 
fixed  point  to  another.  After  paralysis  of  the  inferior  extremities  was 
fully  developed,  he  gave  accurate  directions  how  he  was  to  be  taken 
home,  and  described  his  principal  symptoms.  Two  hours  after  taking 
the  hemlock,  wdien  brought  into  the  police-office,  although  he  could  not 
swallow,  he  gave  his  address ; and  a quarter  of  an  hour  afterwards,  when 
seen  by  Dr.  Tait,  though  he  could  not  speak,  he  appeared  sensible,  and 
tried  to  turn  his  face  toward  him. 

Death  took  place  about  three  hours  and  a quarter  after  eating  the 
poison,  and  was  evidently  occasioned  by  gradual  asphyxia  from  paralysis 
of  the  muscles  of  respiration.  The  appearances  observed  in  the  mucous 
membrane  of  the  stomach  were  most  probably  caused  by  the  unusual 
fluidity  of  the  blood,  and  this,  in  its  turn,  by  the  gradual  asphyxia. 

The  phenomena,  therefore,  observed  in  this  case,  fully  corroborate  the 
physiological  action  of  hemlock,  as  described  by  Dr.  Christison,  from  his 
experiments  on  animals.*  It  evidently  acts  upon  the  spinal  cord,  pro- 
ducing directly  opposite  effects  to  those  occasioned  by  strychnia.  Para- 
lysis of  the  voluntary  muscles,  creeping  from  below  upwards,  is  the 
characteristic  symptom,  unaccompanied  b^y  pains  or  derangement  of  the 
intellectual  faculties.  Some  authors  have  described  delirium  and  frenzy, 
and  others  giddiness  and  convulsions,  to  have  been  occasioned.  But 
such  symptoms  were  not  observed  in  the  case  of  Grow,  nor  in  the  experi- 
ments on  the  lower  animals  by  Dr.  Christison.  Indeed,  the  symptoms 
described  by  Plato  in  the  case  of  Socrates,  resemble  as  nearly  as  possible 
those  which  appeared  in  Gow.  We  are  told  that  Socrates  was  directed 
by  the  executioner  to  walk  about  after  swallowing  the  poison,  until  his 
limbs  should  grow  heavy.  He  did  so,  and  then  lay  down.  On  his  feet 
and  legs  being  squeezed,  they  were  found  insensible ; they  were  also 
pointed  out  by  the  executioner  to  be  cold  and  stiff.  When  paralysis  had 
proceeded  upwards  to  the  abdomen,  Socrates  made  a request  to  Crito, 
proving  that  his  intellect  was  then  unaffected.  In  a short  time  after, 
he  became  convulsed,  his  eyes  were  fixed,  and  he  died.  Whether  stiff- 
ness was  present  in  Gow’s  case  was  not  ascertained.  The  nature  of  the 
convulsions,  whether  violent  or  otherwise,  is  not  stated  in  the  account 
by  Plato,  but  slight  spasms  were  observed  in  Gow. 

It  will  be  observed,  that  when  Socrates  felt  paralysis  coming  on  he 
lay  down.  Hence  the  staggering  and  falling  in  the  street,  observed  in 
Gow,  did  not  take  place.  The  description  of  the  effects  of  the  Kwvetov 
given  by  Nicander,  however,  would  in  this  case  apply  with  great  accuracy. 
He  says  (I  quote  from  Dr.  Christison’s  paper)  : — “ This  potion  carries 
destruction  to  the  powers  of  the  mind,  bringing  shady  darkness,  and 
makes  the  eyes  roll.  But  staggering  on  their  footsteps  and  tripping  on 
the  streets,  they  creep  on  their  hands.  Mortal  stifling  seizes  the  upper 
part  of  the  neck,  and  obstructs  the  narrow  passage  of  the  throat.  The 

'*  Transactions  of  the  Royal  Society  of  Edinburgh,  vol.  xiii. 


484 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


extremities  grow  cold,  the  strong  vessels  in  the  limbs  contract,  he  ceases 
to  draw  in  the  thin  air,  like  one  fainting,  and  the  soul  visits  Pluto.”  If 
we  abstract  the  poetical  parts  of  the  description,  and  remember  the  loss 
of  sight,  staggering  and  tripping  in  the  street,  the  difficulty  of  degluti- 
tion, and  place  the  loss  of  the  intellectual  faculties  last,  this  account  of 
Nicander  agrees  very  well  with  what  was  observed  in  Gow. 

A difference  of  opinion  exists  as  to  whether  the  Conium  maculatum 
of  modern  botanists  be  the  Kwveiov  of  the  ancient  Greeks.  Into  the 
botanical  controversy  I do  not  feel  myself  qualified  to  enter.  But,  if 
the  symptoms  ascertained  to  have  existed  in  the  case  I have  related  be 
compared  with  the  accounts  of  Plato  and  Nicander,  I cannot  help  think- 
ing that  it  will  be  found  to  favor  the  opinion  of  those  who  believe  in 
their  identity. 

Case  XLIX.* — Poisoning  with  Lead — Painter's  Colic — Lead  Paralysis 
— Partial  Recovery. 

History. — Peter  Taylor,  set,  60,  a brewer’s  servant — admitted  September  26th, 
1851.  At  his  occupation  in  the  brewery  he  frequently  uses  half  a hundred  weight 
of  white  lead  at  a time,  for  jointing  pipes,  and  is  in  the  habit  of  painting  with  the 
same  material.  Twelve  mouths  ago  had  a severe  attack  of  Colica  Pictonum,  from 
which  he  slowly  recovered  under  medical  treatment,  and  then  resumed  his  work,  being 
always  subject,  however,  to  transient  twinges  of  pain  in  the  bowels,  as  well  as  in  the 
joints,  which  latter  he  attributed  to  rheumatism.  Six  weeks  ago  he  first  experienced 
debility  and  want  of  power  in  both  hands,  which  has  gradually  increased  since.  His 
speech  also  has  become  slightly  affected. 

Symptoms  on  Admission. — He  has  at  present  no  pain  anywhere,  and  only  com- 
plains of  want  of  power  in  both  wi’ist  joints.  Both  hands  drop  down  from  the  arms, 
especially  the  right,  which  forms  a riglit  angle  with  the  fore-arm.  He  can  flex  them 
voluntarily  when  elevated  by  another,  but  cannot  raise  them  himself.  When  the 
metacarpal  bones  are  supported  by  the  hand  of  another,  he  can  extend  the  last  joints 
of  the  fingers.  He  has  perfect  command  of  the  shoulder  and  elbow  joints.  His  grasp 
of  an  object  is  little  impaired  ; there  is  no  wasting  of  the  extensor  muscles  of  the  arm, 
though  they  feel  soft ; and  sensibility  of  the  paralysed  parts  is  normal.  Bowels  still 
somewhat  constipated,  but  were  opened  freely  yesterday.  Speaks  with  unusual  slow- 
ness, which  lie  thinks  has  increased  lately.  All  the  other  functions  are  healthy. 

Progress  of  the  Case. — October  1st. — Since  admission  the  bowels  have  been  kept 
open  daily  by  small  doses  of  the  sulphate  of  magnesia.  The  arms  have  been  put  up  in 
splints.,  keeping  the  wrist  and  hand  extended  straight  out.  Galvanism  has  been  applied 
twice  daily  for  several  minutes  in  the  course  of  the  extensors.,  and  frictions  over  them  arc 
occasionally  employed  in  the  interval  by  means  of  flannel  cloths.  October  16^/i. — He  was 
ordered  b'  Potass.  Hydriod.  3 ss ; AqucB  Cinnam.  ; Aqiice  font,  aa  § iij.  M.  Sumat 
§ j ter  indies.  To-day  the  splint  was  semoved  from  the  left  arm,  which  still  droops, 
but  is  more  readily  extended.  October  SOth. — Has  complained  of  numbness  in  the 
right  arm,  attributed  to  the  bandage.  The  splint  was,  therefore,  to-day,  taken  off,  but 
the  hand  droops  as  much  as  ever,  although  he  can  move  the  metacarpal  joints  and 
Angers  a little  better.  November  10^/i. — There  is  decided  improvement  in  the  power 
of  motion  in  both  wrist  joints,  especially  the  left.  Extract.  Nucis  Vomicae,  gr.  vj  ; 
Confect.  Rosar.  q.  s.  utfiant  pil.  vj.  Sumat  unam  ter  indies.  November  21s<. — The 
pills  appear  to  cause  occasional  pain  in  the  stomach  and  bowels,  but  have  occasioned 
no  spasmodic  twitches  in  the  muscles  generally.  The  joints  have  not  improved  since 
last  report,  but  he  insisted  on  going  out.  He  was  therefore  dismissed,  with  the  advice 
to  exercise  the  ivrists  in  pumping  water. 

Commentary. — Lead,  as  a poison,  appears  to  act  first  on  the  peri- 
pheral nerves  of  the  body,  and  subsequently  on  the  nervous  centres,  its 
chief  manifestations  being  in  the  nerves  of  the  intestines,  causing  colic, 


Reported  by  Mr.  Scott  Sanderson,  Clinical  Clerk. 


FUNCTIONAL  DISORDERS  OF  THE  NERVOUS  SYSTEM.  4i)5 

and  those  of  the  arms  producing  paralysis.  Why  this  substance  should 
especially  alfect  these  parts,  is  as  much  unknown  as  why  any  other  poison 
should  exert  a special  influence  on  particular  portions  of  the  nervous 
system.  It  has  been  recently  pointed  out  that  the  metal  exists  in  the 
tissues  (in  the  form  of  carbonate),  and  sulphur  consequently  has  been 
recommended  internally  and  externally,  with  a view  of  causing  its  more 
rapid  decomposition  and  elimination  as  a sulphuret.  For  this  purpose 
the  sulphurous  mineral  waters  have  been  recommended.  Common  alum 
was  given  by  G-endrin,  and  an  acidulated  drink  made  with  sulphuric  acid 
by  others.  Theoretically,  this  treatment  has  its  difficulties ; for  supposing 
the  lead  to  be  converted  into  a sulphuret,  how  is  this  in  its  turn  to  be 
removed  from  the  tissues,  any  more  than  the  carbonate,  without  being 
first  rendered  soluble,  and  therefore  poisonous?  On  the  other  hand, 
some  physicians  in  France  who  have  tried  the  chemical  treatment  exten- 
sively, and  among  others  Andral,  Sandras,  Piorry,  and  Grisolle,  assert 
that  it  has  no  influence  whatever,  and  that  patients  abandoned  to  them- 
selves get  well  just  as  soon.  I believe  this  to  be  the  correct  view;  most 
of  the  primary  and  slighter  cases  getting  well  of  themselves  in  hospital, 
in  about  six  weeks.  In  most  cases  the  disease  yields  to  time  and  slow 
elimination  of  the  poison  from  the  economy.  Iodide  of  potassium  also 
is  said  by  Melsens  to  have  decomposing  and  eliminating  powers.  The 
latter  was  employed  in  the  above  case,  but  with  no  great  success. 

Dr.  Christison  informs  me,  that  “ long  ago,  when  there  was  a white 
lead  manufactory  in  Portobello,  I used  constantly  to  have  in  the  Infir- 
mary a case  or  two  of  lead  colic  or  lead  palsy  and  neuralgia.  Every 
case  of  colic  I saw  got  speedily  well  by  the  alternate  use  of  opium  and 
aperients,  and  every  case  of  paralysis  by  generous  living,  stomachic  ton- 
ics, warm  baths,  and  especially  support  and  regulated  exercise  of  the 
arms.  One  man  I well  remember,  who  was  three  times  under  my  care, 
in  consequence  of  his  always  returning  to  the  factory — had  colic,  palsy, 
and  also  neuralgia;  but  he  got  well  in  no  long  time  by  attention  to  the 
above  means.” 

M.  Duchenne  has  pointed  out  the  great  advantage  of  applying  gal- 
vanism not  generally  to  the  arm,  but  more  especially  to  the  muscles 
affected,  which  in  these  cases  are  most  commonly  the  extensores  digi- 
torum,  and  not  the  lumbricales  nor  enterossei — hence  why  the  first 
phalanges  only  cannot  be  extended,  whilst  when  these  are  supported,  the 
second  and  third  phalanges  can  be  voluntarily  raised  without  difficulty.* 

* For  a case  of  Poisoning  by  Aconite,  see  Aneurism,  case  of  Henry  Smith. 


30 


SECTION  V 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Under  this  head  I include  derangements  of  all  those  parts  which  are 
concerned  in  the  primary  digestion — that  is,  not  only  the  different 
portions  of  the  alimentary  canal  strictly  so  called,  but  the  liver,  pan- 
creas, and  peritoneum.  The  lesions  of  the  spleen  I shall  consider  in 
the  section  devoted  to  diseases  of  the  blood,  as  there  can  be  little  doubt 
that  this,  with  the  mesenteric  and  other  ductless  glands,  is  not  only 
concerned  in  the  formation  ot  blood,  but  is  most  commonly  disordered 
during  its  unhealthy  states. 


DISEASES  OF  THE  MOUTH,  PHARYNX,  AND 
(ESOPHAGUS. 

Case  L.^ — Tonsillitis. 

History. — Christina  Slater,  aet.  22,  a well-nourished  servant  girl — admitted  May 
6th,  1857.  Three  weeks  ago,  after  exposure  to  cold,  during  the  family  washing,  she 
experienced  rigors,  headache,  and  thirst,  with  a sense  of  dryness  and  swelling  in  the 
throat,  especially  on  the  right  side;  could  with  difficulty  swallow  either  solids  or 
fluids,  the  latter  occasionally  regurgitating  through  the  nostrils.  These  symptoms 
continued  to  increase  till  the  night  before  admission,  when  she  felt  something  give 
way  in  her  throat.  She  spat  up  some  matter,  and  thereafter  felt  general  relief. 

Symptoms  on  Admission. — Pulse  of  moilerate  strength  and  frequency ; no  cardiac 
hypertrophy  nor  abnormal  murmurs.  Eespirations  easy  and  not  hurried.  The  voice 
is  soft  and  natural,  but  articulation  is  indistinct  and  hissing.  The  jaws  are  so  im- 
movable as  to  be  separable  only  to  the  extent  of  a quarter  inch ; neither  by  the  finger 
therefore,  nor  by  inspection,  can  the  tonsils  be  examined ; but  there  is  tenderness 
on  pressure,  and  considerable  fulness  in  the  right  sub-parotidean  and  sub-maxillary 
regions.  The  tongue,  as  far  as  can  be  exposed,  is  covered  centrally  with  a thick 
white  creamy  coat ; the  edges  being  of  a bright  red  color.  Can  now  swallow  fluids ; 
appetite  returning ; bowels  regular.  The  urine  is  non-albuminous,  slightly  hyperphos- 
phatic,  with  a mucous  sediment.  The  other  functions  are  normal. 

Progress  of  the  Case. — Poultices  were  applied  from  time  to  time;  on  May  \\t\ 
she  was  able  to  open  her  mouth  to  the  full  extent.  Both  tonsils  were  then  seen  to 
be  enlarged,  the  one  on  the  right  side  being  the  size  of  a walnut.  Anteriorly  it  pre- 
sented two  or  three  ulcers,  with  dense  yellow  margins,  about  the  size  of  split  peas. 
Lunar  caustic  is  to  be  applied  to  the  ulcers,  and  she  is  to  use  an  astringent  gargle. 
The  right  tonsil  still  continuing  enlarged,  was  scarified  May  21s^,  with  marked  relief, 
and  diminished  slightly  in  size  afterwards,  under  the  action  of  tincture  of  iodine 
applied  locally.  The  diminution  being  very  slow,  and  patient  otherwise  in  good 
health,  she  was  sent,  June  8^A,  to  Mr.  Syme,  who  excised  one  half  of  the  gland.  June 
10th. — Was  dismissed  cured. 

Gommentary. — Hypertrophy  of  the  tonsils  is  so  common  in  young 
children  as  scarcely  to  demand  notice,  unless  suspicions  of  croup  are 
Reported  by  Mr.  W.  Guy,  Clinical  Clerk. 


DISEASES  OF  THE  MOUTH,  PHARYNX,  AND  (ESOPHAGUS.  46'? 

entertained,  when  they  should  invariably  be  examined.  I have  fre- 
quently seen  the  fauces  almost  closed  from  the  contact  of  enlarged 
tonsils,  so  as  to  cause  croup-like  breathing,  and  give  rise  to  great  alarm. 
Painting  them  with  the  tincture  of  iodine  is  the  best  remedy,  and  in- 
cision may  be  practised  if  much  permanent  inconvenience  be  occasioned. 
In  the  above  case,  all  the  three  lesions  which  affect  the  tonsils  were 
produced — namely  abscess,  ulceration,  and  enlargement.  The  former 
burst,  the  two  latter  were  treated  successfully  by  local  applications  of 
the  solid  nitrate  of  silver,  and  subsequently  half  the  gland  was  excised. 

Case  LI.^ — Follicular  Pharyngitis. 

History. T-Peter  M‘Donald,  get.  42,  a hammerman  in  an  engine  foundry — admitted 
December  1,  1856.  Four  months  ago,  being  previously  healthy,  he  was  attacked 
with  severe  sore  throat,  difficulty  of  deglutition,  and  subsequently  deafness  in  the  left 
ear.  He  could  not  swallow  sufficient  food,  became  weak,  and  in  a fortnight  gave  up 
work.  He  ascribes  his  attack  to  the  sudden  changes  of  temperature  to  which  he  was 
exposed.  The  dysphagia  did  not  continue,  but  he  still  is  weak,  feels  a dryness  in  the 
chroat,  with  frequent  desire  to  swallow  his  saliva,  but  great  difficulty  in  so  doing. 

Symptoms  on  Admission. — The  voice  is  hoarse.  On  examination  with  a spatula, 
numerous  red  bodies,  of  a somewhat  spherical  shape,  about  the  size  of  a large  pin’s 
head,  are  seen  scattered  over  the  mucous  membrane  of  palate,  fauces,  and  pharynx. 
The  mucous  membrane  of  the  fauces  and  pharynx  is  of  a deep  red  color ; no  ulcers 
visible ; no  cough ; no  expectoration.  Digestive,  respiratory,  and  other  systems  are 
normal. 

Progress  of  the  Case. — Under  local  application  to  the  pharynx  with  a sponge,  of 
the  nitrate  of  silver  solution  ( 3 ss  of  crystallized  nitrate  to  '%]  of  distilled  water)  the 
sense  of  dryness  and  the  difficulty  of  swallowing  saliva  were  relieved : his  strength 
improved  under  good  diet,  and  he  was  dismissed  Dec.  29th. 

Gommeniary. — Pharyngitis  is  generally  indicated  by  a high  degree 
of  redness,  with  thickening  of  the  mucous  membrane ; and  in  certain 
specific  forms  of  it,  ulceration  is  likely  to  occur.  For  a knowledge  of 
follicular  pharyngitis,  and  its  importance  in  relation  to  diseases  of  the 
larynx,  we  are  indebted  to  Dr.  Horace  G-reen  of  New  York.  There  can 
be  no  doubt  that  many  cases  of  chronic  cough,  generally  denominated 
bronchitis,  chronic  laryngitis,  or  clergyman’s  sore  throat,  are  dependent 
on  this  lesion,  and  as  little  that  they  are  to  be  cured  or  greatly  alleviated 
by  appropriate  applications  made  to  the  part.  For  an  account  of  these, 
however,  I must  refer  to  what  is  said  under  the  head  of  Laryngitis. 

Case  LIT.f — Stricture  of  the  (Esophagus  from  Epithelioma. 

History — William  Porter,  ast.  68,  a brassfounder — admitted  May  28,  1855.  Two 
years  ago  a cab  ran  over  his  abdomen,  across  the  epigastric  region.  He  vomited  a 
considerable  quantity  of  blood  for  a few  days  after,  and  felt  a pain  in  the  back.  From 
the  pain  then  felt  he  soon  recovered,  an(l  enjoyed  ordinary  health  till  four  months 
before  admission.  He  then  for  the  first  time  experienced  a sense  of  obstruction  to 
the  passage  of  food  at  the  lower  part  of  the  gullet.  The  dysphagia  has  gradually 
increased,  and  has  latterly  been  attended  with  pain.  He  has  had  no  cough,  and  no 
haemoptysis. 

Symptoms  on  Admission. — Skin  dry,  patient  greatly  emaciated;  pulse  68  per 
minute,  weak  and  irregular ; the  tongue  is  covered  with  white  fur.  The  fauces  are 
natural ; his  food  consists  of  bread  or  biscuit,  steeped  in  tea,  milk,  or  water ; he 
does  not  dare  to  swallow  more  solid  food.  That  which  he  takes  (in  the  presence  of 


* Reported  by  Mr.  Alexander  Turnbull,  Clinical  Clerk, 
f Reported  by  Mr.  G.  M.  Reid,  Clinical  Clerk.- 


468 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


the  clerk)  is  returned  within  two  or  three  minutes.  The  patient  believes  that  the 
food  vomited  has  not  entered  tlie  stomach  ; being  asked  to  point  to  the  spot  where 
he  feels  it  stop,  he  puts  his  finger  on  the  sternum,  at  the  level  of  the  fifth  costal 
cartilage.  He  feels  pain  when  the  food  reaches  this  spot.  Three  weeks  ago,  for  a 
fortnight,  the  pain  was  felt  constantly,  even  when  no  food  was  being  taken.  The 
smaller  portion  of  the  food,  which  passes  the  obstruction  and  enters  the  stomach,  is 
retained  with  only  slight  uneasy  sensations.  There  is  no  tumor  to  be  detected  in 
the  epigastrium ; the  hepatic  organ  is  normal  in  size ; the  abdominal  walls  are  easily 
excited  to  rigidity.  The  bowels  are  costive ; no  blood  has  ever  been-  passed  by  stool. 
Nervous  and  other  systems  normal.  Nutrients  to  he  taken  in  small  quantities  at  a 
time  in  a liquid  form  often  repeated. 

Progress  op  the  Case. — May  Uh. — Tongue  clean;  pulse  68,  stronger  than  on 
admission.  Vomiting  appears  to  be  longer  delayed.  May  ^th. — A probang  passed 
readily  along  the  oesophagus  to-day ; there  is  less  uneasiness,  but  no  greater  power 
in  swallowing.  May  %th. — Complains  of  extreme  weakness ; asks  for  beer,  which  is 
granted.  May  \0th. — About  2 p.m.,  while  taking  a mouthful  of  beer,  he  suddenly 
fell  back ; the  mouth  open ; the  neck  stiff ; the  pupils  slightly  contracted ; the  eyes 
turned  upwards ; incoherent  muttering,  without  consciousness.  His  face  was  pale ; 
he  lay  gasping  for  breath  ; there  was  a tracheal  rale,  and  a fremitus  was  felt  over  the 
whole  chest.  An  ineffectual  attempt  to  vomit  was  followed  by  increased  distress. 
He  rapidly  sank,  and  finally  expired  at  ten  minutes  to  three  o’clock. 

Sectio  Cadaveris. — Tioenty-two  hours  after  death. 

Chest. — There  was  a httle  recent  soft  yellowish  lymph  over  the  pleura,  covering 
the  lower  part  of  the  left  lung.  The  subjacent  pulmonary  tissue  felt  firm,  was  of  a 
dark  color,  and  presented  a granular  section ; it  was  also  friable,  and  portions  of 
it  sank  in  water.  About  two  inches  above  the  cardiac  extremity  of  the  oesophagus 
there  was  found  an  epithelial  ulcer,  nearly  encircling  the  tube.  On  slitting  it  up, 
this  ulcer  was  seen  to  be  of  a circular  form,  an  inch  and  a lialf  in  diameter.  Its 
surface  was  raised  about  one-eighth  of  an  inch  above  the  level  of  the  mucous  mem- 
brane, and  presented  the  appearance  of  a pultaceous  mass,  of  a dirty  white  matter, 
resembling  gruel.  On  scraping  a portion  of  it,  its  base  was  seen  to  be  composed  of 
a whitish  curdy  matter,  easily  breaking  down  when  pressed  between  the  fingers. 
The  muscular  coat  below  was  incorporated  with  the  ulcer,  and  much  thickened,  so 
as  to  produce  a stricture  of  the  tube,  through  which,  however,  the  forefinger  could  be 
readily  passed.  Above  the  stricture  the  oesophagus  was  dilated  into  a pouch  the  size 
of  an  orange. 

All  the  other  organs  were  healthy. 

Microscopic  Examination. — The  ulcer  presented  the  usual  structure  of  epithe- 
lioma, as  described  and  figured  pp.  212,  213. 

Case  — Epitheliomatous  Ulceration  of  the  (JEsophagus,  communi- 

cating ivith  the  Lung — Pneumonia  terminating  in  Gangrene. 

History. — John  Fraser,  aet.  55,  a flesher — admitted  September  19th,  1855.  States 
that  for  five  or  six  years  previous  to  admission,  his  health  had  been  excellent ; and 
that  he  took  his  food  without  any  sense  of  uneasiness,  until  three  or  four  weeks  ago. 
He  then  for  the  first  time  felt  as  if  a ball  of  wind  rose  from  his  stomach  to  meet  the 
food,  and  the  food  in  its  passage  also  gave  him  pain.  The  pain  was  gnawing  and 
paroxysmal.  During  the  last  eleven  days  he  has  brought  up  his  food  after  abortive 
attempts  to  swallow  it,  and  for  four  days  he  has  lived  on  gruel,  not  being  able  to 
swallow  any  solids. 

Symptoms  on  Admission. — Tongue  covered  with  white  fur;  fauces  natural;  ap- 
petite reported  to  be  good;  thirst  not  great;  food  consists  of  gruel  or  bread  and 
biscuit  soaked  in  fluid.  Says  that  the  fluid  in  passing  down  into  his  stomach  gives 
him  great  pain  opposite  a point  half  an  inch  above  the  lower  end  of  ensiform  carti- 
lage ; it  is  returned  from  the  stomach  in  a few  minutes,  again  causing  him  pain  at 
the  same  spot.  He  adheres  constantly  to  this  declaration.  Has  no  nausea ; never 
vomited  blood  or  dark-colored  matter.  Abdomen  is  everywhere  tympanitic.  No 
tumor  can  be  detected.  Dulness  of  the  liver  normal.  The  bowels  are  very  rarely 
opened.  The  pulse  is  82,  rather  small  and  weak.  Respiratory  and  other  S}unptoms 
are  normal.  To  have  nutritive  diet  in  a fluid  form.,  in  small  quantities  often  repeated. 

Progress  of  the  Case. — From  September  2 2d  to  October  2d.  Has  been  taking 

* Reported  by  Messrs.  G.  M.  Reid  and  R.  P.  Ritchie,  Clinical  Clerks. 


DISEASES  OF  THE  MOUTH,  PHAETXX,  AND  CESOPHAGES.  46S 


thrice  daily  the  following  powders: — Bkmuthi  Trisnitrat.  3 j ; Pulv.  opi%  gr.  ij. 
M.  et  divide  in  ptdveres  duodecem.  The  dysphagia  continues  unrelieved;  the  pain 
over  ensiform  cartilage  is  felt  as  formerly ; and  there  has  been  also  a sharp  internal 
pain  over  the  mammary  regions.  October  Wth. — Describes  a pain,  as  if  his  flesh  were 
being  torn  away,  passing  from  the  lower  dorsal  vertebrae  to  the  epigastrium.  Ex- 
perienced temporary  and  partial  relief  from  a blister  applied  to  the  epigastrium.  Oct. 
I()^7i. — Ordered  three  ounces  of  sherry  wine  daily^  and  scruple  doses  of  the  hyposulphite 
of  soda.  Nov.  87/i  — Xo  diminution  in  the  pain,  dysphagia,  or  vomiting.  Ordered 
one  drop  of  Fleming'' s tincture  of  aconite  thrice  daily.  Nov.  \Zth. — Vomiting,  pain, 
d weakness  continue.  The  aconite  is  discontinued,  and  naphtha  medicinaUs  in  terv- 
drop  doses,  with  compound  tinct.  of  cardamoms  is  substituted.  On  the  26th  Nov.  this 
mixture  was  also  stopped,  and  ice  was  ordered.  Dec.  1th. — Strong  beef-tea  injections 
per  rectum  are  now  ordered  night  and  morning.  Dec.  \Uh. — To-day  vomited  round 
masses  looking  like  blood,  and  under  microscope,  blood  corpuscles  are  recognised  in 
them.  Dec.  id. — Blood  corpuscles  are  found  in  the  vomited  matters  to-day.  Pulse 
small,  weak,  120  per  minute.  Dec.  2%th. — Has  had  hiccup  for  a few  days  past;  pulse 
100,  very  feeble,  sometimes  intermitting.  Thirst,  which  he  did  not  feel  on  admission, 
has  lately  been  urgent.  Jan.  D,h. — Has  slight  pain  over  right  hypochondrium ; in- 
creased on  pressure ; fine  moist  rales  are  audible  over  base  of  right  lung  posteriorly, 
with  inspiration.  The  urine  is  not  coagulable,  but  is  deficient  in  chlorides.  Jan.  Mh. 
— Deficiency  of  chlorides  confirmed  to-day.  Dulness,  increased  vocal  resonance,  and 
crepitation  with  inspiration,  are  detected  over  lower  two-thirds  of  right  lung  posterior- 
ly. Pulse  weak,  small,  and  scarcely  perceptible.  To  have  | ij  of  wine  additional. 
Jan.  1th. — Same  signs  as  in  last  report.  Chlorides  are  more  abundant.  W eakness 
extreme.  Jan,  %th. — Chlorides  again  decreased ; the  pulse  is  more  imperceptible ; the 
skin  cold ; in  the  evening  vomited  three  ounces  of  bright  red  blood.  He  died  almost 
immediately  afterwards  at  9 p.m. 

Sectio  Cadaveris. — Sixty-two  hours  after  death. 

The  body  was  much  emaciated. 

Throat. — The  larynx,  pharynx,  and  cervical  portion  of  oesophagus  were  natural. 

Thorax. — The  heart  was  natural.  There  were  a few  adhesions  in  the  left  pleura, 
but  the  lung  was  healthy.  On  the  right  side  of  the  chest  there  were  firm  adhesions 
superiorly,  and  on  the  external  lateral  aspect.  In  attempting  to  remove  the  lung  a 
fungating  growth  situated  over  the  spinal  column  was  broken  into.  This  growth 
(connected  with  the  oesophagus)  was  found  to  have  involved  a portion  of  the  tissue  of 
the  right  lung  near  its  root.  On  removal  of  the  oesophagus,  it  was  seen  that  a portion 
of  it,  about  three  inches  in  length,  commencing  a little  above  the  root  of  the  lung, 
and  going  down  to  about  an  inch  above  the  diaphragm,  was  converted  into  a fungat- 
ing substance  of  soft  cheesy  consistence.  A part  of  anterior  wall  of  the  oesophagus 
had  been  broken  down  and  removed  in  taking  out  the  right  lung ; the  whole  of  the 
internal  aspect  of  the  affected  portion  of  the  oesophagus  presented  a fungatiiig  ulcer- 
ated surfaee.  The  calibre  of  the  tube  must  in  consequence  have  been  much  dimin- 
ished. The  lower  end  of  the  oesophagus,  as  well  as  the  stomach  and  pylorus,  were 
natural.  In  the  stomach  there  were  three  ounces  of  a brownish  fluid  resembling 
coffee  grounds. 

On  removing  and  cutting  into  the  right  lung,  a cavity  about  the  size  of  a walnut 
was  found  in  its  posterior  part,  a little  above  the  root  of  the  lung.  This  cavity  was 
filled  with  a brown  foetid  fluid,  and  the  surrounding  pulmonary  tissue  was  softened, 
hepatized,  and  broken  down.  Higher  up  were  two  smaller  cavities,  presenting  similar 
characters,  and  surrounded  by  a layer  of  condensed  pneumonic  substance. 

The  abdominal  organs  were  natural. 

Microscopic  Examination. — The  fungating  mass  presented  all  the  usual  appear- 
ances of  epithelioma  containing  imbedded  in  the  deeper  friable  portion  of  the  growth, 
numerous  masses  of  concentrically  arranged  cells,  such  as  are  represented  Eig.  233, 
p.  213. 

Commentary. — E.pithelioma  of  the  oesophagus  was  present  in  the 
two  cases  above  recorded  in  different  degrees.  In  case  LIL,  the  dis- 
ease was  limited  to  a patch  about  one  and  a half  inch  in  diameter, 
causing  at  that  point  a stricture  of  the  tube,  and  immediately  above  it 
a considerable  dilatation.  From  the  impossibility  of  taking  nourishment, 
extreme  debility  was  induced,  of  which  he  died.  In  Case  LIII.,  the 


470 


DISEx^SES  OF  THE  DIGESTIVE  SYSTEM. 


epithelioma  was  more  extensive,  surrounding  the  oesophagus  internally 
over  a space  three  inches  in  depth,  causing  great  thickening  of  the  tube 
extending  through  all  the  coat,  and  even  affecting  the  root  of  the  right 
lung.  The  whole  of  the  involved  tissues  were  of  the  consistence  of 
soft  cheese,  and  here  and  there  pulpy  and  even  diffluent.  It  was  evi- 
dent that  at  length  a communication  was  formed  between  the  oeso- 
phagus and  the  lung,  the  occurrence  of  which  was  indicated  by  a pneu- 
monia, with  all  the  physical  signs  and  general  symptoms  characteristic 
of  that  lesion. 

Case  LIV."^ — Carcinomatous  Stricture  of  (Esophagus — Cancer  of  the 
Liver — Pulmonary  Emphysema  and  Tubercle — Pneumonia. 

History. — John  Currie,  set  63,  a cooper — admitted  18th  February,  1857.  Was 
accustomed  to  drink  heavily  till  within  the  last  half  year.  Was  well  fed,  strong, 
and  healthy.  Has  had  rheumatic  fever  thrice,  the  last  time  being  twelve  years  ago, 
without  any  cardiac  symptoms  which  he  can  remember.  Had  inflammation  of  the 
che-st  eighteen  years  ago.  Had  general  dropsy  nine  months  ago ; entered  the  hos- 
pital, and  was  discharged  cured  in  three  weeks.  It  is  about  six  months  ago  since 
the  patient  first  experienced  pain  in  the  epigastrium  after  taking  food,  with  pyrosis 
and  anorexia.  For  three  months  he  continued  in  this  state,  losing  flesh  and  becoming 
weaker.  Three  months  ago  he  began  to  vomit  his  food,  at  first  in  the  evening,  and 
subsequently  during  and  after  all  his  meals.  He  has  vomited  a little  blood  on  three 
or  four  occasions.  The  character  of  the  vomited  matters  is  reported  by  him  to  have 
been  as  at  present. 

Symptoms  on  Admission. — The  tongue  is  clean  ; there  is  no  pain  nor  any  diffi- 
culty in  swallowing  till  the  food  reaches  a point  which  he  indicates  as  beneath  the 
lower  part  of  the  sternum  and  the  epigastrium.  He  has  to  rest  after  each  mouthful 
till  the  food  passes  this  point.  If  it  passes,  he  has  no  further  pain ; but  the  greater 
part  does  not  pass,  and  causes  him  great  pain  till  it  is  dislodged  by  vomiting.  The 
matter  vomited  consists  of  undigested  food  and  clear  mucus.  Fluids  and  solids  are 
equally  troublesome  for  him  to  swallow.  He  has  often  hiccup  while  eating,  and 
brings  up  flatus  with  great  relief.  He  feels  a constant  “ working  ” at  his  stomach. 
There  is  a fulness  and  resistance  on  palpation  over  epigastrium ; but  little  ten- 
derness, and  no  tumor.  The  area  of  hepatic  dulness  vertically  below  the  nipple 
measures  three  inches,  and  laterally  three  and  a half.  No  splenic  enlai’gement 
detected.  No  abnormality  on  examination  of  abdomen.  Bowels  are  rather  costive. 
The  cardiac  dulness  at  the  level  of  the  nipple  is  If  inch.  The  apex  is  felt  and  dis- 
tinctly seen  beating  in  the  sixth  intercostal  space,  and  it  is  seen  also  in  the  fifth 
intercostal  space.  These  two  pulsations  alternate,  or  are  not  exactly  synchronous. 
At  the  apex,  over  a limited  area  of  about  one  square  inch,  a short,  blowing  murmur, 
not  loud,  is  heard  with  the  first  sound,  the  second  sound  being  healthy.  At  the 
base,  both  sounds  are  feeble,  but  free  from  abnormal  murmur.  The  pulse  is  76 ; 
irregular  in  rhythm.  The  respiratory  system  is  normal,  with  the  exception  of  a 
few  snoring  rales  posteriorly.  The  urine  is  high  colored,  sp.  gr.  1027 ; not  albu- 
minous. 

Progress  of  the  Case. — I took  charge  of  this  case  on  the  1st  of  May,  up  to 
which  time  his  symptoms  had  continued  the  same,  notwithstanding  cai’eful  regula- 
tion of  his  diet  and  the  administration  of  morphia,  tr.  ferri  muriatis,  creasote,  wine, 
and  the  application  of  a blister.  The  report  on  J/ay  is No  improvement ; 
pain  in  the  epigastrium  still  severe.  He  is  weaker,  much  emaciated,  and  destitute 
of  appetite.  May  30^/i. — Patient’s  diet  now  consists  of  arrowroot  twice  daily,  beef- 
tea,  tea  and  bread,  and  3 iv  of  sherry  wine.  He  is  umfble  to  take  any  other  nourish- 
ment. Since  admission,  has  been  rarely  out  of  bed.  June  10th. — No  change  in 
symptoms.  Continues  same  diet.  July  Is^. — For  the  past  week  the  strength  has 
gradually  increased.  He  has  been  up  out  of  bed  for  several  days,  and  to-day  he 
ventured  into  the  green  for  a short  time.  Has  some  calf’s  foot  jelly.  July  lOth. — 
Has  relapsed : he  now  feels  a constriction  higher  up  in  the  oesophagus,  opposite  the 
lower  part  of  his  throat,  and  is  unable  to  swallow  even  the  little  he  has  hitherto 
taken.  Is  greatly  emaciated.  Weakness  extreme.  July  2,1th. — Complains  now 

* Reported  by  Messrs.  J.  T.  Walker  and  W.  H.  Davies,  Clinical  Clerks. 


DISEASES  OF  TDE  MOUTH,  PHAEA'NX,  AXD  CESOPHAGUS.  471 


wholly  of  the  constriction  superiorly.  Beef-tea  enemata  with  port  wine  have  been 
ordered  four  times  a day.  July  z()th. — Enemata  discontinued  from  the  resistance 
of  the  patient.  He  is  able  to  swallow  wine,  which  he  relishes.  Aug.  Id. — Since 
last  report,  in  same  state,  but  more  feeble ; lies  very  much  on  his  left  side ; groans 
at  intervals,  his  voice  being  comparatively  strong;  but  articulation  is  very  indis- 
tinct. Has  no  cough  nor  apparent  dyspnoea.  Not  taken  any  food  for  four  days. 
Aug.  3o?.— Died  apparently  from  exhaustion  at  10.30  p.  m. 

Sectio  Cadaveris. — Thirty-nine  hours  after  death. 

Body  presented  the  last  stage  of  emaciation,  the  abdominal  wall  at  the  umbilicus 
being  so  retracted  as  to  be  in  contact  with  the  vertebral  column. 

Thorax. — The  pericardium  was  universally  adherent ; the  adhesions  were  old  and 
firm.  The  lower  half  of  each  aortic  valve  was  thickened  and  almost  rigid ; but  on 
trial  there  is  no  incompetence.  The  heart  weighed  nine  and  a half  ounces,  the  left 
ventricle  being  slightly  thinner  than  usual.  Both  lungs  were  emphysematous  an- 
teriorly ; and  throughout  the  spongy  portion,  indurated  nodules  could  be  felt  varying 
in  size  from  a coffee  bean  to  that  of  a hazel  nut.  On  section,  these  presented  aggre- 
gations of  miliary  tubercle  of  a yellow  color,  for  the  most  part  of  cheesy  consistence, 
but  here  and  there  softened,  forming  purulent  collections  and  small  abscesses  the 
size  of  a pea.  In  the  left  lung,  the  posterior  third  of  the  lower  lobe  presented  all  the 
characteristics  of  red,  in  one  or  two  places  passing  into  grey,  hepatization.  In  the 
right  lung,  posteriorly,  were  two  or  three  masses  of  red  hepatization  the  size  of  a 
walnut. 

Digestive  Organs. — The  posterior  third  of  the  tongue  presented  a tuberculated 
appearance ; the  mucous  membrane  on  section  was  found  thick,  dense,  almost  cartila- 
ginous, of  greyish  color,  and  yielding  on  pressure  a thin  greyish  white  juice.  The 
mucous  membrane  of  the  pharynx  was  natural.  In  the  oesophagus,  an  inch  and  a half 
above  the  bifurcation  of  the  trachea,  there  existed  a stricture  admitting  only  the  point 
of  the  little  finger.  When  opened  the  mucous  membrane  appeared  natural,  the  sub- 
areolar tissue  somewhat  thickened.  Lower  down,  the  cardiac  orifice  was  felt  exees- 
sively  contracted,  so  that  nothing  larger  than  a crow’s  quill  could  be  passed  through 
it.  The  stricture  extended  along  nearly  two  inches  in  length,  being  strictly  limited 
to  the  oesophagus.  The  liver  and  stomach  being  removed  together,  a large  mass  of 
greyish- white  color  and  firm  consistence  was  found  projecting  from  the  posterior 
surface  of  the  liver,  and  firmly  adherent  to  the  cardiac  portion  of  the  stomach  just 
where  the  oesophagus  enters  it.  From  the  surface  of  the  liver  there  projected  other 
rounded  masses  of  greyish-white  color,  with  central  depressions,  and  so  firm  as  to 
creak  under  the  knife.  On  laying  open  the  stricture,  the  mucous  membrane  was  found 
not  ulcerated ; but  in  the  sub-mucous  tissue  was  deposited  hard,  cancerous  matter, 
not  separable  by  any  margin  from  the  similar  substance  already  described  as  project- 
ing from  the  liver.  The  stomaeh  was  contracted,  but  otherwise  healthy. 

Abdomen. — The  kidneys  felt  indurated;  but  when  examined,  appeared  natural. 
The  spleen  weighed  only  two  ounces;  its  structure  was  natural.  Other  organs 
healthy. 

Microscopic  Examination. — The  cancerous  masses  in  the  liver  and  in  the  oeso- 
phagus contained  numerous  large  cancer  cells  in  all  stages  of  development,  embedded 
in  a fibrous  stroma.  The  tubercles  in  the  lungs  exhibited  the  usual  appearance  of 
miliary  tubercle  in  various  stages  of  disintegration,  associated  with  pus.  The  red  and 
grey  hepatization  was  composed  of  an  exudation  in  the  air-cells  and  smaller  bronehial 
vessels,  which  presented  various  stages  of  transformation  into  pus,  being  most  recent 
in  the  former,  and  most  perfect  in  the  latter.  Many  of  the  pus  cells  contained  fatty 
granules,  and  exhibited  different  degrees  of  disintegration. 

Commentary. — This  man  literally  died  of  starvation,  from  the  utter 
impossibility  of'  introducing  nourishment  into  the  system.  The  can- 
cerous mass  originally  fermed  in  the  liver  had  surrounded  and  com- 
pressed the  oesophagus  and  cardiac  orifice  of  the  stomach,  so  as  to  reduce 
the  canal  to  the  size  of  a crow’s  quill,  a stricture  that  extended  through 
a curved  line,  nearly  two  inches  long.  A second  stricture,  but  not  to 
so  great  an  extent,  existed  above  this  in  the  oesophagus.  It  is  not  sur- 
prising, therefore,  that  at  last  no  kind  of  nourishment  could  pass  these 
obstructions,  the  absence  of  contractile  power  in  the  diseased  oesophagus 


472 


DISEASES  OF  TUE  DIGESTIVE  STSTESf. 


above  being  insufficient  to  propel  even  fluids  through  the  stricture 
below. 

What  appears  to  me,  however,  the  most  remarkable  feature  in  this 
case,  is  the  occurrence  in  the  same  individual  of  recent  cancer,  tubercle, 
and  pneumonia.  Whether  the  tubercle  or  the  cancer  was  first  formed, 
it  becomes  exceedingly  difficult  to  determine,  but  certainly  the  nodulated 
groups  of  miliary  tubercle  in  the  lungs  were  in  every  respect  similar 
in  general  appearance  and  structure  to  what  is  observable  in  phthisical 
cases.  It  is  true  there  was  no  especial  accumulation  of  tubercle  at  the 
apex  of  either  lung,  neither  was  there  cough,  nor  any  symptoms  of 
pulmonary  disease  shown  throughout  the  whole  course  of  his  disease. 
But  as  a decided  form  of  exudation  its  presence  was  undoubted.  The 
pneumonia  must  have  come  on  during  the  latter  days  of  his  life,  when 
he  was  in  a state  of  extreme  weakness.  But  it  occasioned  no  active 
symptoms,  and  though  conjoined  with  great  emphysema  anteriorly  in 
both  lungs,  produced  no  dyspnoea.  The  pathological  fact,  however, 
of  the  occurrence  of  these  three  forms  of  exudation  in  one  individual 
is,  though  undoubtedly  rare,  well  calculated  to  demonstrate  the  fallacy 
of  all  exclusive  views  as  to  their  production  in  individuals  of  a peculiar 
diathesis. 

Temporary  dysphagia  occasionally  occurs  in  cases  of  hysteria  or  of 
spinal  irritation,  but  when  permanent  it  is  always  the  result  of  organic 
disease  of  the  pharynx  or  oesophagus.  In  the  great  majority  of  cases  it 
is  owing  to  some  growth,  cancerous,  epitlieliomatous,  aneurismal,  or  of 
some  other  form,  which,  by  attacking  the  parts  themselves,  induces 
stricture  of  its  wails,  or,  by  compressing  them  from  without,  causes  a 
mechanical  obstruction  to  the  tube.  In  a few  rare  cases  it  has  depended 
on  pouch-like  or  spindle-form  dilations,  which,  by  becoming  impacted 
with  food,  have  caused  the  impediment.  In  all  these  cases,  the  cure 
will  depend  on  the  means  at  our  disposal  of  removing  the  obstructing 
cause,  such  as  external  tumors  compressing  the  part ; but  if  it  depend 
on  disease  of  the  pharynx  or  oesophagus,  the  treatment  must  be  for  the 
most  part  .palliative.  There  may  be  a simple  stricture,  which  may 
require  surgical  interference  by  bougies  or  catheters,  but  more  generally, 
as  observed  by  the  physician,  it  is  the  result  of  cancer  or  epithelioma, 
as  in  the  cases  narrated.  Under  such  circumstances,  the  treatment  must 
be  directed  to  support  nutrition  by  unirritating  food,  given  in  small 
quantities  and  in  a form  that  the  patient  can  most  easily  swallow. 
Bemedies  of  various  kinds  to  alleviate  or  check  the  vomiting  may  be 
tried,  but  are  seldom  of  permanent  benefit.  Very  rarely  an  effort  at 
healing  is  set  up  by  nature,  which  for  a time  causes  diminution  in 
the  more  distressing  symptoms,  of  which  Case  XIII.  is  a remarkable 
example. 

FUNCTIONAL  DISORDEBS  OF  THE  STOMACH. 

Case  LV.* — Dyspepsia. 

History. — James  Scott,  aet.  61 — admitted  2Vth  September,  1852.  He  states  that, 
about  two  months  previous  to  admission,  he  experienced  severe  shooting  pains  dart 
ing  from  the  left  scapula  to  the  epigastrium  and  left  hypochondrium.  For  many 

* Reported  by  Mr.  James  D.  Maclaren,  Clinical  Clerk. 


FUXCnONAL  DISORDERS  OF  THE  STOMACH. 


473 


years  back  he  has  been  much  addicted  to  intemperate  habits,  and  latterly  his  appe- 
tite for  food  has  been  considerably  impaired. 

Symptoms  ox  Admission. — On  admission,  the  tongue  is  furred,  and  cracked  in  the 
centre ; he  has  almost  constantly  a sour  taste  in  the  mouth,  worse  in  the  morning 
after  taking  food ; frequent  acid  eructations ; bad  appetite,  and  considerable  thirst. 
About  a quarter  of  an  hour  after  meals  he  experiences  a feeling  of  heat  and  pain  in 
the  epigastrium,  with  acid  eructations  and  flatulence ; the  latter  also  troubles  him 
during  the  night,  when  the  stomach  is  empty.  These  symptoms  continue  generally  for 
about  an  hour  and  a half,  when  they  gradually  abate,  and  soon  after  disappear  entirely. 
He  then  again  takes  food,  and  the  symptoms  return  in  about  a quarter  of  an  hour 
afterwards,  as  already  noticed.  He  does  not  think  that  one  kind  of  food  disagrees 
with  him  more  than  another.  He  has  often  much  nausea  and  loathing  of  food,  but 
no  vomiting.  There  is  some  tenderness  on  pressure  at  a point  about  the  centre  of 
the  epigastrium,  where  he  states  there  is  always  more  or  less  pain,  generally  of  a dull, 
heavy  character,  but  sometimes  occurring  in  sharp  twinges,  shooting  to  the  left  scapula, 
and  somewhat  increased  on  pressure.  There  is  no  unusual  hardness  or  tumor  to  be  felt : 
and  there  is  no  dulness  on  percussion.  There  is  no  tenderness  or  enlargement  of  the 
liver ; urine  normal.  He  is  of  a very  desponding  disposition,  and  does  not  sleep  well 
at  night.  Other  functions  normal.  Potaasce  bicarbonatis  3 ij ; Tinct.  Gentian.  Co. 
§ i ; Inf  us.  Gentian,  Co.  ^ v.  M.  ft.  mist.  Half  a wine-glassful  to  be  taken  thrice  a day. 

Progress  of  the  Case. — December  31s^. — Still  complains  of  flatulence  and  dis- 
tension of  the  abdomen ; considerable  pain  in  the  epigastrium,  increased  on  pressure. 
Applicentur  hirudines  quatuor  epigastrio  et  postea  foveatur.  Jan.  3c?. — Appetite 
improved ; still  acid  eructations,  with  sour  taste  in  the  mouth ; pain  in  the  epigas- 
trium, relieved  after  the  application  of  the  leeches  and  warm  fomentations.  He  is 
very  desponding  about  his  complaints,  which  he  much  exaggerates.  Jan.  \0th. — ■ 
The  sour  taste  and  flatulence  diminished ; pain  and  uneasiness  in  the  stomach  much 
relieved  ; no  tenderness  on  pressure ; appetite  much  improved ; no  sickness  or  vomit- 
ing; bowels  regular;  stools  natural.  Dismissed  in  order  to  return  to  his  work.  The 
food  ordered  has  been  of  a gentle,  un  stimulating,  but  nutritious  kind. 

Commentary. — In  this  case  derangement  of  digestion  depended  on 
intemperate  habits,  and  was  accompanied  by  excess  of  acidity  in  the 
stomach.  The  treatment  was  directed  to  counteract  this  condition  by 
alkalies,  vegetable  bitters,  and  a regulated  diet,  which,  to  a certain 
extent,  succeeded.  But  all  such  cases  require  exercise,  regular  habits, 
and  moral  control,  without  which  medical  treatment  is  unavailing. 

Case  L VI*. — Dyspepsia — Oxaluria. 

History. — John  Millar,  set.  28,  a typefounder — admitted  December  26th,  1852' 
He  states  that  he  had  always  enjoyed  good  health,  with  the  exception  of  occasional 
palpitation  of  the  heart,  until  about  eight  months  ago.  Vertigo  came  on  suddenly 
when  he  was  at  work,  but  disappeared  in  a few  minutes.  Since  then,  he  has  had 
many  attacks  of  the  same  kind ; and  of  late,  these  have  been  accompanied  with  pain 
and  palpitation  of  the  heart,  and  tinnitus  aurium.  Some  years  ago  he  was  mueh 
addicted  to  drink,  but  for  the  last  four  years  he  has  been  more  temperate. 

Symptoms  on  Admission. — On  admission,  the  heart  was  found  to  be  healthy,  and 
the  pulse  natural.  The  tongue  was  dry  in  the  centre,  moist  and  white  at  the  edges, 
with  numerous  transverse  fissures.  He  had  a disagreeable  taste  in  his  mouth  in  the 
morning,  and  no  appetite  for  food ; had  never  vomited  nor  experienced  pain  in  the 
stomach ; bowels  constipated.  There  was  an  anxious,  haggard  expression  of  coun- 
tenance, and  an  evident  tendency  to  exaggerate  his  symptoms ; he  complained  of  ver- 
tigo, tinnitus  aurium,  and  muscae  volitantes.  The  urine,  after  standing  some  time, 
exhibited  a slight  deposit,  in  which  numerous  large  crystals  of  oxalate  of  lime  were 
visible  on  microscopic  examination ; sp.  gr.  1028 ; otherwise  normal.  The  other 
functions  were  normal.  IJ  Acid.  nit.  ; Acid,  muriat.  aa  3 iss  ; Tinct.  gent.  co.  5 i ; 
Inf  us.  gent.  co.  § v if.  A table-spoonful  to  be  taken  three  times  a day. 

Progress  of  the  Case. — January  %th. — Since  last  report,  the  oxalates  have  dis- 
appeared, the  appetite  has  improved,  the  cardiac  and  cerebral  symptoms  are  removed, 
and  he  is  to-day  dismissed  cured. 


* Reported  by  Mr.  James  D.  Maclaren,  Clinical  Clerk. 


474 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


Commentary. — Dr.  Golding  Bird  was  the  first  to  point  out  that 
oxaluria,  associated  with  dyspepsia,  was  a very  common  disorder,  and 
that  its  treatment  by  nitro-muriatic  acid  was  the  most  successful  one. 
The  oxalic  acid  is  probably  derived  from  urea  or  uric  acid,  and  its 
presence  in  the  urine  is  often  associated  or  alternates  with  these  com- 
pounds. No  doubt  the  tonic  treatment  practised  in  the  above  case  is 
the  best  mode  of  relief,  but  here  also  a regulated  diet,  with  exercise  and 
mental  occupation,  are  necessary  to  render  the  benefit  permanent. 

Case  L VII.^^ — Dyspcyosia — Hypochondriasis — Oxaluria. 

History. — Thomas  Pollock,  aet.  24,  hawker — admitted  26th  December  1862* 
He  says  that,  three  years  and  a half  ago,  when  stooping  down  in  a field  during  a 
dark  night  to  evacuate  his  bowels,  he  felt  a sharp,  hard  body,  like  the  stump  of  a 
shrub,  penetrate  his  anus,  causing  acute  pain,  which  continued  for  a fortnight,  and 
has  occasionally  returned  ever  since.  No  blood  passed  at  the  time,  but  he  has  been 
under  the  care  of  various  medical  practitioners,  and  undergone  numerous  kinds  of 
treatment.  He  has  never  had  diarrhoea ; but  is  addicted  to  masturbation.  He  has 
consulted  the  numerous  works  advertised  in  the  papers  on  manly  vigor,  etc.,  but 
has  derived  no  benefit  from  them. 

Symptoms  on  Admission. — On  admission,  tongue  moist,  but  furred,  cracked,  and 
fissured  in  the  centre ; says  he  experiences  a feeling  of  load  after  taking  food,  with 
occasional  nausea.  He  has  no  vomiting,  but  an  acid  and  sometimes  disagreeable 
taste  in  the  mouth ; frequent  flatulence  and  constipation,  for  which  he  is  in  the 
habit  of  taking  aperient  medicine.  On  placing  the  hand  on  the  epigastrium,  he 
says  that  there  is  soreness  beneath  the  xiphoid  cartilage,  increased  on  pressure. 
Has  occasional  involuntary  emissions  of  semen.  The  urine  contains  a slight 
sediment  on  standing,  which  is  crowded  with  large  and  small  crystals  of  oxalate 
of  lime ; sp.  gr.  1020 ; otherwise  normal.  Sleepless  at  night ; anxious  and 
desponding  about  his  complaints,  which  he  attributes  to  the  accident  formerly 
mentioned,  although  it  produced  no  local  effects  at  the  time,  nor  any  structural 
change  since.  Says  that  he  has  frequent  vertigo,  tinnitus  aurium,  muscse  voli- 
tantes,  and  cephalalgia.  The  other  functions  are  normal.  li  Add.  nitrid ; Add. 
muriat.  aa.  3 i ; Tinct.  gent.  eo.  § i ; Infus.  gent.  co.  3 v.  M.  A table-spoonful  three 
times  a day. 

Progress  op  the  Case. — January  3t?. — He  has  continued  to  take  the  acid 
mixture,  but  does  not  admit  that  he  is  in  any  way  better.  On  the  2d,  the  oxalates 
disappeared  from  the  urine,  and  were  replaced  by  a copious  deposit  of  amorphous 
lithates.  Omittatur  mist.  add.  A’  ’ ' Tinct.  cardamom,  eo.  §i; 


Hh. — As  he  still  continues  to  complain  of  pain  in  the  sacral  region,  which  he 
attributes  to  the  accident,  a blister.,  three  inches  by  four.,  was  ordered  to  be  applied 
there.  January  10th. — Since  the  application  of  the  blister,  the  pain  in  the 
sacrum  has  disappeared.  He  expresses  himself  as  being  much  better,  and  was  now 
dismissed. 

Coynmentary. — In  this  case  the  presence  of  oxalates  in  tbe  urine 
was  associated  with  the  same  class  of  symptoms  as  in  the  former  one, 
but  the  tendency  of  the  patient  to  exaggerate  his  complaints  was  more 
marked.  He  had  also  a firm  belief  in  tbeir  being  caused  by  an  accident, 
which  possibly  never  happened,  and  even  if  it  had,  could  not  have 
occasioned  his  symptoms.  The  acid  and  tonic  mixture  reumved  the 
oxalates,  but  lithates  took  their  place  in  the  urine,  which  in  their  turn 
were  got  rid  of  by’  alkalies.  Still,  the  fixed  idea  as  to  the  cause  of  the 
disease  continued,  and  he  seemed  no  better.  A blister  was  now  applied 
to  the  sacrum,  and  he  readily  adopted  the  idea  that  his  local  complaints 
disappeared  with  the  pain  of  the  blister,  and  became  cheerful  and  well. 
No  case  could  better  illustrate  the  effects  of  mental  depression  on  the 
* Reported  by  Mr.  William  Calder,  Clinical  Clerk. 


Infus.  quassice  § vii.  M.  Two 


and  morning.  January 


FUNCTIONAL  DISORDERS  OF  THE  STOMACH. 


475 


digestive  organs  than  this.  For  a period  of  three  years  he  had  been  the 
subject  of  delusion  and  genital  irritations,  heightened  by  the  study  of 
those  publications,  which,  to  the  disgrace  of  the  newspaper  press,  are 
daily  advertised  to  the  people  as  the  only  means  of  restoring  vigor  to 
the  constitution.  At  length,  satisfied  of  their  inefficiency,  he  entered 
the  Infirmary;  the  error  of  his  practices  was  kindly  pointed  out  to  him, 
nutritious  diet,  regular  habits,  and  tonic  treatment  were  obviously  bene- 
ficial ; and  fortunately  his  hypochondriasis  yielded  to  the  simple  expe- 
dient of  substituting  real  for  supposed  pain,  and  leading  him  to  imagine 
that  the  one  had  cured  the  other. 

General  Pathology  and  Treatment  of  Dyspepsia. 

By  dyspepsia  (from  8i;cr7re7rTco,  I digest  with  difficulty)  are  generally 
understood  all  those  functional  derangements  of  the  stomach  which  are 
primary  in  their  origin,  that  is,  not  dependent  upon,  or  symptomatic 
of,  inflammation  or  other  disease  in  the  economy.  Such  a disordered 
condition  is  exceedingly  common,  and  often  constitutes  the  despair  of 
the  physician,  arising,  as  it  frequently  does,  from  causes  which  are 
obscure,  or,  if  discovered,  are  beyond  his  control.  This  will  become 
apparent  by  considering,  in  the  first  place,  those  circumstances  which 
require  to  be  united  to  secure  a healthy  digestion.  These  are — 1st, 
A proper  quantity  and  quality  of  the  ingesta.  2d,  Sufficient  mastica- 
tion and  insalivation.  3d,  x\ctive  contractility  in  the  muscular  coat  of 
the  stomach.  4th,  Proper  quantity  and  quality  of  the  gastric,  biliary, 
and  pancreatic  fluids.  5th,  A consecutive  and  harmonious  action  of  the 
intestinal  canal.  Dyspepsia,  or  indigestion,  may  be  produced  by  any 
cause  which  occasions  derangement  of  one  or  more  of  these  conditions ; 
and  hence  it  is  why  so  many  different  circumstances  may  produce  some- 
what similar  symptoms,  and  why  so  many  different  remedies  have  beon 
found  effectual  in  various  cases.  Notwithstanding  that  you  will  fre- 
quently meet  with  instances  which  baffle  all  preconceived  rules,  there 
can  be  no  doubt  that  a careful  attention  to  the  essential  physiological 
conditions  above  enumerated  will,  in  a great  majority  of  cases,  conduct 
you  to  a successful  rational  treatment.  Thus — 

1.  Of  all  the  causes  of  dyspepsia,  excesses  in  eating  and  drinking  are 
the  most  common.  An  over-extended  stomach,  or  too  rich  a meal,  not 
unfrequently  induces  a feeling  of  weight  or  fulness  in  the  epigastrium, 
nausea  and  eructation  of  acid,  bilious,  or  gaseous  matters,  with  a loaded 
tongue,  headache,  and  other  general  symptoms.  This  is  acute  dyspepsia, 
or  the  emharras  gastrique  of  the  French.  Occasionally,  there  is  more  or 
less  vomiting  of  bilious  matter,  when  the  attack  is  vulgarly  called  a 
bilious  seizure.  If  called  to  see  such  a case,  immediately  on  its  occur- 
rence, and  before  the  ingesta  have  left  the  stomach,  as  determined  by 
the  sense  of  load  at  the  epigastrium  and  by  percussion,  an  emetic  should 
be  given  ; and  if  vomiting  is  about  to  occur,  it  should  be  assisted  by  warm 
diluents.  As  soon  as  the  stomach  is  quieted,  or,  if  you  have  been  called 
in  at  a late  period,  when  the  ingesta  have  passed  into  the  intestines,  a 
purgative  should  be  administered,  consisting  of  four  grains  of  calome 


476 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


with  four  of  compound  extract  of  colocjnth,  followed  in  a few  hours  hj 
a draught  of  salts  and  senna.  If  necessary  also  an  enema  may  be  given. 
The  purging,  with  a day  or  two’s  confinement  to  farinaceous  food,  will 
generally  get  rid  of  such  an  attack ; but  their  frequent  repetition  leads 
to  the  chronic  form  of  dyspepsia,  in  which  careful  regulation  of  the  diet, 
with  exercise,  must  constitute  the  chief  treatment.  Hence  the  advantage 
of  what  is  called  “ change  of  air,”  and  much  of  the  benefit  wdiich  is 
derived  from  watering  places.  Chronic  dyspepsia,  however,  is  far  more 
commonly  caused  by  excess  of  spirituous  and  vinous  drinks,  than  by 
eating;  and,  in  such  cases,  abandonment  of  the  evil  habit  is  a sine  qua 
non  in  the  treatment.  Tea-drinkers  are  very  liable  to  the  disease,  and 
its  frequency  among  female  servants  is  probably  owing  to  over-indul- 
gence in  this  beverage. 

2.  It  may  frequently  be  noticed,  that  those  who  have  acquired  the 
habit  of  eating  rapidly  are  more  or  less  dyspeptic.  I knew  a journey- 
man printer,  who  had  been  much  tormented  with  indigestion,  but  who 
was  cured  by  changing  his  residence.  The  reason  of  this  cure  was  for 
some  time  a mystery ; on  again  changing  his  house,  the  disease  returned ; 
still  no  apparent  cause  could  be  discovered.  I ascertained,  at  length, 
that  it  depended  not  on  the  locality  -per  se,  but  on  its  distance  from  the 
printing-house.  When  far  olF  he  ate  his  dinner  witn  his  family  rapidly, 
having  only  just  time  enough  to  walk  home  and  back  within  the  hour. 
When  he  lived  near,  the  time  otherwise  spent  in  walking  was  occupied 
in  eating,  or  in  cheerful  converse  with  his  wife  and  family.  Since  I 
made  this  observation,  it  has  often  occurred  to  me  that  the  distance  of 
the  residences  of  artizans  from  their  place  of  employment  may  be  the 
occasional  cause  of  the  dyspeptic  symptoms  they  frequently  suffer  from. 
The  exact  object  of  the  saliva  in  the  process  of  digestion,  whether  it  be 
to  convert  the  farinaceous  compounds  of  the  food  into  glucose,  or  by  its 
viscidity  to  mix  up  air  with  the  portions  swallowed,  is  not  positively 
determined ; but  its  necessity  for  digestion  is  shown  by  what  happens 
in  cases  where  the  under  lip  has  been  lost  by  accident  or  disease,  or 
where  salivary  fistulas  have  formed ; in  such  cases  dyspepsia  is  generally 
present,  and  in  some  the  disordered  digestion  has  been  cured  by  opera- 
tions that,  by  restoring  the  parts  to  their  normal  condition,  prevent  the 
escape  of  saliva.  Again,  persons  habituated  to  the  dirty  habit  of  spit- 
ting, are  for  the  most  part  dyspeptic.  In  all  cases  where  dyspepsia  can 
be  traced  to  this  source,  the  treatment  becomes  obvious. 

3.  The  contractile  movements  of  the  stomach,  which,  by  kneading  the 
ingesta,  and  keeping  them  in  constant  motion,  secure  their  intimate 
admixture  with  the  gastric  juice,  and  the  rapid  transference  to  the 
duodenum  of  such  portions  of  it  as  are  transformed  into  chyme,  are 
evidently  of  great  importance  to  the  proper  performance  of  digestion. 
The  experiments  of  physiologists  have  shown  that  digestion  goes  on  in 
gastri^c  juice  taken  out  of  the  stomach  much  slower  than  in  the  stomachy 
and  that  section  of  the  pneumogastric  nerves,  by  arresting  the  contrac- 
tile movements,  permits  only  the  circumference  of  the  mass  in  contact 
with  the  secreting  surface  to  be  digested.  These  facts  at  once  explain 


FUNCTIONAL  DISORDERS  OF  THE  STOMACH. 


477 


the  well-known  influence  of  mental  emotions  upon  the  stomach.  Con- 
tentment and  hope  are  as  favorable,  as  dissatisfaction  and  despondency 
are  injurious,  to  good  digestion.  Nothing  is  more  common  than  dys- 
pepsia among  literary  men  who  overtask  their  mental  faculties ; among 
3"Oung  persons  of  very  excitable  minds  ; and  among  individuals  of  a 
melancholy  temperament,  hypochondriacs,  etc.  etc.  It  is  in  such  cases 
that  cheerful  society,  active  and  appropriate  occupations,  change  of  scene, 
removal  from  mercantile  or  literary  employments,  variety  in  trains  of 
thought,  and  so  on,  are  beneficial.  Hence  also  many  of  the  good  effects 
of  travel,  visits  to  watering-places,  etc.  etc. 

4.  Our  knowledge  with  regard  to  the  offices  performed  by  the  gastric, 
biliary,  and  pancreatic  juices  in  the  digestion  has  of  late  years  been  much 
advanced.  Thus,  the  gastric  juice  operates  more  especially  on  the  al- 
buminous, and  the  pancreatic  juice  on  the  fatty  compounds  of  the  food. 
The  function  of  the  bile  is  more  obscure ; it  probably  acts  as  a means  of 
precipitating  or  separating  some  of  the  excretory  matters  from  chyme, 
and  so  facilitates  assimilation  of  the  nutritive  portions.  Digestion  may 
be  deranged  by  all  those  causes  which  increase  or  diminish  too  much  the 
secretion  of  these  three  fluids.  Thus,  excess  of  acidity  in  the  stomach  is 
one  of  the  most  common  causes  of  dyspepsia,  and  is  associated  with  that 
form  of  it  which  accompanies  scrofulous  and  tubercular  diseases.  It  may 
be  in  such  excess  as  to  neutralise  the  alkaline  action  of  the  pancreatic  juice, 
and  render  it  incapable  of  emulsionising  fatty  matters.  In  such  cases 
the  alkalies,  with  bitter  tonics  and  the  direct  introduction  of  animal  oils 
in  excess,  are  indicated.  On  the  other  hand,  the  gastric  juice  may  be 
diminished  in  quantity,  as  frequently  occurs  in  persons  who  suddenly 
overtask  the  powers  of  the  stomach  at  feasts,  or  in  old  persons  with 
feeble  digestion.  The  sense  of  load  after  eating  is  generally  indicative 
of  slow  digestion  from  this  cause.  In  acute  cases,  a stimulant  rouses  the 
stomach  to  increased  action,  and  hence  the  moderate  use  of  drams  and 
generous  wines  after  dinner  is  occasionally  useful.  In  old  persons  the 
.sense  of  load  and  feebleness  is  best  removed  by  giving  up  tea,  and  drink- 
ing at  night  a little  weak  brandy  and  water.  In  chronic  cases,  acids  are 
indicated,  especially  muriatic  acid.  The  Tr.  Ferri  co,  of  the  pharma- 
copoeia is  a useful  preparation  in  chlorotic  females.  The  prepared  gastric 
juice  of  the  calf  has  been  lately  recommended  as  a remedy  in  this  case ; 
and  is  undoubtedly  in  some  cases  of  much  service. 

We  have  no  distinct  means,  as  far  as  I am  aware,  of  rousing  the 
pancreas  into  action,  and  yet  many  cases  are  on  record  in  which  fatty 
matters  have  passed  undigested  through  the  alimentary  canal  in  conse- 
quence of  obstruction  to  the  pancreatic  duct.  In  such  cases,  and  in  all 
those  in  which  fatty  matters  are  difficult  to  digest,  alkalies,  especially 
the  sodcB  hicarh  with  vegetable  tonics,  are  indicated. 

When  the  bile  is  deficient,  constipation  and  dyspepsia  are  usual  re- 
sults, and  are  to  be  relieved  by  gentle  mercurial  purgatives,  with  extract 
of  taraxacum,  and  by  remedies,  such  as  rhubarb,  and  especially  the  com- 
pound rhubarb  pill,  which,  by  acting  on  the  duodenum,  also  favor  the 
flow  of  bile  into  the  upper  part  of  the  alimentary  canal.  Dr.  Clay,  of 
Manchester,  has  recommended  in  such  cases  the  administration  of  ox- 
gall, a remedy,  which,  although  not  extensively  given,  is  evidently 


478 


DISEASES  OF  THE  DTGESTITE  STSTEiT. 


rational,  and  calculated  by  its  purgative  action  to  be  bigbly  serviceable. 
Excess  of  bile,  on  the  other  hand,  ought  to  be  treated  by  drastic  purgatives, 
diuretics,  and  diaphoretics,  according  to  circumstances,  to  cause  excess 
of  excretion.  Exercise  should  also  be  insisted  on  to  call  the  lungs  into 
action,  and  thus  relieve  the  liver  in  its  office  of  separating  hydrocarbon. 

5.  A derangement  of  the  consecutive  and  harmonious  action  of  the 
alimentary  canal  is  another  frequent  cause  of  dyspepsia,  for  it  is  as  neces- 
sary that  those  portions  of  the  food  which  are  not  assimilable  should  be 
removed  out  of  the  economy,  as  that  the  nutritive  materials  should  be 
absorbed.  Hence,  whatever  impedes  the  contractility  of  the  intestinal 
canal,  whatever  alters  the  structure  of  its  mucous  membrane,  or  what- 
ever mechanically  obstructs  its  calibre,  induces  dyspeptic  symptoms. 
The  removal  of  these  various  conditions,  whether  by  stimulating  the 
nervous  centres  by  appropriate  diet,  or  by  purgatives  and  astringents, 
need  not  be  more  particularly  dwelt  upon  here.  I would  only  observe 
that  the  constant  use  of  laxatives,  however  they  may  temporarily  relieve, 
cannot  cure,  and  that  in  all  chronic  cases  a proper  action  of  the  bowels 
must  be  obtained  as  much  as  possible  by  means  of  dietetic  and  hygienic 
regulations. 

In  many  cases  of  dyspepsia,  two  or  more  of  these  classes  of  causes 
may  be  combined  wso  as  to  render  the  indications  for  treatment  complex 
and  apparently  contradictory.  In  other  cases,  one  or  more  causes  may 
exist,  although  from  the  indications  present  their  nature  cannot  be  deter- 
mined ; in  such  cases,  our  treatment  must  always  be  more  or  less  vague 
and  unsatisfactory.  Lastly,  there  are  a few  instances  where  dyspepsia 
can  only  be  explained  by  idiosyncrasy^  in  which  we  find  this  or  that 
particular  article  of  diet  to  derange  the  digestive  function,  and  in  which 
avoidance  of  the  offending  cause  is  the  only  plan  of  treatment  that  is  at- 
tended with  success. 

In  addition  to  the  different  kinds  of  dyspepsia  to  which  I have 
directed  your  attention,  it  is  practically  important  to  keep  in  remem- 
brance the  leading  symptoms  which  may  be  present,  and  the  remedies  by 
which  they  may  be  removed.  The  symptoms  are  anorexia,  acid  eructa- 
tions, sense  of  load  at  the  stomach,  cardialgia,  vomiting,  flatulence,  pal- 
pitations of  the  heart,  and  cephalalgia.  Some  persons  talk  of  a stomach 
cough,  but  this  is  more  commonly  dependent  on  sources  of  irritation  in 
the  oesophagus  or  pharynx,  which  have  hitherto  been  overlooked.  I have 
already  alluded  to  the  mode  of  treating  most  of  these  symptoms.  Pal- 
pitations of  the  heart  often  occasion  alarm  in  young  dyspeptic  persons; 
and  in  such  cases,  besides  remedies  directed  towards  the  stomach,  change 
of  scene,  removing  attention  from  the  affected  organ,  and  varied  reading 
should  be  enjoined.  The  sense  of  load  in  the  stomach  is  most  fre- 
quently removed,  as  I have  previously  said,  by  acids ; and  sour  eructa- 
tions and  cardialgia  are  best  relieved  by  alkalies  and  bitter  tonics. 
Vomiting  and  flatulence  are  often  very  troublesome  symptoms.  The 
varied  remedies  which  may  be  employed  in  a case  of  chronic  vomiting 
may  be  gathered  from  the  following  history  : — 

Oase  LVIII.* — Dyspepsia — Vomitiny  of  fermented  matter  containing 

Sarcinoe. 

History. — Thomas  Spence,  aet.  53,  a weaver — admitted  September  6,  ]852, 

* Reported  by  Mr.  William  Calder,  Clinical  Clerk. 


FUXCTIOXAL  DISORDERS  OF  THE  STOMACH. 


479 


ITe  states  that  for  fourteen  or  fifteen  years  past  he  has  been  subject  to  occasional 
vomiting,  which  generally  occurred  on  Sundays,  owing,  he  supposes,  to  want  of 
exercise  at  his  usual  employment.  On  these  days  he  scarcely  ever  took  his  meala 
from  fear  of  the  almost  certain  vomiting  which  would  follow.  For  two  or  three 
years  past  he  has  been  liable  to  frequent  heartburn,  water-brash,  and  acid  eructa- 
tions, but  was  able  to  continue  at  his  usual  employment  till  about  six  months  ago. 
Since  then,  he  has  been  gradually  losing  his  appetite,  and  his  strength  has  become 
much  prostrated.  He  has  never  vomited  blood  or  any  dark-colored  matter,  and  has 
never  passed  any  such  by  stool. 

Symptoms  on  Admission. — On  admission,  tongue  clean ; no  difficulty  in  degluti 
tion ; appetite  capricious,  but  always  best  in  the  morning  and  early  part  of  the  day. 
Shortly  after  taking  food,  he  begins  to  have  uneasy  sensations  in  the  epigastrium, 
sickness,  and  a sense  of  weight  at  the  stomach.  When  these  symptoms  appear, 
the  abdomen  generally  begins  to  swell,  and  in  about  an  hour  to  an  hour  and  a 
half  the  food  is  vomited.  The  rejected  matters  consist  generally  of  the  half-digested 
food,  with  a thick,  dirty,  frothy  scum  on  the  surface,  resembling  yeast.  He  has 
also  frequent  pyrosis,  acid  eructations,  and  flatulence,  the  latter  sometimes  so 
great  as  to  occasion  a sensation  of  choking,  especially  after  vomiting.  These 
symptoms  are  worse  after  some  kinds  of  food  than  others : oatmeal,  especially  in 
the  form  of  porridge,  produces  them  in  the  severest  form ; broths,  vegetables,  or 
any  kind  of  slops,  disagree  with  him ; animal  food  suits  him  best,  but  when  even 
this  is  taken  for  any  length  of  time,  the  symptoms  soon  reappear.  The  abdomen 
at  present  is  much  swollen,  very  tense,  and  tympanitic  on  percussion,  with  consider- 
able tenderness  over  the  epigastrium.  The  bowels  are  generally  constipated  ; the 
stools  usually  of  a dark  color  and  hard  consistence.  He  has  occasionally  slight  pain 
and  difficulty  in  voiding  his  urine,  which  is  slightly  phosphatic.  Other  functions 
are  normal. 

Progress  of  the  Case. — On  taking  charge  of  this  patient  on  the  1st  of  November, 
I found  him  vomiting  from  time  to  time  large  quantities  of  fluid  mixed  with  undi- 
gested matters,  on  which  there  gathered,  after  a short  time,  a thick  brownish  scum, 
exactly  resembling  yeast.  On  examining  this  scum  with  the  microscope,  it  was 
ascertained  to  contain  a large  number  of  sarcinge  ventriculi  (see  p.  98,  Fig.  88), 
mingled  with  starch  corpuscles,  more  or  less  broken  down,  and  granular  matter. 
From  the  ward-books  I learnt  that  his  treatment  had  consisted  in  the  successive 
administration  of — 1.  The  local  application  of  leeches;  2.  Of  the  sulphite  of  soda, 
in  scruple  doses,  with  two  grains  of  aromatic  powder  three  times  a day  ; 3.  Of  half 
a grain  of  protochloride  of  mercury  at  night ; 4,  Of  a scruple  of  the  sulphite  of  soda 
every  three  hours,  which  was  subsequently  increased  to  half  a drachm ; 5.  Of 
creasote  mixture ; 6.  Of  a naphtha  mixture  ; 7.  Of  bismuth  and  aromatic  powders ; 
and  8.  Of  pills  of  calomel  and  opium.  These  different  kinds  of  treatment,  some  of 
which,  especially  that  of  the  sulphite  of  soda,  had  been  continued  for  several  weeks 
without  intermission,  seemed  to  have  produced  no  good  effect.  November  Wth. — 
During  the  last  four  days,  he  has  vomited  every  night,  four  hours  after  dinner,  that 
is,  about  six  p.m.  The  ejected  matter  presents  the  same  yeast-like  character  formerly 
described ; but  the  sarcinge,  though  still  abundant,  are  not  so  numerous.  He 
complains  of  a great  sense  of  distension,  and  a feeling  of  “working”  or  “bubbling” 
in  the  stomach  shortly  before  vomiting.  Acid.  Hydrocyan.  dU.  m.  xviij  ; Syrup. 
Aurant.  3j.  Aquee  ^ v.  J/.,  half  an  oz.  three  times  a day.  November '^.Oth. — The 
hydrocyanic  acid  checked  the  vomiting  till  last  night,  when  it  returned  with  more 
violence  than  ever.  November  24^7i. — Vomiting  still  continues  regularly  every  day. 
Omittatur  Mist.  Acid.  Hydrocyan.  ^ Liquor . Potass.  3 ss  ; Aquee  § vss.  Two  table- 
spoonfuls to  be  taken  every  four  hours.  December  2<7. — Alkaline  mixtures  again  checked 
the  vomiting,  which,  however,  returned  last  night  to  a slight  degree.  AppUcet 
Vesicat.  4x5  Epiejastrio.  December  87A. — Vomiting  has  once  more  returned  daily  since 
last  report.  H Tinct.  Ferri  Muriat.  ^ i.  Sumat  3 ss  ter  in  die  ex  aqud.  December 
16th. — The  vomiting  has  been  again  checked,  but  once  more  returned  in  a slight 
degree  at  one  a.m.  this  morning.  The  matter  ejected  exhibits  very  little  of  the 
usual  frothy  scum,  but  consists  of  a brown  liquid  like  coffee,  with  a few  shreds  of 
undigested  food.  It  is  of  intensely  acid  re-action,  and  contains  only  a few  sarcinae. 
The  dose  of  the  Acid  Tincture  has  been  reduced  to  M.  xv.  The  diet  during  this 
period  has  been  principally  animal,  porridge  and  vegetables  invariably  increasing  his 


480 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


complaint.  To-day  lie  left  the  hospital  to  visit  his  friends  in  the  country,  expressing 
himself  as  greatly  relieved. 

Commentary. — The  kind  of  chronic  vomiting  and  dyspepsia  here 
spoken  of  has  been  long  known  in  Scotland,  and  was  described  by  Cullen 
as  a form  of  pyrosis.  It  was  supposed  to  be  associated  with  the  habit 
of  largely  consuming  oatmeal  as  a principal  part  of  the  diet;  but  its 
real  pathology  was  unknown.  In  1843  Mr.  Goodsir  discovered  in  the 
ejected  matter  from  the  stomach,  in  a case  of  this  kind,  organized  forms, 
which,  from  their  resembling  a wool-pack,  he  denominated  sarcin(B.  He 
considered  that  they  were  of  a vegetable  nature,  and  by  multiplying 
fissiparously,  gave  to  the  contents  of  the  stomach  the  appearance  of  yeast, 
which  is  also  known  to  be  dependent  on  the  development  and  growth  of 
vegetable  structures.  The  occurrence  of  these  sarcime  in  the  stomach  of 
course  explains  their  frequent  presence  in  the  fieces,  although,  whether 
they  are  ever  developed  in  the  intestines  is  unknown.  In  two  cases  I 
have  seen  them  in  the  urine,  when  they  were  uniformly  smaller  in  size 
than  the  sarcince  ventriculi.  They  have  also  been  discovered  by  Virchow 
in  an  abscess  of  the  lung;  and  I have  seen  them  in  the  juice  squeezed 
from  an  oedematous  lung.  Dr.  Tilbury  Fox  has  found  them  on 
the  skin.  The  origin  and  exact  mode  of  development  of  these  struc- 
tures are  unknown ; but  their  presence  is  no  doubt  the  real  cause  of 
the  chronic  vomiting  and  other  symptoms  of  the  individual  affected ; 
and  the  cure  of  the  disease  will  depend  on  the  use  of  such  means  as  are 
capable  of  insuring  their  destruction  and  preventing  their  return.  It 
is  obvious,  however,  that  the  means  which  destroy  or  check  vegetable 
growths  on  the  external  surface  of  the  body  (see  Favus),  are  not 
applicable  to  the  mucous  lining  of  the  stomach.  Besides,  we  do  not 
know  whether  these  parasites  grow  in  an  exudation  poured  out  on  the 
mucous  membrane,  or  are  developed  only  in  a fluid.  Again,  it  is 
very  possible  that,  on  being  introduced  from  without,  the  conditions 
necessary  for  their  development  may  be  dependent  on  particular  kinds  of 
ingesta — a view  which  derives  support  from  the  facts  observed  in  the 
case  before  us,  namely,  that  the  sarcinee  were  always  increased  by  farina- 
ceous kinds  of  food.  On  all  these  points,  however,  we  are  as  yet  igno- 
rant, and  our  efforts  at  cure  hitherto  have  not  so  much  been  directed  to 
cutting  off  the  sources  of  growth,  as  to  destroying  the  sarcinee  after  it 
has  proceeded  to  a certain  extent.  AVith  this  view  it  has  been  imagined, 
that  the  sulphite  of  soda  would  destroy  them,  by  causing,  on  its  union 
with  the  gastric  juice,  the  extrication  of  sulphurous  acid,  which  is  so 
destructive  to  vegetable  life.  This  remedy  has  consequently  been  given, 
and  not  unfrequently  with  success ; but  in  the  present  case  it  was  of 
no  benefit.  Subsequently  a variety  of  medicines  were  administered, 
several  of  which  succeeded  in  checking  the  vomiting  for  a time.  Indeed, 
it  was  remarked  that  the  mere  circumstance  of  changing  the  medicine 
was  sufficient  to  stop  the  vomiting  for  several  days,  when  it  returned  and 
continued  as  before.  Of  all  the  numerous  remedies  tried,  the  Tr.  Ferri 
Muriatis  seems  to  have  done  most  good.  The  following  case  offers  a re- 
markable contrast  to  the  one  just  given,  for  although  of  some  standing 
it  was  rapidly  cured  by  the  sulphite  of  soda. 


FUNCTIONAL  DISOEDEES  OF  THE  CTOruACII. 


481 


Case  LIX.* — Dyspepsia — Vomiting  of  fermented  matter  containing  Sarcinm. 

History. — Christina  Torrence,  set.  18,  servant — admitted  July  11,  1853.  For 
the  last  three  years  has  been  suffering  from  more  or  less  pain  in  the  stomach,  loss  of 
appetite,  and  occasional  vomiting,  generally  soon  after  meals.  The  ejected  matters 
have  always  been  very  acid,  and  have  varied  in  appearance  with  that  of  the  food 
taken,  which,  for  the*^  most  part,  consisted  of  tea  and  porridge,  with  very  little 
animal  food.  She  is  thin,  and  her  general  strength  has  been  much  reduced.  She 
has  taken  all  kinds  of  medicines,  and  has  been  treated  homoeopathically  for  some 
time  without  the  slightest  relief. 

Prooress  of  the  Case. — On  admission  she  was  ordered  bismuth  and  aromatic 
powders,  which  slightly  alleviated  some  of  the  symptoms.  On  the  14th,  however, 
there  was  vomiting  of  a brown  frothy  fluid,  to  the  extent  of  3 iv,  which,  oa  micro- 
scopic examination,  was  demonstrated  to  contain  numerous  sarclnea.  A scruple  of 
Sulphite  of  Soda  was  ordered  to  he  taken  three  times  a day.  On  the  22d,  vomiting 
again  returned,  but  the  rejected  fluid  contained  no  sarcinse.  From  this  time  all  pains 
ceased,  other  symptoms  disappeared,  and  she  was  dismissed  quite  well  July  28th. 

Commentary . — Althougli  it  occasionally  happens,  as  in  the  above  case, 
that  a cure  may  be  rapidly  accomplished,  this  is  not  to  be  hoped  for 
when  the  disease  is  very  chronic.  In  addition  to  what  has  been  said 
on  this  subject,  I may  add,  that  whenever  everything  has  been  tried  and 
failed,  I have  recently  found  that  complete  abstinence  from  food  for  one  or 
two  days,  while  the  body  is  supported  by  nutritive  enemata,  has  checked 
the  vomiting  and  accumulation  of  fluid;  that  full  doses  of  opium,  the 
stomach  being  empty,  will  still  further  diminish  irritation;  and  lastly, 
that  I have  caused  great  relief  and  prevented  vomiting  and  much 
exhaustion,  by  removing  the  fluid  from  the  distending  stomach  witli  a 
stomach-pump,  instead  of  allowing  it  to  proceed  to  such  a point  as  to 
occasion  much  pain. 

OEGANIC  DISEASES  OF  THE  STOMACH. 

Case  LX.f — Chronie  Ulcer  of  the  Stomach — Recovery > 

History. — Janet  Grant,  let.  30,  married — admitted  14th  November,  1852.  She 
stated  that  she  enjoyed  tolerably  good  health  till  twelve  months  ago,  when  she  had 
an  attack  of  haematemesis,  which  returned  on  three  successive  days  early  in  the 
morning.  The  vomiting  was  preceded  by  a sense  of  weight  and  uneasiness  in  the 
epigastrium,  nausea,  dimness  of  sight,  and  feeling  of  syncope,  which  actually 
occurred  on  one  or  two  occasions.  Alter  vomiting  took  place,  she  generally  suffered 
from  severe  griping  pains  in  the  bowels  until  they  were  opened.  The  stools  were 
often  of  a dark  brown  color.  The  quantity  of  matters  ejected  from  the  stomach 
varied  from  one  to  two  pints,  and  contained  coagula  of  blood.  She  has  been  twice 
received  into  the  Infirmary,  and  on  both  occasions  dismissed  much  relieved.  After 
January,  1852,  she  continued  in  good  health,  and  was  able  to  follow  her  usual  occupa- 
tion until  the  3d  of  November,  1852,  when  the  hmmatemesis  returned,  having  been 
preceded  by  the  symptoms  already  enumerated.  On  this  occasion  there  was  less 
blood  than  formerly ; but  the  vomited  matter  still  contained  numerous  bloody 
coagula.  She  had  no  recurrence  of  vomiting  for  eight  days,  but  remained  very  weak, 
and  was  confined  to  bed.  On  the  11th  November  she  passed  by  stool  some  matters 
like  slimy  tar.  Since  then  she  has  frequently  vomited,  sometimes  as  often  as  three 
or  four  times  a day,  a quantity  of  matter  consisting  principally  of  dark-colored 
bbol.  The  pain  in  the  head,  epigastrium,  and  between  the  scapulae,  has  increased 
since  that  time. 

Symptoms  on  Admission. — On  admission,  tongue  moist,  slightly  loaded ; appetite 
bad  ; food  is  rejected  from  the  stomach  almost  immediately  after  being  taken ; pain 


31 


^ Reported  by  Mr.  Joseph  Johnston,  Clinical  Clerk, 
f Reported  by  Mr.  F.  M.  Russell,  Clinical  Clerk. 


482 


DISEASES  OF  THE  DIGESTIVE  SYSTEM, 


and  tenderness  in  the  epigastrium  on  pressure ; slight  tenderness  over  the  whole 
abdomen,  which  becomes  much  distended  after  taking  food.  Bowels  rather  costive ; 
no  blood  in  the  stools  at  present,  and  no  blood  corpuscles  in  the  vomited  matters 
when  examined  by  the  microscope.  Urine  normal.  Other  functions  normal.  ^ 
Sulph.  Magnes,  § ss ; Acid.  Sulph.  dil.  3 i ; Infus.  Rosarum  5 viij.  Summit.  § ij,  et 
repetant.  eras  mane.  Acid.  Gallic.  3 i ; Pulv.  Opii  gr.  iij.  M.  et  divide  in  pulv. 
xij.  Suniat  unum  ter  in  die. 

PuoGiiKss  OF  THE  Case. — November  IMh. — Had  some  vomiting  to-day,  but  no 
blood.  Still  considerable  pain  in  the  epigastrium.  Bowels  freely  moved  by  medicine ; 
stools  very  dark  in  color.  Nov.  l^th. — Omitt.  Acid.  Gallic.  1^  Bismuthi  albi  3ss; 
Pulv.  Opii.  gr.  iss.  M.  et  div.  in  pulv.  vj.  Sumat  unum  ter  in  die.  P'arinaccous  diet. 
Nov.  18^/i. — Complains  of  burning  pain  at  lower  part  of  the  sternum;  former  pain  in 
epigastrium  somewhat  easier;  no  vomiting  since  the  16th;  bowels  open;  stools 
still  of  a dark  color ; great  thirst ; tongue  loaded  and  coated  with  brown  fur  in 
centre;  with  bad  taste  in  the  mouth.  Nov.  2Qth. — Still  considerable  pain  and 
tenderness  in  epigastrium,  which  is  now  referred  to  one  spot  about  the  size  of  a 
crown-piece;  bowels  confined;  pulse  '75,  natural.  Applicentur  hirudines  iv  epigas- 
irio,  Repetat.  mist,  cathartic,  si  opus  sit.  Nov.  23c/. — Complains  still  of  pain  in 
epigastrium,  which  was  slightly  relieved  by  the  leeches ; has  had  no  return  of  vomit- 
ing; bowels  open.  Applicet.  Vesicat.  (3x2)  epigastrio.  Nov.  26/A. — Pain  in  epi- 
gastrium considerably  relieved  since  the  application  of  the  blister.  Still  bad  appetite 
and  sour  taste  in  mouth.  U Ca^'b.  Potass.  3 i.  Div.  in  pulv.  xij  ; sumat  unum  ter  in 
die.  Dec.  2th. — Pain  in  epigastrium  much  relieved,  and  only  returns  at  intervals, 
and  in  much  less  degree  than  formerly.  She  now  takes  her  food  well ; bad  taste  in 
mouth  gone ; bowels  still  costive;  pulse  80,  of  good  strength.  Dec.  11th. — Her  former 
stomach  symptoms  have  entirely  disappeared.  Dismissed. 

Commentary. — The  vomiting  excited  on  taking  food,  the  hgema- 
temesis,  and  the  local  pain  increased  at  the  epigastrium  on  pressure,  in- 
dicated the  presence  of  an  ulcer  in  the  stomach,  which,  by  opening  blood- 
vessels, had  several  times  caused  extravasations  of  blood.  Before  I saw 
her,  an  astringent  mixture,  with  gallic  acid,  had  been  ordered  to  check 
the  tendency  to  hemorrhage.  For  this  I substituted  quietude,  a farinaceous 
diet,  to  be  taken  in  small  quantities  at  a time,  frequently  repeated,  and 
powders  of  white  bismuth  and  opium,  to  check  acidity  and  relieve  pain. 
The  pain  not  subsiding,  six  leeches  were  ordered  to  the  epigastrium,  fol- 
lowed by  warm  fomentations,  and  subsequently  a blister  was  applied 
there,  the  result  of  which  treatment  was  gradual  abatement,  and  at  length 
complete  disappearance  of  all  her  symptoms. 

Case  LXL^ — Chronic  Ulcer  of  the  Stomach — Cure. 

History. — Mary  Keid,  set.  38,  married — admitted  Deeember  20th,  1852.  She 
states  that  about  four  years  ago,  having  been  exposed  to  cold  and  w^et,  she  was  seized 
with  shivering,  followed  by  severe  pains  in  the  epigastrium,  with  uneasy  sensations  in 
the  lower  part  of  the  abdomen,  resembling  labor  pains ; these  were  aceompanied  by 
thirst,  loss  of  appetite,  siekness,  and  vomiting.  These  symptoms  disappeared,  but 
re-occurred  at  intervals  up  to  December,  1851,  when  she  had  a more  severe  attaek  than 
before,  and  since  then  she  has  always  been  complaining  more  or  less  of  the  same 
thing.  About  three  months  ago,  she  felt  as  if  something  gave  way  in  the  left  hypo- 
chondrium,  and  nearly  fainted.  She  immediately  afterwards  vomited  about  a tea- 
cupful of  blood ; this  took  place  four  or  five  times  during  the  night ; but  the  last 
time  the  ejected  matters  were  paler  and  more  watery,  having  somewhat  the  appear- 
ance of  finely-grated  earrots.  The  loss  of  appetite,  thirst,  pain  in  epigastrium  and 
bowels,  with  frequent  severe  headaehe,  have  continued  up  to  the  present  time.  She 
has  had  no  return  of  the  haematemesis,  but  generally  vomits  her  food  about  half  an 
hour  after  it  has  been  taken. 

Symptoms  on  Admission. — On  admission,  she  has  a pale  amemic  appearance. 
The  tongue  is  furred,  appetite  bad,  pain  in  epigastrium  and  distension,  with  a sense 

*■  Reported  by  Mr.  F.  S.  B F.  de  Chauraont,  Clinical  Clerk. 


ORGANIC  DISEASES  OF  THE  STOMACH. 


483 


of  load  at  the  stomach  after  meals,  which  continues  till  relief  is  afforded  by  vomiting, 
which  comes  on  generally  in  about  half  an  hour.  She  complains  also  of  pain  in  the 
left  hypochondrium  ; has  no  uneasy  sensations  in  the  bowels,  but  habitual  costive- 
ness, for  which  she  has  been  in  the  habit  of  taking  laxative  medicine.  She  has  been 
much  troubled  with  palpitation,  but  the  heart  sounds  and  impulse  are  normal ; 
pulse  96,  small,  and  rather  soft ; micturition  normal ; urine  of  a pale  color,  sp.  gr. 
1022,  with  slight  deposit,  showing  phosphates  under  the  microscope.  Catamenia 
now  present.  She  does  not  sleep  well,  has  slight  headache  and  occasional  vertigo, 
with  muscte  volitantes,  pain  in  lumbar  region,  but  no  tenderness  over  spine.  Other 
functions  normal.  To  remain  quiet  in  bed.  Farinaceous  diet  in  small  quantities. 
To  have  the  bowels  genthf  opened. 

Progress  of  the  Case. — December  23c?. — Bowels  moved  since  last  report;  com- 
plains of  much  pain  in  the  epigastrium ; has  had  no  vomiting  of  blood  since  admis- 
sion, Applicent.  hirudines  iv  part,  dolent.  et  postea  foveatur.  Omitt.  alia.  1^  Lactis 
Recent.  § xii ; Aq.  Colds  3 vj  M.  To  be  taken  as  a drink  when  thirsty.  Dec.  ZOth. — 
Continues  somewhat  easier ; complains  still  of  occasional  pain  in  stomach ; appetite 
rather  improved ; less  thirst.  Bowels  very  costive.  Jan.  Aih. — Complains  still  of 
severe  pain  in  epigastrium,  with  nausea,  but  no  vomiting.  Tongue  rather  furred. 
It  has  been  found  that  the  patient  has  been  getting  up  and  walking  about  after  the 
visit,  and  has  taken  some  beaf-steak,  contrary  to  orders.  Pulv.  Scammon.  et 
Pulv.  Jalap,  aa  gr.  x.  M.  P't.  palv.  hora  somni  sumend.  Jan.  Q>th. — Bowels  Avell 
opened,  tongue  much  cleaner,  feels  better,  and  slept  well  during  the  night.  To  have 
rice  diet.  Has  been  com})laining  again  of  pain  in  stomach ; tongue  furred,  but 
moist;  appetite  rather  better;  slept  well  during  the  night;  bowels  open.  Jan.  i)tJi. — 
Has  been  rather  sick  to-day,  and  vomited  a little  during  the  night  for  the  first  time 
since  admission.  She  still  complains  of  pain  in  epigastrium.  Apjpllcet.  Veslcat.  (3  x 2) 
part,  doleyd.  Jan.  12th. — Has  been  much  relieved  since  the  application  of  the  blister, 
and  expresses  herself  as  feeling  a great  deal  better.  Tonguu  moist,  and  cleaner  than  be- 
fore ; less  thirst ; appetite  improved ; bowels  still  costive.  Jayi.  %)th. — Dismissed  cured. 

Commentary . — This  case  in  all  its  essential  features  is  very  similar 
to  the  former  one,  with  the  exception  that  vomiting,  instead  of  occurring 
immediately  after  taking  food,  came  on  half  an  hour  later.  The  same 
treatment  was  pursued,  but  was  not  so  carefully  followed  out,  for  it  was 
ascertained  tliat  she  was  continually  getting  out  of  bed,  and  committing 
indiscretions,  which  caused  returns  of  the  symptoms. 

Case  LXII.'^ — Chronic  Ulceration  and  Perforation  of  the  Stomach — PeritO‘ 
nitis — Limited  Pneumonia  with  Gangrene — Abdominal  Ahscees,  simu- 
lating Pleurisy — Death. 

History. — Evina  Clark,  aet.  29,  single,  housemaid — admitted  December  7,  1852. 
From  the  age  of  fifteen,  she  had  more  or  less  derangement  of  the  functions  of  the 
stomach,  as  exhibited  by  frequent  vomiting  of  greenish  matters,  not  preceded  by  any 
nausea.  She  attributes  her  complaint  to  a severe  stomach  disease  at  the  age  of  fifteen, 
which  confined  her  to  bed  for  some  months.  Two  months  ago  the  vomitings  became 
more  frequent,  and  have  continued  worse  than  usual  ever  since.  She  has  been  in  the 
habit  of  taking  very  large  quantities  of  bicarbonate  of  soda,  sometimes  even  as 
much  as  1 oz.  per  day.  On  the  day  before  admission,  she  took  a dose  of  castor-oil, 
and  this  morning  (Dec.  7)  she  rose  at  five  o’clock  to  stool,  then  returned  to  bed.  At 
half-past  five,  she  again  rose  to  see  what  o’clock  it  was  and  again  returned  to  bed,  and 
fell  asleep  without  having  experienced  any  pain.  About  six  o’clock  she  awoke  with 
severe  pain  in  the  epigastrium,  and  a feeling  of  faintness.  Her  mistress,  on  being 
summoned  to  her  bedside,  administered  to  her  half  a glass  of  brandy  in  some  hot 
water.  Immediately  after  this  was  swallowed  the  former  pain  became  excruciating ; 
the  abdomen  was  then  fomented  with  hot  water,  and  medical  assistance  sent  for.  The 
medical  man  ordered  warm  bran  poultices  to  be  applied,  which  somewhat  relieved  the 
symptoms ; three  hours  afterwards,  the  pain  again  becoming  violent,  one  drachm  of 
tincture  of  opium  was  administered,  and  she  was  sent  to  the  Infirmary.  The  cata- 
menia have  always  been  regular. 

- Reported  by  Mr.  F.  S.  B.  F.  de  Chaumont,  Clinical  Clerk. 


484 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


Symptoms  on  Admission. — On  admission  she  was  in  a state  of  extreme  depression, 
the  surface  cold,  face  livid,  pulse  108,  almost  imperceptible ; and  the  house-clerk 
administered  a draught,  which  was  at  hand,  composed  of  Sp.  Ammon.  Aromat.  min. 
X ; S'p.  jEther.  Sulph.  min.  xv ; Sol.  Mur.  Morph,  min.  xx ; Aquce  § ss.  Warm 
fomentations  to  the  epigastrmm  were  also  ordered.  When  first  seen  at  the  hour  of 
visit,  she  complained  of  intense  pain  in  the  abdomen,  especially  in  the  epigastrium 
and  left  hypochondrium,  which  was  increased  by  pressure.  The  tongue  w as  slightly 
furred  in  the  centre,  but  moist.  She  had  great  thirst,  no  nausea ; bowels  had  been 
freely  opened  at  five  o’clock  in  the  morning.  Heart  sounds  normal ; pulse  136,  the 
strength  having  much  improved  since  the  draught,  Avhich  caused  no  increase  of  the 
pain.  Is  evidently  under  the  influence  of  opium.  All  the  other  functions  are  nor- 
mally performed.  To  have  immediately  an  enema  of  beef-tea  with  an  ounce  of  brandy. 
The  warm  fomentations  to  be  continued. 

Progress  of  the  Case. — In  the  evening  the  pain  was  diminished  to  a feeling  of 
soreness;  pulse  129,  small;  lividity  of  face  and  depression  continued;  surface 
cold;  no  rigors.  Has  had,  at  intervals  of  three  hours,  lour  enemata  of  beeldea,  with 
an  egg,  two  containing  an  ounce  of  brandy,  and  two  with  one  drachm  of  laudanum. 
She  has  also  been  sucking  ice  to  relieve  her  thirst.  December  ^th. — There  has  been 
profuse  sweating  during  the  night;  face  is  still  pale,  pulse  126,  weak  and  thready; 
acute  pain  continues  on  pressure  below  ensiform  cartilage.  The  abdomen  is  tense  and 
tympanitic,  but  the  tenderness  is  slight ; considerable  flatulence  in  stomach ; febrile 
symptoms  well  pronounced.  Bisrnuthi  albi  gr.  xviii ; Pulv.  Opii  gr.  iii.  M. 
Jiant  pil.  vi.  One  to  be  taken  every  six  hours.  The  nutritive  and  an6dyne  enemata 
to  be  continued.  Dec.  2th. — She  vomited  yesterday  afternoon,  3 p.m.,  about  a pint  of 
green  fluid,  and  at  the  same  time  passed  a fluid  fmculent  stool.  Slept  a little  during 
the  night.  To-day  she  is  somewhat  refreshed,  but  the  symptoms  are  the  same  as 
yesterday.  Dec.  \Qth. — Yesterday  evening,  the  epigastric  pain  having  increased,  and 
extended  into  left  hypochondrium,  six  leeches  were  applied,  followed  by  warm  fo- 
mentations. To-day  pain  and  tenderness  continue  ; pulse  120  ; improved  in  strength. 
Six  more  leeches  to  be  applied.  The  anodyne  and  nutritive  enemata  to  be  continued.  To 
suck  ice  to  relieve  the  thirst.  Dec.  \lth. — Bowels  were  open  shortly  before  the  visit; 
pulse  128,  full;  tongue  dry;  thirst  continues;  but  appetite  is  returning.  Tender- 
ness of  epigastrium  and  abdomen  has  nearly  disappeared.  To  have  beef-tea^  by  the 
mouthy  in  table-spoonfuls  at  a time.,  and  occasionally  toast  and  water  to  relieve  the 
thirst.  Dec.  V2th. — The  beef-tea  produced  a disagreeable  but  not  painful  sensation 
in  the  stomach,  but  there  has  been  no  vomiting.  Pulse  to-day  128,  of  good  strength; 
feels  much  easier,  and  can  turn  herself  more  freely  in  bed.  There  have  been  two 
faecal  evacuations  since  yesterday.  Dec.  \Zth. — She  has  no  pain;  pulse  128,  of  mode- 
rate strength.  To  have  a little  toasted  bread  soaked  in  beef-tea.  Dec.  lAih. — The 
toast  and  beef-tea  occasioned  uneasiness  and  tightness  in  the  epigastrium  and  both 
hypochondria,  followed  by  dyspnoea  and  general  restlessness,  but  no  pain.  The  bowels 
were  opened  twice  during  the  afternoon  and  evening.  To-day  there  is  tenderness 
over  the  right  hypochondrium;  febrile  symptoms  have  again  returned;  pulse  132, 
rather  feeble.  Six  leeches  to  be  applied  over  the  tender  part.  To  have  enemata  of  brandy 
and  beef-tea  every  two  hours.  To  suspend  the  administration  of  food  by  the  mouth. 
Dec.  \^th. — At  the  evening  visit  yesterday  the  febrile  symptoms  had  greatly  increased ; 
thirst  excessive ; tongue  dry  and  cracked ; abdominal  tenderness  much  relieved  by 
the  application  of  the  leeches.  To-day  the  febrile  symptoms  continue ; face  is  flushed ; 
and,  on  being  interrogated,  she  states  that  she  had  a rigor  and  feeling  ot  cold  j^ester- 
day  afternoon.  On  percussing  the  chest  posteriorly,  there  is  dulness  over  lower  third 
of  right  lung,  with  double  friction  murmur  and  segophonic  vocal  resonance ; on  the 
left  side  also  slight  dulness  inferiorly,  with  crepitation,  during  inspirations,  pulse 
132,  feeble.  The  enemata,  which  have  been  continued  at  intervals,  are  no  longer 
retained.  Intermittantur  enemata.  To  have  a little  calfs-foot  jelly  by  the  mouth, 
alternated  with  a table-spoonful  of  clear  brown  soup  every  two  hours.  B Solutionis 
tartratis  antimonii  3 iij  ; Potassm  acetatis  3 ij  ; ^P-  cetheris  nitrici  3 v j aqute  ^ v. 
M.  Fiat  mistura.  A tahle-spoonftd  every  four  hours  in  two  or  three  table-spoon- 
fuls of  water.  Dec.  \Uh. — Yesterday  evening  there  was  great  exhaustion  and 
feebleness;  the  mixture  was  suspended:  and  a table-spoonful  of  wine  was  ordered 
every  two  hours.  To-day  no  tenderness  over  abdomen,  but  the  dyspnoea  and  the 
physical  thoracic  signs  continue ; febrile  symptoms  still  strongly  marked ; pulse  140, 
soft  and  vibrating;  there  is  much  flatulence.  At  her  own  request,  she  was  allowed 


OP.GtANIC  DISEASES  OF  THE  STOMxiCH. 


485 


fifteen  grains  of  the  hi-carbonate  of  soda.  To  continue  the  jelly  and  brown  soup., 
with  half  an  ounce  of  sherry  every  hour.  Dec.  \lth. — Feels  better  to-day  ; urine 
loaded  with  lithates ; flatulence  has  been  relieved  by  the  bicarbonate  of  soda. 
Dec.  ISb'i. — Xo  change.  To  have  milk  and  lime-water  to  drink.  Dec.  \^th. — Coni- 
])lains  of  increased  pain  in  inferior  portion  of  right  side  of  chest,  where  there  is 
still  dulnes.'!  and  loud  friction.  Some  dyspnoea.  Six  leeches  to  be  applied.  Dec.  ‘iOit/i. 
Pain  was  relieved  by  the  leeches,  but  the  dyspnoea  and  physical  signs  on  both 
sides  of  chest  continue.  Blister  4 by  3 to  be  applied  over  lower  portion  of  right  lung 
posteriorly.  Dec.  'list. — Has  had  copious  sweating  during  the  night  ; otherwise  the 
sa  no.  Dec.  Ti  l. — Much  weaker  ; pulse  13C>,  small  and  weak ; lithates  have  disappear- 
ed from  the  urine ; great  dyspnoea.  H Sp.  TEth.  Nit.  3 ss  ; Tinct.  Colchici  I ij  ; 
Ajuce  3 V ; a table-spoonful  every  four  hours.  To  have  an  enema  of  beef-tea  and  egg  ; 
and  rice,  with  beef-tea,  by  the  mouth.  Dec.  23c?.— Is  free  from  pain  ; general  symp- 
toms unchanged;  pulse  124,  weak;  sliglit  subsultus  tendinum;  appetite  capricious; 
prefers  arrow-root  to  rice.  Dec.  loth. — Complains  now  of  diarrhoea.  Habeat  enema  c. 
Tr.  Opii  min.  xl.  Dw.  IQth. — Diarrhoea  continues  ; early  this  morning  took  the  fol- 
lowing draught; — Sol.  Mur.  Morph,  m.  xv ; Tinct.  Catechu  3 ss ; Syrup.  Limonurn 

Z j M No  change  in  the  febrile  symptoms,  dyspnoea,  or  the  pulmonary  physical  signs  ; 
has  no  pain  ; pulse  121,  weak  ; skin  clammy ; states  that  slie  felt  very  cold  during  the 
night.  Dec.  Idth. — Diarrhoea  continues.  2h  haw  an  enema  of  starch  and  opium. 
Dec.  28?  i. — Diarrhoea  has  ceased;  dyspnoea  and  febrile  symptoms  increased ; no  pain; 
face  pale  and  anxious.  Dec.  THh. — Evidently  weaker  ; breathing  labored ; pulse  140, 
weak  and  thready ; countenance  of  a yellow  waxy  tinge.  There  was  profuse  sweating 
this  morning ; other  symptoms  unchanged.  Dec.  30?/i. — She  continued  to  sink,  and 
died  this  morning  at  3 a.m.,  death  having  been  preceded  by  repeated  vomiting  of  dirty 
brownish-green  matter. 

Sectio  Cadaveris. — Thirty-three  hours  after  death. 

Head  not  examined. 

Tiioiiax. — Two  drachms  of  clear  serum  in  the  pericardium  ; heart  healthy ; the  right 
lung  healthy,  but  its  lower  lobe  and  the  diaphragm  on  that  side  were  considerably  pushed 
upwards  by  an  abscess  containing  nearly  a pint  of  pus,  situated  above  the  liver  and  below 
the  diaphragm ; the  left  lung  also  healthy,  with  the  exception  of  a gangrenous  ulcer,  the 
size  of  a shilling,  in  the  centre  of  the  lower  lobe  interiorly,  where  it  rested  on  tlie  diaphragm. 
This  ulcer  presented  a brownish,  broken  up,  sloughing  surface,  and  was  surrounded  by  red 
hepatization,  occupying  the  pulmonary  substance  to  about  the  extent  of  a hen’s  egg. 

Abdomen. — On  reflecting  the  integuments,  a considerable  quantity  of  pus  escaped 
from  the  abscess  above  alluded  to  on  the  right  side,  immediately  below  the  diaphragm 
and  above  the  liver.  This  abscess  contained  nearly  a pint  of  pus,  and  was  situated 
in  a circumscribed  pouch  formed  by  the  diaphragm  above,  the  liver  below,  the  peri- 
toneum anteriorly  and  externally,  and  false  lymph  of  considerable  tenacity  internally. 
liVmph  also  glued  these  parts  and  the  small  curvature  of  the  stomach  together.  On 
reflecting  the  integuments,  the  anterior  wall  of  the  abscess  was  removed,  and  so  the 
pus  escaped.  The  stomach,  transverse  colon,  and  coils  of  intestine  in  the  superior 
third  of  the  abdomen,  were  all  glued  together  by  bands  and  flakes  of  lymph,  which, 
though  of  tolerable  tenacity,  Avere  gelatinous  in  consistence,  and  could  readily  be  torn 
through  by  the  fingers.  In  the  left  hypochondrium  there  Avas  a layer  of  this  lymph 
half  an  inch  in  thickness,  softened,  purulent,  and  gangrenous  in  the  centre,  situated 
above  the  spleen,  and  communicating,  by  a sloughened  opening,  Avith  the  ulcer  and 
hepatization  in  the  lung  formerly  described.  On  cutting  open  the  stomach,  in  the  line 
of  its  large  curvature,  there  flowed  out  a dirty,  greenish-broA\m,  grumous  liquid,  con- 
taining coagulated  masses,  apparently  of  milk,  tinged  of  a dark-red  color  by  port  Avine. 
In  the  posterior  part  of  the  stomach,  about  its  centre,  was  observed  an  oval  ulcer,  the 
size  of  a five-shilling  piece,  with  smooth,  thickened  edges,  and  surrounded  by  puckered 
folds  of  the  mucous  membrane,  which  Avas  otherwise  healthy.  The  ulcer  was  adherent 
to  the  pancreas  behind,  which  constituted  its  base;  but  the  adhesions  round  its  supe- 
rior half  were  composed  of  the  same  gelatinous  lymph  as  has  been  previously  alluded 
to.  On  dissecting  the  ulcer  from  its  attachments,  it  was  seen  to  have  completely  per- 
forated the  coats  of  the  stomach,  althoiigh  the  opening  behind,  viewed  on  the  serous 
surface,  Avas  not  above  the  size  of  a shilling.  On  removing  the  intestines  from  the 
pelvis,  flakes  of  purulent  lymph  were  observed  between  several  of  their  coils  and  on 
the  serous  membrane  of  the  pelvic  cavity.  All  the  other  organs  healthy. 


486 


DISEASES  OF  THE  DIGESTIVE  SYSTESI. 


Commentary. — All  the  facts  connected  with  this  case  were  obtained 
wdth  great  accuracy,  and  left  us  in  little  doubt,  from  the  commencement, 
that  we  had  to  treat  a chronic  ulcer  of  the  stomach,  which,  on  the  morn- 
ing of  the  day  she  was  admitted,  had  perforated  the  organ,  and  induced 
the  violent  pain  she  complained  of.  The  peritonitis,  which  may  have 
been  induced  by  the  perforation  alone,  was  undoubtedly  augmented  by 
the  brandy  and  water  administered  to  rally  her  from  the  state  of  collapse 
into  which  she  was  thrown  by  the  immediate  effects  of  the  accident.  On 
entering  the  house  also  about  five  hours  after  she  became  ill,  a stimulat- 
ing and  anodyne  draught  was  administered  by  the  clerk  to  rouse  her  from 
her  depressed  condition.  As  this  was  followed  by  no  increase  of  local 
pain,  but  by  improvement  of  the  vital  powers,  we  may  fairly  conclude  that 
the  practice,  though  highly  questioiiable,  was  not  productive  of  injury. 
Nothing,  indeed,  is  more  natural  on  the  sudden  occurrence  of  violent 
pain  in  the  epigastric  region  with  a feeling  of  syncope,  than  to  have  re- 
course to  stimulants,  for  perforations  of  the  stomach  are  rare  occurrences, 
and  it  is  not  every  one  who  at  such  a moment,  even  among  the  profes- 
sion, has  sufiicient  coolness  and  discrimination  to  detect  the  real  nature 
of  the  disease.  Hence,  why  so  frequently  these  perforations  are  fatal, 
not  so  much  from  their  own  natural  results  as  from  the  stimulating  reme- 
dies administered,  which  pass  through  the  aperture  into  the  abdominal 
cavity.  Indeed,  had  not  brandy  and  water  been  given  in  this  instance, 
there  is  every  reason  to  suppose  that  the  perforation  might  not  have 
occasioned  much  mischief,  for  it  occurred  early  in  the  morning,  before 
breakfast,  and  long  after  her  evening  meal,  and  consequently  when  the 
organ  was  empty  ; and,  besides,  it  is  to  be  observed  that  such  perfora- 
tions have  a great  tendency  to  become  re-closed  by  the  rapid  formation 
of  fibrous  lymph  round  their  edges.  In  this  case,  however,  extensive 
peritonitis  was  already  occasioned  when  I first  saw  her,  and  the  subse- 
c[uent  treatment  was  directed— 1st,  To  prevent  the  introduction  of  further 
matters  into  the  stomach;  2d,  To  rally  her  from  collapse  by  stimulating 
and  nutritive  enemata  ; and  3d,  To  conduct  the  inflammation  to  a favor- 
able termination  by  local  fomentations  and  opiates  largely  administered 
in  the  form  of  enemata,  and  subsequently  in  pills  by  the  mouth.  This 
treatment  w^as  attended  with  apparent  success,  so  that  on  the  fifth  day 
nourishment  was  cautiously  administered  by  the  mouth,  and  also  with 
tolerable  benefit.  On  the  eighth  day,  however,  rigors  appeared,  followed 
by  fever,  which  was  attributed  to  a pleurisy  on  the  right  side,  where  in- 
creased thoracic  dulness  was  discovered  infer iorly,  with  loud  friction  and 
gegophony.  Circumscribed  pneumonia  evidently  also  existed  on  the  left 
side,  as  indicated  by  crepitation.  This  formidable  complication  was 
attempted  to  be  relieved  by  gentle  salines,  and  topical  bleeding  by  leeches. 
It  was  soon  apparent,  however,  from  the  appearance  of  dyspnoea  and  other 
symptoms,  that  there  was  now  little  hope  of  recovery,  and  notwithstand- 
ing the  liberal  use  of  stimulants,  the  patient  sunk  on  the  twenty-third 
day.  Dissection  exhibited  exactly  what  was  anticipated  with  regard  to 
the  stomach  and  peritoneum,  but  showed  that  the  signs  of  the  presumed 
pleurisy  were  occasioned  by  an  abscess,  which,  by  pushing  up  the  dia- 
phragm and  occupying  the  lower  portion  of  the  thoracic  space  on  the 
right  side,  had  given  rise  to  all  the  physical  signs  of  pleuritis.  On  the 
left  side  there  was  limited  pneumonia  as  was  expected,  the  lung  com- 


ORGANIC  DISEASES  OF  THE  STOMACH. 


487 


municatiDg  by  a gangrenous  ulcer  in  the  diaphragm,  -with  the  lymph  ex- 
uded above  and  around  the  spleen.  The  edges  of  the  ulcer  of  the 
stomach  were  firmly  united  to  the  pancreas,  so  that  the  patient  undoubt- 
edly died  from  the  extensive  peritonitis. 

Case  LXIIL* — Chronic  Ulceration  in  the  Stomach — Perforation  occasioned 
hj  a Fall  {?) — Recovery. 

History. Barbara  Ferguson,  servant,  aged  51 — admitted  January  6,  1853.  States 

that  she  enjoyed  excellent  health  till  about  eight  yeais  ago,  when  she  tirst  began  to 
complain  of  her  stomach— suffering  from  pain  of  a cutting  or  grinding  character, 
always  worse  after  taking  food.  Her  appetite  has  all  along  continued  good,  but  she 
often  experienced  considerable  thirst ; has  never  had  nausea  or  vomiting.  She  believes 
that  she  has  been  getting  worse  lately,  but  has  had  no  distinct  exacerbation.  On 
January  the  4th  instant,  stepping  upon  a chair,  her  foot  slipped,  and  she  fell  wkh  the 
stomach  across  the  back  of  it.  She  was  immediately  seized  with  intense  pain  in  the 
epigastrium,  rapidly  extending  over  the  whole  abdomen.  She  did  not  faint,  and  was 
still  able  to  speak,  but  had  to  be  carried  to  bed.  The  accident  occurred  about  9 p.  m., 
three  hours  after  she  had  taken  any  food,  which  had  consisted  ot  some  coffee,  with  a 
few  mouthfuls  only  of  bread.  She  was  immediately  ordered  a one-grain  pill  ol  opium, 
which  was  to  be  repeated  every  four  hours.  On  the  next  day,  as  the  acute  pain  still 
continued,  four  leeches  were  applied  to  the  epigastrium,  followed  by  warm  fomentations. 
She  has  had  nothing  by  the  mouth  except  the  opium  pills,  up  to  the  date  of  admission. 

SvMPTOMS  ON  Admission. — On  admission  she  appears  very  weak  and  nervous,  and 
in  a state  of  partial  collapse;  the  countenance  is  sallow;  pulse  100,  weak;  heart 
sounds  normal ; no  headache,  but  a feeling  of  vertigo  on  attempting  to  rise  or  change 
her  position ; tongue  clean,  moist ; no  nausea  or  vomiting ; appetite  gone ; considerable 
thirst ; pain  in  epigastrium,  which,  with  the  whole  abdomen,  is  excessively  tender  on 
liressure ; she  has  had  great  dysuria  and  pain  on  micturition  ever  since  the  accident. 
All  other  functions  are  normal;  ordered  to  have  no  food  by  the  mouth.,  hut  an  enema 
of  beef-tea  with  the  yolk  of  an  egg  immediately.,  to  be  followed  in  two  hours  by  an  opiate 
enema,  with  40  minims  of  tincture  of  opium  ; to  be  kept  quiet  and  not  get  out  of  bed. 

Progress  op  the  Case, — January  *lth. — Was  almost  free  from  pain  yesterday 
evening,  and  felt  altogether  much  better,  having  slept  a good  deal  during  the  afternoon. 
The  beef-tea  enema,  with  yolk  of  egg,  has  been  repeated  at  intervals  of  four  hours,  and 
she  had  another  opiate  at  4 A.  m.,  after  which  she  slept  well.  To-day  she  feels  easier ; 
pain,  or  rather  tenderness,  in  epigastrium  somewhat  diminished ; and  considerable 
pressure  may  now  be  exerted  without  causing  uneasiness.  She  has  still  thirst ; tongue 
dry;  very  little  inclination  for  food;  pulse  100,  soft.  Jan.  8th. — Was  considerably 
easier  last  night,  and  expressed  a desire  for  some  food  ; the  pulse  was  of  better  strength, 
90.  To-day  is  still  improving ; complains  of  no  pain  when  lying  quiet,  but  still  pain 
on  pressure  in  epigastrium ; she  expresses  fear  and  pain  when  other  parts  are  touched, 
but  not  to  the  same  extent ; pulse  95,  of  moderate  strength.  She  has  had  the  beef -tea, 
etc.,  enemata  as  before,  with  an  opiate  enema  every  10  or  12  hours — to  have  beef- 
tea  and  milk  by  the  mouth,  in  table-spoonfuls  at  a time,  repeated  every  five  minutes  if 
the  patient  desires  it.  Jan.  Wi. — Felt  rather  uneasy  after  taking  the  beef-tea  and 
milk,  which  occasioned  a sense  of  “ working  ” in  the  stomach.  An  opiate  enema  was 
ordered  in  about  two  hours,  and  in  the  evening  she  expressed  herself  as  free  from  un- 
easiness, and  rather  refreshed  from  the  beef-tea.  To-day  she  feels  not  quite  so  well, 
and  her  general  appearance  is  more  depressed.  She  has  continued  the  beef-tea,  but 
has  had  an  egg  and  beef-tea  twice  a day  in  addition ; pulse  88,  of  good  strength ; 
bowels  have  not  been  open  since  admission ; to  have  a warm  water  enema,  with  an  ounce 
of  castor  oil,  followed,  if  necessary,  by  an  opiate  one.  Jan.  \0th. — Felt  rather  weak 
and  exhausce  i after  bowels  were  opened  ; the  opiate  enema  was  administered  two  hours 
afterwards,  and  she  has  felt  better  since ; had  some  tea,  with  a little  toast,  by  the 
mouth  this  morning ; takes  beef-tea  for  dinner,  but  cannot  eat  rice  or  any  farinaceous 
food ; no  bad  effects  have  followed  taking  food  by  the  mouth  ; pulse  88,  of  good 
strength  ; little  pain  complained  of,  and  she  can  now  sustain  considerable  pressure  on 
epigastrium  without  suffering.  Slept  less  last  night  than  before ; urine  clear,  sp.  gr. 
1020,  eontains  phosphates.  Omit  the  enemata.  Jan.  ‘l\th. — Since  the  last  report  she 
has  been  doing  well,  and  gradually  gaining  strength.  Dismissed. 

* Reported  by  Mr.  F.  S.  B,  F.  de  Chaumont,  Clinical  Clerk. 


488 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


Commentary. — Many  cases  are  on  record  of  evident  perforations  of 
the  stomach,  which  have  been  cured  by  judicious  treatment,  and  the  one 
just  narrated  seems  to  me  to  be  an  instructive  example  of  this  favorable 
termination  of  the  lesion.  The  symptoms  at  the  commencement  were 
very  like  those  of  Case  LXII.,  but  were  induced  by  a blow  on  the  epi- 
gastrium, instead  of  coming  on  after  straining  at  stool.  Violent  pain, 
tenderness  on  pressure,  and  collapse  were  the  immediate  effects.  For- 
tunately, I saw  the  patient  immediately  after  the  accident,  and  took  care 
not  to  administer  brandy  or  stimulating  draughts.  A grain  of  opium  in 
the  form  of  pill  was  administered  every  four  hours,  quietude  enjoined, 
and  complete  abstinence  insisted  on.  Next  day  the  local  pain  continued, 
and  on  the  following  morning  I sent  her  to  the  Infirmary.  Nourishment 
was  administered  by  enemata,  and  on  the  fourth  day  was  cautiously  given 
by  the  mouth,  and  no  untoward  symptom  ensued.  From  this  time  she 
slowly  recovered.  Of  course  we  have  no  positive  evidence  that  there 
was  a perforation  in  this  case.  For  eight  years,  however,  she  had  been 
subject  to  severe  attacks  of  pain  in  the  stomach,  increased  on  taking  food, 
but  there  had  been  no  vomiting.  It  is  possible  that  the  blow  may  have 
been  sufficiently  strong  in  itself  to  induce  the  pain  and  subsequent  symp- 
toms, although,  from  all  the  inquiries  I could  make,  it  did  not  appear  to 
be  so.  One  of  her  fellow-servants  indeed  maintained  that  it  must  have 
been  trifling.  Wherever  anatomical  evidence  fails,  there  must  be  more  or 
less  uncertainty  hanging  over  the  history  of  those  cases  which  recover ; 
but,  taking  all  the  circumstances  into  consideration,  I cannot  help  think- 
ing that  had  brandy  and  water  been  given  in  this  as  in  the  former  in- 
stance, there  is  every  chance  that  here  also  fatal  peritonitis  would  have 
been  occasioned. 

From  what  I have  observed  of  post-mortem  examinations  in  the 
Eoyal  Infirmary  of  Edinburgh,  it  does  not  appear  to  me  that  chronic 
ulcer  of  the  stomach  is  a common  disease  here.  Without  having  made 
any  exact  calculation,  nothing  positive  can  be  said,  but  I do  not  think 
that  the  disease  exists  in  more  than  3 per  cent  of  those  examined  ; 
whereas  in  the  Copenhagen  and  some  German  hospitals,  it  is  said  to 
vary  from  6 to  13  per  cent.^  This  frequency  of  it  has  been  thought  to 
be  dependent  on  habits  of  intemperance  and  particular  diet ; and,  if  so, 
■we  might  have  anticipated  that  the  habit  of  drinking  raw  whisky  would 
have  rendered  it  more  common  in  Scotland  tnan  it  appears  to  be.  Its 
morbid  anatomy  was  first  admirably  described  and  figured  by  Cruvel- 
hier.f  The  ulcer  is  chronic,  of  circular  or  oval  form,  generally  varying 
in  size  from  a fourpenny  to  that  of  a crown-piece,  having  an  abrupt, 
slightly  thickened  margin,  as  if  it  had  been  punched  out,  and  an  indurated 
smooth  base.  It  may  be  shallow  or  deep,  and  frequently  perforates  all 
the  coats  of  the  stomach,  in  which  case  the  external  is  larger  than  the 
internal  aperture.  It  has  a great  tendency  to  contract  adhesions  by  its 
external  borders  to  neighboring  viscera,  .more  especially  the  pancreas, 
immediately  over  which,  in  the  posterior  wall  of  the  stomach,  the  ulcer 
is  most  commonly  situated.  When  it  occurs  in  the  anterior  wall,  it  less 

* See  an  able  Memoir  on  the  subject  by  Dr.  Brinton.  London,  1857. 

I Anat.  Pathologique.  Liv’s.  x.  et  xx. 


ORGANIC  DISEASES  OF  THE  STOMACH. 


489 


readily  contracts  adhesions,  and  therefore  is  more  likely  to  induce  per- 
foration. The  ulcer  may  heal  at  any  period  of  its  progress,  leaving  a 
cicatrix,  which  varies  in  appearance  according  to  the  amount  of  tissue 
previously  lost.  Sometimes  there  is  a mere  scar,  at  others  a stellate 
puckering.  Occasionally  there  is  a dense  thickening  with  rigid  folds, 
causing  contractions  in  one  place,  and  pouches  in  another,  and  this  coii' 
traction  may  even  be  circular,  causing  a stricture  of  the  organ.  Mineral 
deposits  are  now  and  then  found  adherent  to  the  cicatrix. 

The  three  leading  symptoms  of  chronic  ulcer  of  the  stomach  are  pain, 
increased  on  pressure,  vomiting  after  taking  food,  and  haematemesis.  Of 
these,  the  last  is  the  most  important  in  a diagnostic  point  of  view,  be- 
cause its  presence  renders  certain,  what  would  otherwise  oidy  be  conjec- 
tural. The  disease,  however,  may  exist  without  as  yet  having  so  iujured 
a blood-vessel  as  to  occasion  hemorrhage.  Hence  the  symptoms  of 
chronic  dyspepsia,  with  vomiting  after  food  and  fixed  pain,  if  long  con- 
tinued, should  invariably  give  rise  to  the  suspicion  of  an  ulcer,  and  lead 
to  an  appropriate  treatment. 

The  remedies  I have  found  most  efficacious,  in  simple  chronic  ulcer 
of  the  stomach,  are  quietude,  careful  regulation  of  the  diet,  bismuth  and 
opium  pills  or  powders,  and  sometimes  warmth,  at  others  cold  applied 
locally.  It  may  frequently  be  observed  that  the  mere  coming  into  a 
hospital  and  remaining  quietly  in  bed  has  a favorable  effect  in  modi- 
fying the  distressing  symptoms.  I have  also  remarked  that  those  patients 
who  are  always  getting  up  and  walking  about  suffer  much  more  than 
those  who  remain  in  bed,  especially  at  the  commencement  of  the  disease. 
Hence,  repose  in  an  easy  position  should  be  enjoined.  The  diet  should 
consist  of  farinaceous  pulpy  substances,  occasionally  mixed  with  beef-tea, 
or  milk,  given  in  small  quantities  frequently  repeated.  If  the  stomach 
will  not  tolerate  the  food  warm,  it  should  be  given  cold.  When,  despite 
this  treatment,  vomiting  continues,  it  is  best  to  suspend  all  nourishment 
for  a day  or  two,  and  give  nutritive  enemata.  As  the  patient  gets  bet- 
ter, the  amount  of  solid  food  should  be  very  cautiously  increased.  Thirst 
is  a distressing  symptom  in  such  cases,  and  is  best  allayed  by  allowing 
ice  to  dissolve  in  the  mouth  slowly,  or  sipping,  at  intervals,  milk  and 
limewater,  mingled  in  equal  proportions.  The  pain  is  alleviated  best  by 
bismuth  and  opium,  combined  in  the  form  of  pill  or  powder.  Some- 
times local  warmth,  but  more  frequently  pounded  ice,  mixed  with  salt  in 
a bladder,  applied  over  the  part,  will  give  relief.  Two  or  three  leeches, 
or  a counter-irritant,  may  succeed  when  everything  else  fails,  and  should 
be  tried.  Quietude  and  suspending  all  ingesta  for  a time,  I believe  to 
be  the  best  remedies  for  hemorrhage,  and  where  exhaustion  from  want 
of  food  exists,  nutrient  enemata,  with  wine,  must  be  administered. 
When  a perforation  occurs,  I have  already  pointed  out  the  great  im- 
portance of  avoiding  the  giving  of  stimuli  by  the  mouth  (Cases  LXII. 
LXIII.),  and  have  stated  the  practice  which  should  be  perseveringly 
followed,  namely,  the  administering  of  opium  in  the  form  of  pill,  quiet- 
ude, avoidance  of  purgatives,  and  nourishing  at  first  by  enemata,  and 
then  cautiously  by  unirritating  substances,  given  in  small  quantities  by 
the  mouth. 


490 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


— Cancer  of  Stomachy  Pancreas,  a7id  Mesenteric  Glands — Cystic 
Atrophy  of  Right  Kidney. 

ITistory. — Thomas  Gaffney,  aet.  50,  married,  a laborer — admitted  November  24, 
1856.  States  that  up  to  twelve  months  ago  he  was  in  good  health,  but  since  that 
time  he  has  been  troubled  with  pyrosis,  occasional  vomiting,  and  diminished  appetite. 
Three  months  ago,  feeling  much  pain  in  the  epigastrium,  he  noticed  tliat  he  had  a 
tumor  in  that  region.  It  was  very  sore,  continued  to  increase  in  size,  and  became 
more  and  more  painful.  At  present  he  is  very  emaciated,  and  suffers  severe  paiu  in 
wliatever  position  he  places  himself. 

Symptoms  on  Admission. — Teeth  and  gums  dry  ; tongue  dry,  with  a longitudinal 
fissure  dovm  the  centre.  Thirst  only  occasionally  felt.  Has  no  api^etite.  Has  no 
difficulty  in  swallowing  ; but  complains  of  constant  pain  in  the  epigastrium.  It  is  not 
distinctly  increased  on  taking  food.  The  food  cannot  be  retained  on  his  stomach, 
coming  up  in  mouthfuls  from  an  hour  to  an  hour  and  a half  after  ingestion.  The 
vomited  matter  is  described  as  resembling  in  color  coffee  grounds.  On  examining  the 
epigastrium  in  the  mesial  line,  two  inches  below  the  ensiform  cartilage,  and  three  inches 
above  the  umbilicus,  there  is  felt  a small  tumor  about  the  size  of  a walnut,  of  an  irregu- 
lar margin  superiorly.  The  convex  surface  looks  outwards  and  downwards.  It  may  be 
moved  upwards  and  to  the  right,  but  not  dowinvards  or  to  the  left.  In  left  half  of 
epigastrium,  over  a space  of  two  square  inches,  there  is  dulness  on  percussion,  and  on 
palpitation,  a deep-seated,  strongly-resisting  tumor  is  felt,  with  a distinct  margin  to  the 
right  side.  It  appears  to  pass  upwards  under  the  superior  part  of  left  hypochondrium, 
where  percussion  gives  forth  a comparatively  dull,  resonance.  Percussion  elsewhere 
over  abdomen,  tympanitic.  Over  the  hepatic  organ  and  over  the  tumor  there  is  great 
tenderness  on  percussion.  Occasionally  the  tumor  is  felt  more  distinctly,  and  is  then 
rough  and  nodulated.  The  chest  is  barrel-shaped.  Percussion  is  unusually  resonant. 
Kespiration  is  feeble  anteriorly  and  is  harsh  posteriorly,  the  expiratory  murmur  being 
prolonged.  No  dyspnoea.  Sputum  scanty.  Priecordial  region  unusually  resonant  on 
percussion.  Transverse  dulness,  two  and  a quarter  inches.  Cardiac  sounds  healthy,  but 
feeble.  Apex  of  heart  cannot  be  felt.  Pulse  small  and  weak,  68  per  minute.  Sleeps  but 
little.  Urine  normal.  The  diet  is  to  he  carefully  regidatcd  ; small  quantities  of  nutri- 
tive food  and  wine  to  he  taken  at  frequent  intervals.  A mixture  of  snow  and  salt  put  into 
a bladder  is  to  he  applied  over  the  tumor.  To  take  two  of  the  following  pills  every  night : 
I^  Morph,.  Acet.,  gr.  iss  ; Conserv,  Ilosar.,  gr.  xij.  Fiat  niassa  in  pilidas  sex  dlvidenda. 

Progress  of  the  Case. — Decemher  1st. — The  local  application  of  cold  has  afforded 
him  considerable  relief,  so  much  so  that  he  docs  not  like  to  be  without  it.  He  is 
unable  to  take  a sufficient  amount  of  aliment,  and  is  gradually  getting  weaker.  Dec. 
4:th. — The  pills  at  night  continue  to  lull  his  pain.  His  diet  consists  of  strong  beef- 
tea  three  half  pints  per  diem  ; bread  and  milk  ; milk  and  rice  pudding ; with  six 
ounces  of  wine.  Patient  always  vomits  after  eating,  however  little,  and  continues  to 
sink.  Dec.  Mh. — Died  at  10.30  a.m. 

Sectio  Cadaveris. — Twenty -eight  hours  after  death. 

Abdomen. — Permission  could'  only  be  obtained  to  examine  the  abdomen.  On 
opening  the  stomach  it  was  seen  to  contain  a considerable  quantity  of  yellow^  pultace- 
ous  substance,  being  half-digested  food  tinged  with  bile.  The  pyloric  orifice  w’as 
compressed  by  a mass  of  cancerous  exudation,  seated  in  the  smaller  curvature,  and 
projecting  into  the  stomach  ; this  mass  w'as  about  5 inches  in  diameter,  rounded  at 
the  margins ; nodulated  internally  with  two  projecting  portions,  so  situated  as  to 
act  as  valves  in  front  of  the  pyloric  orifice,  through  wdiich  a finger  could  be  easily 
passed  behind  them.  The  thickness  of  this  mass  was  in  one  place  two  inches,  gradu- 
ally diminishing  towards  the  margins  to  half  an  inch.  The  tissue  w'as  friable,  easily 
breaking  down  under  the  finger,  but  not  yielding  cancerous  juice.  The  pancreas 
was  generally  healthy,  but  an  inch  of  the  duodenal  extremity  was  involved  in  the 
cancerous  tumor.  The  cardiac  orifice,  wdiich  was  half  an  inch  from  the  margin  of 
the  cancerous  tumor  formerly  described,  was  quite  healthy,  as  was  the  rest  of  the 
stomach  not  involved.  Several  mesenteidc  glands  in  the  neighborhood  of  the  pan- 
creas w'ere  enlarged,  nodulated,  and  filled  wdth  cancerous  exudation.  Anteriorly  the 
stomach  was  strongly  adherent  to  a portion  of  the  liver,  wdiich  below,  over  the  tumor 
described,  felt  hard  and  nodulated.  In  the  position  of  the  right  kidney  was  a cyst,  the 

* Reported  by  Mr.  'William  Guy,  Clinical  Clerk. 


ORGANIC  DISEASES  OF  THE  STOMACH. 


491- 


size  of  the  human  head,  containing  a yellow  serum.  Internally  it  presented  a smootli 
serous  surface,  here  and  there  interrupted  by  circles,  and  fragments  of  circles  leading 
into  pouches.  Some  of  these  openings  were  perfectly  circular,  with  smooch  abrupt  mar- 
gins, and  were  about  the  size  of  a fourpenny  piece  ; others  were  about  the  size  of  half  a 
c'-own  or  five  shilling  piece.  Here  and  there,  on  the  surface  of  the  serous  membrane, 
were  corruo-ated  indurated  lines  with  black  calcareous  plates  upon  them,  the  result  of 
cicatrizations.  Externally  the  pouch  was  smooth,  covered  with  shreds  of  cellular  tissue  ; 
at  its  inferior  portion  was  an  induration,  measuring  two  inches  in  length,  and  being  cut 
into  four,  was  found  to  consist  of  cortical  renal  substance  about  one-sixth  of  an  inch  in 
thickness.  Immediately  behind  this  renal  substance^  was  a cyst,  communicating  with 
one  of  the  pouches  previously  described,  about  the  size  of  halt  a crown.  No  trace  of 
tubercular  structure  could  anywhere  be  seen. 

A portion  of  lung  was  also  removed  about  two  inches  square ; it  was  spongy 
throughout,  but  presented  gelatinous-looking  masses,  about  one-sixth  of  an  inch  in 
diameter,  scattered  through  its  substance.  They  could  be  squeezed  and  compressed 
between  the  fingers,  but  had  a certain  amount  of  firmness.  On  section  they  pre- 
sented a smooth  surface  of  grey  color. 

Microscopic  Examination. — The  cancerous  mass  in  the  stomach  presented  cancer 
cells  in  all  stages  of  formation,  with  granule  cells  here  and  there  embedded  in  masses 
of  molecular  substance.  The  mesenteric  and  epigastric  glands  on  being  cut  presented 
a fragile  surface,  from  which  a glutinous  substance  could  readily  be  scraped.  This 
contained,  when  examined  microscopically,  large  cancer  cells  multiplying  endogen- 
ously; here  and  there  granule  cells,  with  a few  fibres  and  numerous  molecules. 
The  rounded  masses  in  the  lung  were  of  the  same  structure. 

Case  LXV.* — Colloid  Cancer  icith  'perforating  Ulcer  of  Stomach — 

Peritonitis. 

History. — James  Douglas,  mt.  55,  a porter — admitted  September  15,  1854.  About 
fourteen  weeks  ago,  being  previously  quite  healthy,  he  began  to  experience  a burning 
pain  in  the  epigastrium,  more  severe  after  taking  food,  and  also  a sensation  as  of  a 
ball  rising  in  his  throat.  For  three  weeks  he  continued  to  work,  but  gradually  grew 
worse ; eight  weeks  ago,  he  vomited,  for  two  days,  dark  colored  matter  like  coffee 
grounds.  Has  since  been  troubled  with  pyrosis,  has  lost  his  appetite,  and  become 
weaker  and  thinner. 

Sympto.ms  on  Admission. — Is  greatly  emaciated.  Tongue  moist,  slightly  furred ; 
appetite  bad ; no  dysphagia ; feels  pain  in  the  epigastric  region  constantly  of  a burn- 
ing character,  more  severe  after  taking  food ; no  vomiting,  but  has  eructations  of  a 
thin  watery  fluid.  The  epigastrium  feels  hard  on  palpation ; in  the  region  of  the 
umbilicus  there  is  a distinct  tumor  stretching  across  the  abdomen  ; movable  under  the 
integument ; not  very  tender  to  the  touch.  Bowels  habitually  costive.  Has  no  cough, 
Pulse  56,  vveak.  Urine  not  coagulable,  of  sp.  gr.  1019.  Other  systems  normal. 

Progress  op  the  Case. — September  IMh  to  October  2th. — The  patient  has  been 
treated  by  the  administration  of  antacids,  bismuth,  and  magnesia ; by  the  injection 
of  nutritive  enemata ; by  occasional  opiates  at  night ; by  suitable  aperients,  and  care- 
ful regulation  of  the  diet.  He  has  gained  no  strength  ; is  indeed  much  weaker ; at 
present  he  has  a burning  sensation  along  the  whole  course  of  the  oesophagus.  Oct. 
\Mh. — This  morning  experienced  acute  pain  in  the  abdomen,  which  is  now  distended, 
and  generally  painful  on  pressure  and  deep  inspiration.  Pulse  84,  pretty  firm.  Eight 
leeches  were  applied  to  the  abdomen,  followed  by  warm  fomentations,  and  opium  in 
grain  doses.  Oct.  lUh. — Has  had  much  vomiting  this  morning,  of  dark  coffee- 
colored  fluid ; pulse  is  feeble,  and  extremities  are  cold.  While  eating  his  dinner  to- 
day, he  fell  forward,  and  immediately  expired. 

Sectio  Cadaver  is. — Twenty -tivo  hours  after  death. 

Body  very  much  emaciated. 

Thorax. — Thoracic  organs  normal. 

Abdomen. — On  opening  the  abdomen  a large  quantity  of  dark-colored  fluid  was 
found,  in  which  were  suspended  flakes  of  white  lymph.  To  the  inner  surface  of  the 
peritoneum  pieces  of  soft  recent  lymph  were  attached,  but  it  was  quite  free  of  small 
round  nodules.  The  stomach  and  the  intestines  were  loosely  glued  to  each  other, 
and  to  the  parietal  peritoneum  by  soft  Wm  '-h.  The  fingers  alone  were  sufficient  to 

* Reported  by  Mr.  Robert  Rhind,  Clinical  Clerk. 


492 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


separate  the  bowels.  On  examining  attentively  the  anterior  surface  of  the  stomach 
two  or  three  small  perforations  could  be  detected.  The  largest  was  nearly  an  inch 
long  on  the  outer  surface  of  the  stomach,  and  corresponded  to  an  ulceration  about 
2-^  indies  in  extent  internally.  The  pyloric  half  of  the  stomach  was  transformed 
into  a large,  intensely  hard,  glue-like  mass,  and  was  about  the  size  of  a cocoa  nut,  or 
two  closed  lists.  On  opening  the  stomach,  the  mucous  membrane,  towards  the  car- 
diac extremity,  was  perfectly  sound,  but  at  the  pyloric  end  it  had  undergone  ulcera- 
tion at  several  points,  especially  near  the  smaller  curvature  and  the  pylorus.  The 
pyloric  orifice  was  of  sufficient  diameter  to  admit  easily  the  little  finger.  The  pancreas, 
liver,  and  surrounding  organs  were  healthy.  The  texture  of  the  growth  was  as  hard 
as  cartilage,  and  creaked  under  the  knife,  but  on  section  presented  the  usual  charac- 
ters of  colloid  cancer.  (See  p.  232.)  The  mucous  membrane  of  the  intestines  was 
perfectly  healthy.  The  other  abdominal  organs  were  normal. 

Microscopic  Examination. — The  colloid  cancer  presented  the  characteristic  struc- 
ture described  and  figured  p.  232. 

Commentary/. — An  indurated  swelling  in  the  epigastric  region, 
pain  and  vomiting  after  food,  are  the  usual  symptoms  of  cancer  in  the 
stomach;  and  they  were  all  present  in  the  two  cases  just  noticed. 
There  was,  besides,  hsematemesis,  indicating  ulceration  in  Case  LX., 
and  in  addition,  sudden  pain,  with  peritonitis,  in  Case  LXI.,  pointing 
out  the  occurrence  of  perforation.  The  vomiting  did  not  appear  so  soon 
in  the  last  as  in  the  first  case,  and  it  will  be  noticed  that  in  it  the 
pyloric  constriction  was  not  great.  On  the  other  hand,  ulceration  was 
more  extensive  with  pyrosis,  and  led  to  perforation  with  fatal  peritonitis. 
The  atrophy  of  the  right  kidney,  which  was  converted  into  a fibrous 
sac,  had  not  apparently  in  Gaffney  produced  any  complaint  whatever 
during  life.  All  the  symptoms  observed  in  this  man,  with  the  excep- 
tion of  hmmatemesis,  may  be  produced  by  a tumor  outside  the  stomach, 
as  well  as  by  disease  of  the  stomach  itself,  pressing  on  the  organ,  and 
nothing  is  more  difficult  (if  indeed  it  be  ever  possible)  than  to  diagnose 
the  former  condition  frem  the  latter,  which,  however,  occurs  rarely. 
(See  p.  520.) 

In  many  cases  the  lesion  hitherto  described  as  scirrhus  of  the  pylorus 
or  stomach  seems  to  be  a simple  hypertrophy  of  their  muscular  and 
fibrous  coats,  which  may  or  may  not  be  associated  with  cancer  of  the 
neighboring  glands.  A simple  stricture  of  the  pylorus  may  in  this 
way  produce  more  or  less  thickening  of  the  stomach,  in  consequence  of 
the  chronic  vomiting  excited  by  it;  or  by  increasing  the  muscular 
power  necessary  to  overcome  the  obstruction,  just  as  happens  in  the 
intestines,  bladder,  and  other  hollow  viscera,  when  the  parts  below  them 
are  strictured.  (See  Figs.  170  to  172,  p.  190.)  I have  recorded  four 
cases  of  this  kind  in  my  work  on  “ Cancerous  and  Cancroid  Growths” 
(Edinburgh,  1848,  p.  46,  et  seq.)  Tn  all  such  cases  it  is  observable, 
that  the  same  emaciation  and  cachectic  appearances  are  present  as  in 
instances  of  undoubted  cancer — a circumstance  which  is  attributable  to 
the  impeded  nutrition  of  the  body  rather  than  to  a supposed  cancerous 
diathesis.  On  this  account  I have  long  ceased  to  place  any  confidence 
in  the  so-called  “cachectic  appearance”  as  diagnostic  of  cancer,  attribut- 
ing it  either  to  imperfect  nutrition,  or  to  wearing  down  of  the  body  from 
excessive  pain.  This  cachexia  is  often  present  in  many  other  forms  of 
morbid  growth,  and  frequently  absent  when  the  disease  has  been  proved 
to  be  cancerous  by  a microscopic  examination. 

Of  all  forms  of  cancerous  disease,  that  of  the  stomach  is  perhaps  the 


DISEASES  OF  THE  STOMACH. 


493 


most  distressmg;  it  cuts  off  the  supply  of  nourishment  which  should 
enter  the  system,  and  induces  (in  addition  to  the  wearing-down  pain,) 
loss  of  sleep,  loss  of  blood,  and  more  or  less  constant  vomiting.  Our 
duty  in  such  cases  is  to  relieve  and  support  the  system ; and  to  this  end 
opiates  in  large  doses,  nutritive  enemata,  careful  regulation  of  the  diet, 
and  ice  allowed  to  dissolve  in  the  mouth,  are  the  best  remedies.  A 
local  frigorific  mixture,  as  recommended  by  Dr.  J.  Arnott,  and  the  ap- 
plication of  a few  leeches  to  the  epigastrium,  are  also  occasionally  bene- 
ficial. In  Case  LX.  the  cold  application  was  of  marked  service. 

The  histological  changes  which  occur  in  various  disorders  of  the 
stomach  were  first  investigated  by  Dr.  Handfield  Jones,  who  has 
described  and  figured  the  appearances  presented  by  the  follicles,  their 
contained  cells,  and  other  minute  structures  under  a variety  of  circum- 
stances.'^ There  may  be  hypertrophy  and  atrophy  of  the  solitary 
glands;  atrophy  of  the  glandular  tubes;  fatty  degeneration;  wasting 
and  black  discoloration  of  their  epithelial  contents ; fibroid  thickening. 


etc.  His  researches  have  been  for  the  most  part  confirmed  by  Dr.  F. 
Schlapferf  and  Dr.  Wilson  Fox.J  The  latter  observer  has  added  some 
important  fiicts  connected  with  chronic  catarrh  of  the  stomach,  thicken- 
ing of  the  limitary  membrane,  and  cystic  degeneration  of  the  glands. 

* Pathological  and  Clinical  Observations  respecting  Morbid  Conditions  of  the 
Stomach.  London,  1845.  f Virchow’s  Archiv.  B.  7,  p.  158.  1854.. 

^ Medico-Chir.  Trans,  of  London.  Yol.  XLI.  1858. 


Fig.  417.  Appearance  of  the  gastric  glands  in  recent  catarrh  of  the  stomach. 
Their  external  outline  is  irregular,  and  they  are  filled  with  enlarged  secreting  cells. 
— ( Wilson  Fox.) 

Fig.  418.  Commencing  cystic  formation  in  a gastric  follicle,  which  is  constricted 
in  some  places  (6,  c)  and  swollen  at  others.  «,  Shows  the  thickening  of  the  limitary 
membrane ; and  c?,  slight  fatty  degeneration  of  the  epithelium  — ( Wilson  Fox.) 

Fig.  419.  A cyst  in  the  pyloric  portion  of  the  stomach,  composed  of  a fibrous 
envelope,  and  contents  wholly  composed  of  cylindrical  epithelium.  At  a,  the  limi- 
tary membrane  of  the  gastric  glands  commences  to  be  thickened ; and  at  d,  tht-ir 
contents  have  undergone  the  fatty  degeneration,  so  common  in  chronic  catarrh. — 
( Wilson  Fox.)  340  diam. 


494 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


Dr.  Habershon,*  as  well  as  Dr.  Fox,  points  out  tlie  rapid  changes  which 
take  place  in  the  glands  of  the  stomach  after  death,  and  the  great 
caution  therefore  required  in  forming  conclusions,  when  examination  of 
the  minute  structure  is  too  long  delayed.  As  a guide  to  the  clinical 
student  and  practitioner.  I give  the  more  important  morbid  changes 
which  have  been  observed  in  the  gastric  glands,  from  the  excellent 
representations  of  Dr.  Fox.  Dr.  Jones  has  the  great  merit  of  having 
laid  the  foundation  for  a clinical  history  of  these  lesions,  although  the 
observations  are  as  yet  far  too  few  to  enable  us  to  connect  them  with 
diagnosis  and  treatment  at  the  bed-side.  From  what  is  known  on  this 
subject,  I must  refer  to  the  works  I have  named,  hoping  that  before 


Fig.  420. 


Fig.  422. 


long  these  researches  may  be  extended  by  clinical  histologists,  and  ulti- 
mately lead  to  a more  exact  knowledge  of  the  dyspeptic  and  organic 
diseases  of  this  important  organ. 


As  a further  contribution  to  this  subject,  I may  observe  that  in  the 
case  of  a man — Robert  Lindsay — aet.  60,  who  died  in  the  clinical  ward, 
March  27,  1860,  with  a well-marked  tumor  of  the  pylorus,  a careful 
histological  examination  revealed  the  following  facts.  The  history  of 
the  case,  and  the  appearance  presented  by  the  thickened  structure  of  the 
pylorus,  presented  nothing  unusual. 

Various  sections  through  the  thickened  and  indurated  white  pyloric 
structure,  with  a Valentin’s  knife,  showed  the  morbid  growth  to  be 
compostM  of  hypertrophy  of  the  gastric  follicles,  as  represented  Fig. 
423.  The  cells  of  some  follicles  had  undergone  the  fatty  degeneration, 
so  that  they  were  filled  with  molecular  and  granular  matter,  in  which 

* On  Diseases  of  the  Alimentary  Canal,  p.  62.  8vo,  bound.  1857. 

Fig.  420.  The  gastric  glands  in  chronic  catarrh  of  the  stomach,  the  breaking 
down  of  the  upper  portion  being  probably  due  to  'post-mortem  change.  «,  a mass  of 
pigment ; 6,  6,  free  fat  drops ; c,  thickened  limitary  membrane ; d,  d,  d,  complete 
fatty  degeneration  of  the  epithelium. — {Wdson  Fox.) 

Fig.  421.  Chronic  catarrh  of  the  stomach,  with  hypertrophy  of  the  fibrous  tissue 
between  the  glands.  The  section  has  been  treated  with  acetic  acid,  which  exhibits 
more  distinctly  the  nuclei  of  the  fibrous  tissue,  and  gives  a cloudy  appearance  to  the 
follicular  epithelium. — ( Wilsori  Fox.) 

Fig.  422.  Fatty  degeneration  affecting  the  upper  layer  of  the  follicular  epithelium, 
c,  and  fil)rous  connective  tissue,  a,  a,  producing  erosion  of  the  surface  •,  6,  fatty 
degeneration  of  the  epithelium  and  sub-mucous  fibrous  tissue. — ( Wilson  Fox.) 

340  dia7Ti. 


DISEASES  OF  THE  STOMACH. 


495 


all  structure  was  lost.  In  others,  however,  even  where  the  follicles. 


Fig.  423 

were  enormously  distended,  as  seen  at  d in  the  figure,  the  gland  struc- 
ture was  still  preserved. 

Case  LXVI.^ — Poisoning  hg  Oxalic  Acid — Recovery, 

History. — Thomas  Clarke,  set.  47,  shoemaker — admitted  May  21st,  1859.  He  was 
brought  to  the  hospital  by  the  police  at  9.10  p.m.  At  8 p.m.  he  had  swallowed  a penny- 
worth of  oxalic  acid  (about  6 drachms),  partly  dissolved  in  a tea-cupful  of  water,  and 
partly  in  a crystalline  state.  At  about  8.20  p.m.  he  ’tvas  conveyed  to  the  police-office, 
where  he  vomited  twice,  and  refused  to  take  some  medicine  which  was  offered  him. 
He  was  then  brought  to  the  Infirmary.  Patient  stated  afterwards  that  about  8.20 
P.M.  he  felt  a burning  sensation  in  the  lower  part  of  the  oesophagus  and  stomach,  which 

* Reported  by  Dr.  Carter,  Resident  Physician. 

Fig.  423.  The  gastric  and  pyloric  glands  hypertrophied  in  a cancroid  tumor  of 
the  pylorus,  a,  Enlarged  follicle ; 6,  transverse  section  of  such  a follicle ; c,  out- 
line of  another  follicle ; (/,  the  largest  follicle  observed,  mostly  drawn  in  outline. 
The  whole  of  it,  however,  was  composed  of  enlarged  epithelial  cells,  as  seen  in  the 
upper  part  of  the  drawing.  In  the  centre  the  appearance  of  the  isolated  cells  is 
seen,  which  were  very  numerous  in  the  field  of  the  microscope,  e,  Fragment  of  a 
follicle;  many  of  these  of  all  sizes  and  shapes,  resulting  from  sections  in  various 
directions,  M'ere  observed,  as  will  be  at  once  understood  by  the  histologist.  /,  Mass 
of  cells  undergoing  the  fatty  degeneration,  y.  Another  mass  completely  disinte- 
grated. The  follicles  presented  all  sizes  and  shapes  intermediate  between  a and  tZ, 
and  many  of  them  all  the  stages  of  fatty  degeneration.  250  diam. 


496 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


was  followed  by  vomiting.  The  matters  thrown  up  consisted  of  some  bread  which  he 
had  taken  at  about  6 o’clock  p.  m.,  and  some  of  the  crystals  of  the  acid. 

Symptoms  on  Admission. — At  the  time  of  admission — 9.10  p.m. — he  was  pallid; 
skin  cold,  but  without  moisture ; his  features  pinched ; pupils  if  anything  rather 
dilated ; pulse  72  and  weak.  He  complained  of  burning  sensation  about  his  gums, 
the  lower  part  of  his  throat,  and  in  his  stomach,  which  latter  was  very  painful  when 
pressed  upon.  He  answered  questions  intelligently,  but  was  unwilling  to  give  much 
information.  He  vomited  twice  after  entering  the  hospital,  and  was  seized  with  a 
rigor  which  lasted  for  about  ten  minutes.  An  attempt  was  made  to  pass  the  stomach 
pump  tube,  but  as  this  seemed  to  occasion  excessive  pain,  and  as  he  had  vomited  so 
frequently,  it  was  not  employed.  He  was,  at  9.25  p.  m.,  made  to  drink  about  three 
parts  of  a pint  of  warm  water,  in  which  was  suspended  one  ounce  of  prepared  chalk. 
This  remained  on  his  stomach  for  about  ten  minutes,  and  was  then  rejected.  He 
said  that  he  felt  immediate  relief  from  the  burning  sensation  after  he  had  taken  the 
chalk.  A similar  dose  was  again  administered  and  retained  permanently.  He  was 
placed  in  a bed  a short  distance  from  the  fire,  and  warm  bottles  applied  to  his  feet. 
At  10.80  he  felt  much  better,  and  took  about  half  a pint  of  strong  beef-ten,  with  an 
ounce  of  brandy  in  it,  and  was  ordered  to  have  the  same  mixture  at  1 o’clock,  and  to 
drink  milk  ad  libitu7n  throughout  the  night  if  thirsty. 

Progress  of  the  Case. — May  ‘I'id. — Expresses  himself  as  feeling  tolerably  well; 
but  complains  of  some  slight  uneasiness  in  his  throat  and  stomach,  and  of  weakness, 
which,  however,  he  has  felt  for  some  time  as  a consequence  of  illness  and  of  privation. 
His  tongue  is  covered  with  a thickish  fur;  he  has  little  appetite  and  great  thirst; 
his  bowels  were  open  during  the  night.  Pulse  CO,  still  weak.  He  continued  to  feel 
pain  in  the  stomach,  with  dyspeptic  symptoms,  for  son;e  time ; similar,  he  says,  to 
those  he  labored  under  before  taking  the  poison.  Ihese  weie  diminished  and  ulti- 
mately got  rid  of  by  powders  containing  five  grains  of  bismuth,  and  a quarter  of  a grain 
of  opium.  He  was  dismissed  cured,  June  18. 

Case  LXYII.* — Poisonmg  hj  Sulphuric  Acid — Recovery. 

History. — John  Calder,  aet.  2 — admitted  July  21st,  1868.  This  healthy  child 
shortly  after  breakfast,  having  been  left  alone  in  a room,  was  heard  by  its  mother 
to  utter  a scream.  He  was  found  with  a bottle  in  his  hand  containing  sulphuric  acid, 
which  he  had  applied  to  his  mouth,  and  from  which  he  had  subtracted  about  § ij. 
Some  of  this  had  been  spilt  on  the  child’s  chin,  breast,  and  clothes.  Water  was  given 
to  it,  and  the  child  immediately  brought  to  the  Infirmary  in  its  mother’s  arms.  She 
says  that  on  the  way  a brownish  colored  fluid,  with  the  milk  and  bread  previously 
eaten,  was  vomited. 

SyxMptoms  on  Admission. — The  resident  physician  on  hearing  the  nature  of  the 
case,  immediately  administered  3 ij  of  carbonate  of  magnesia  suspended  in  water,  when 
the  child  eructated  a considerable  quantity  of  gas.  The  pulse  then  was  100,  weak ; sur- 
face pale ; tongue  of  a dead  white,  as  if  acted  on  by  the  acid,  which  has  also  flowed 
ovei’»the  lower  lip,  chin,  and  breast.  Otherwdse  the  child  w’as  quite  healthy. 

Progress  of  the  Case. — Vespere. — Up  to  this  time  the  child  has  been  quiet,  dozing 
occasionally.  Deglutition  is  painful,  but  milk  and  beef-tea  have  been  given  at  inter- 
vals. Has  had  one  stool ; pale  and  pultaceous.  My  22d — Has  passed  a restless 
night,  but  this  morning  does  not  seem  to  suffer  much  pain.  Chalk  in  lime  water  has 
been  given  from  time  to  time  during  the  night,  and  a beef-tea  enema  this  morning, 
which  was  retained.  Pulse  145,  weak.  The  tongue,  a few  patches  inside  the  mouth, 
the  centre  of  the  lower  lip  and  chin,  forming  a streak  about  an  inch  broad,  ai  e covered 
w'ith  eschars.  There  is  another  also,  the  size  of  half  a crown,  on  the  breast.  My 
28(/. — Takes  nourishment  with  some  pain  on  swallowing.  Desquamation  of  the 
dorsum  of  the  tongue  has  taken  place  in  patches.  My  ^ith. — Eschars  have  separated. 
July  25/A. — Still  slight  pain  on  swaliowing,  otherwise  well.  Dismissed. 

Case  LXVIII.f — Poisoning  hg  Corrosive  Sublmate — Recovery. 

History. — Alexander  Tweedle,  aet.  19 — admitted  May  24th,  1861.  He  stated 
that  a quarter  of  an  hour  previously  he  had  swallowed  by  mistake,  instead  of  whisky, 


* Reported  by  Mr.  Alfred  Lewis,  Clinical  Clerk, 
f Reported  by  Mr.  John  Simpson,  Clinical  Clerk. 


DISEASES  OF  THE  LIVED. 


497 


half  a wine  glassful  of  a bottle  marked  poison,  which  was  found  to  contain  camphor, 
turpentine,  and  corrosive  sublimate,  and  used  to  destroy  insects.  Had  not  vomited 
since. 

Symptoms  on  Admission. — Only  complained  of  great  dryness  and  heat  in  his 
throat,  otherwise  was  quite  well.  An  emetic  of  sulphate  of  zinc  (gr.  xx)  was  imme- 
diately given,  and  a quantity  of  fluid,  smelling  strongly  of  camphor  and  turpentine, 
was  at  once  ejected.  The  whites  of  six  eggs  were  then  administered.  The  tests  of 
caustic  potash,  iodide  of  potassium,  copper  and  nitrate  of  silver,  indicated  a consider- 
able quantity  of  corrosive  sublimate  iu  the  fluid  contained  in  the  bottle  he  had  brought 
with  him. 

Progress  op  the  case. — May  l^th. — Complained  of  no  bad  symptoms  last  night ; 
slept  well — dismissed. 

Commentary . — In  the  first  of  these  three  cases  of  irritant  poisoning, 
the  man  was  induced  to  commit  suicide  when  laboring  under  dyspepsia, 
want  of  food,  and  impossibility  of  obtaining  employment.  In  the  second 
case — that  of  a young  child — vomiting  having  oecurred  before  admission, 
an  antacid  was  immediately  given,  which  neutralised  what  was  left  of 
the  sulphuric  acid  in  the  stomach.  Fortunately  also  the  irritant  was 
swallowed  shortly  after  taking  a meal.  In  the  third  case,  an  emetic 
acted  perfectly  before  the  corrosive  sublimate  had  time  to  occasion  bad 
consequences,  and  white  of  eggs  was  at  once  administered.  Prompt 
judicious  measures  induced  in  all  of  them  recovery. 

DISEASES  OF  THE  LIVER. 

Notwithstanding  the  obscurity  which  still  rests  upon  the  functions 
of  the  liver,  the  progress  of  histological  pathology  has  tended  to  make 
us  better  acquainted  with  the  minute  changes  which  occur  in  many 
diseases  of  the  organ.  The  nature  of  fatty  enlargement,  of  cirrhosis, 
and  of  the  disintegration  of  cell-texture  following  obstruction  of  the 
bile-ducts,  is  now  understood,  but  much  research  is  still  necessary.  A 
careful  comparison  of  the  structural  changes  observed  in  the  liver  after 
death,  with  the  clinical  history  and  symptoms  observed  in  the  liver  during 
life,  is  what  is  greatly  desired  to  advance  onr  knowledge  of  hepatic  diseases. 
This  knowledge,  however,  can  scarcely  be  hoped  for,  until  medical  men, 
and  especially  such  as  practise  in  the  East,  become  efficient  histologists. 
More  recently  some  light  has  been  thrown  upon  diagnosis,  by  paying 
attention  to  the  transformations  which  bile  undergoes  during  its  excre- 
tion by  the  kidneys.  It  is  the  application  of  therapeutics  to  these 
diseases,  however,  and  a correct  appreciation  of  the  class  of  remedies 
called  cholagogues,  which  in  the  present  state  of  medicine,  requires  most 
to  be  determined.  Such  an  investigation  necessitates  physiological, 
histological,  and  chemical  knowledge,  added  to  good  powers  of  clinical 
observation.  But  of  all  the  subjects  of  research  now  open  to  the  young 
investigator,  I know  of  none  in  which  patience  and  exactitude,  based 
on  a scientific  rather  than  an  empirical  system  of  inquiry,  is  likely  to 
yield  more  useful  results. 

Case  LXIX.^ — Acute  Congestion  of  the  Liver — Hepatitis — Recovery. 

History. — Thomas  Russell,  get.  38,  laborer  at  a gas-work — admitted  January 
26th,  1855.  States  that  about  three  weeks  ago,  after  indulging  freely  in  the  use  of 

* Reported  bv  Mr.  W.  J.  Marshall,  Clinical  Clerk. 

32 


498 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


ardent  spirits,  he  experienced  general  shivering  and  pain  in  the  right  hypochondrium 
with  tinnitus  aurium  and  a sense  of  faintness.  Subsequently  he  felt  pain  in  the  ii<>-ht 
shoulder,  and  at  length  w'as  obliged  to  leave  off  work.  His  comrades  who  w^nt  honic 
with  him,  told  him  that  he  looked  yellow  in  the  face.  At  night  he  became  very  hot. 
He  returned  to  his  work  on  the  following  day,  and  continued  at  his  employment  fora 
fortnight,  but  was  very  weak,  and  suffered  much  from  the  pain  in  his  side'  and  in  the 
shoulder.  Since  then  he  has  been  confined  to  bed,  under  medical  care,  applyino- 
counter-irritants  locally,  and  taking  pills  which  have  made  his  mouth  soi  e. 

Symptoms  on  Admission. — On  admission,  he  complains  of  pain  in  the  right  hypo- 
chondrium and  right  shoulder,  in  the  former  of  which  situations  it  is  peiTiianent  and 
increased  by  pressure,  while  in  the  latter  it  is  only  occasional.  The  tongue  is  covered 
Avirh  a moist  white  fur  ; the  breath  has  a mercurial  foetor ; the  gums  are  painful ; appe- 
tite good.  Bowels  open.  Pressure  and  percussion  over  the  liver  painful.  Vertical 
hepatic  dulness  44  inches.  Pulse  72,  soft.  Sleeps  little  in  consequence  of  the  pain  ; 
Urine  normal ; no  jaundice.  Other  functions  w'ell  performed.  To  apply  six  leeches  to 
the  right  hypochondrium,  and  the  parts  afterwards  to  he  fomented.  To  take  two 
compound  rhubarb  pills  every  night. 

PkogPxEss  op  the  Case. — February  — The  leeches  and  fomentations  have  in  no 
w'ay  benefited  the  pain,  which  to  day  is  as  severe  as  on  admission.  Bowels  still  open. 
Stools  darker  than  formerly,  but  healthy.  February  Sd. — Since  last  report  all  pain 
has  left  him  ; he  declares  himself  to  be  w-ell,  and  at  his  own  request  was  discharged. 

Case  LXX.* — Acute  Jaundice. — Albuminuria. — Recovery. 

History. — Walter  Halliday,  aet.  61,  tailor — admitted  July  6th,  1867.  States  that 
he  has  generally  been  a temperate  man,  although  occasionally  he  has  taken  spirits 
moderately.  On  the  first  of  this  month,  wdien  working  below  an  open  windotv,  he 
was  suddenly  seized  with  rigors,  followed  by  great  thirst,  heat  of  skin,  and  headache. 
Next  morning  he  w'ent  to  work  as  usual,  but  w'as  obliged  to  desist  in  the  middle  of 
the  day  and  go  home.  The  rigors  have  returned  occasionally  ever  since,  and  he  has 

experienced  obscure  pain  in  the  lumbar  region.  The  skin  became  jaundiced  on  the 

second  day  of  his  illness,  and  the  yellow  tint  has  been  increasing  in  intensity  since. 
He  has  also  occasionally  vomited. 

Symptoms  on  Admission. — The  tongue  is  moist  and  covered  with  a wdiitish  fur. 
No  difficulty  in  taking  food,  nor  pain  afterwards.  No  tenderness  or  pain  in  abdomen  ; 
but  feels  a pain  in  the  lumbar  region,  wdiich  sometimes  darts  round  the  right  side 
towards  the  umbilicus.  Appetite  impaired.  Bowels  costive.  Vertical  dulness  of 
liver  on  percussion  4 inches.  The  skin  over  the  whole  body  is  of  a deep  yellow  tint, 
dotted  with  spots  of  purpura  the  size  of  pin  heads  ; but  is  cool  and  moist  The  urine 
is  deep  colored,  like  Madeira  wine.  It  is  very  albuminous  on  the  addition  of  heat, 

and  contains  a large  quantity  of  bile.  Pulse  88,  small  and  weak.  Other  organs 

healthy.  Potass.  Acet.  3 ij.  ; Sp.  jEiher.  Nit.  §ss  ; Aquee  § vi ; AI.  One  ounce  to  be 
taken  every  three  hours.  Jidy  8th. — Bowels  were  freely  opened  yesterday  in  conse- 
quence of  a Calomel  and  Jalap  powder  which  was  given.  Stools  w ere  fluid  and  of  a 
Clark -brown  color. 

Progress  of  the  Case. — Jidy  0^7i. — On  microscopic  examination  of  the  urine  it 
was  seen  to  contain  numerous  casts,  with  delicate  w^alls,  having  in  their  interior  large 
epithelial  cells.  Passes  more  urine  than  formerly.  To  have  Pidv.  Doveri  gr.  x,  at 
bed-time,  followed  by  a diaphoretic  dra^lght.  Two  compoxmd  rhubarb  pills  to  betaken 
every  night.  Jidy  \ Wi. — The  urine  and  skin  are  now  of  a healthy  color.  The  pulse, 
however,  remains  low,  and  the  patient  weak  and  languid.  Nutrients,  tonics  and  wine, 
with  gentle  exercise,  were  now  given,  under  wdiich  he  became  thoroughly  well,  and 
was  discharged  August  3d. 

Commentary . — These  two  cases  are  examples  of  the  slighter  forms 
of  hepatic  disease,  although  what  that  disease  is  it  becomes  eo  easy 
matter  to  determine.  In  the  first  case  we  have  pain,  increased  on 
pressure  in  the  right  hypochondrium,  and  in  the  right  shoulder,  ushered 
in  by  rigor  and  febrile  symptoms.  On  percussion  the  liver  is  found  to 
be  slightly  enlarged.  After  coming  into  the  house  the  disease  subsides 


•Reported  by  Mr.  W.  H.  Davies,  Clinical  Clerk. 


DISEASES  OP  THE  LIVEPw 


499 


in  a few  clays.  The  leeches  and  fomentations  did  not  seem  to  alleviate 
the  pain,  but  the  purgative  produced  a more  healthy  intestinal  discharge. 
In  the  second  case  there  was  little  local  pain,  but  evidently  something 
had  caused  interference  with  the  secretion  of  bile.  The  skin  was  deeply 
jaundiced,  the  stools  of  a dark  clay  or  leaden  color,  and  the  urine 
loaded.  This  condition  was  also  ushered  in  with  rigors  and  febrile 
symptoms.  Ptyalism  was  produced  before  he  entered  the  house, 
without  occasioning  the  slightest  benefit.  On  the  contrary,  the  disease 
increased.  But  under  the  action  of  diuretics  and  diaphoretics,  to  favor 
secretion  of  the  bile  already  absorbed,  as  well  as  of  mercurial  purgatives 
to  rouse  the  duodenum  and  upper  parts  of  the  alimentary  canal  to  a 
more  healthy  action,  he  rapidly  recovered.  AVhether  the  disorder  in 
these  cases  was  congestive  or  inflammatory,  or  both,  cannot  be  de- 
termined. Whatever  the  lesion,  it  so  operated  in  the  one  case  as  to 
induce  great  pain,  and  in  the  other  to  obstruct  the  gall-ducts  and  occa- 
sion jaundice. 

In  jaundice,  the  diminished  excretion  of  bile  by  the  intestines  is 
attempted  to  be  compensated  for  by  its  entering  more  or  less  largely 
into  the  secretions  of  the  kidney  and  skin — especially  the  former.  In 
intense  forms  of  the  disease,  casts  of  the  renal  tubes  are  frequently  seen 
in  the  urine,  their  contained  cells  deeply  tinged  with  bile  pigment. 
Frerichs  has  carefully  described  and  figured  the  histological  changes 
which  occur  in  the  kidneys  and  skin  under  such  circumstances.  These 
consist  in  the  accumulation  of  yellow,  brown,  and  green  pigment,  in 
the  cells  of  the  tubuli  uriniferi,  and  not  unfrequently  the  pigment  is 
infiltrated  through  the  parenchymatous  tissue  of  the  kidney.  He  has 
even  seen  it  assume  the  form  of  hard  coal-like  masses,  which  must 
have  greatly  interfered  with  the  functions  of  the  organ.  In  the  skin 
the  deep  layer  of  round  epidermic  cells  contain  a yellowish  or  deeply 
brown  granular  pigment,  and  the  secreting  cells  of  the  sudoriferous 
glands  are  similarly  affected,  but  never  to  the  extent  which  may  be 
observed  in  the  kidney.^'  Such  observations  indicate  the  importance 
of  diuretics  and  sudorifics  in  the  treatment  of  jaundice,  in  addition  to 
the  means  usually  adopted  for  stimulating  the  upper  part  of  the  alimen- 
tary canal. 

A new  impulse  has  been  given  to  the  diagnosis  of  the  causes  on 
which  jaundice  depends  by  the  writings  of  Frerichs,  Harley,  and  others. 
Jaundice  may  be  a symptom — 1st,  of  various  affections  of  the  blood,  as 
in  fevers,  disease  of  the  heart,  lungs,  and  nervous  system ; 2d,  of 
mechanical  obstruction  in  the  duodenum,  from  accumulation  of  fieces  in 
neighboring  bowels,  or  from  tumors;  3d,  of  hepatic  congestion,  occa- 
sioned by  fright  and  other  temporary  circumstances ; 4th,  from  obstruc- 
tion of  the  ducts  in  the  liver  itself  or  the  gall-bladder;  and  5th,  from 
structural  changes  in  the  hepatic  tissue.  Hence  jaundice  may  be  con- 
veniently divided,  as  was  originally  done  by  Hr.  Alison,  into  jaundice 
from  obstruction  and  jaundice  from  non-elimination. 

The  symptoms  are  chiefly  referrible  to  the  skin,  which  is  tinted 
yellow;  to  the  bowels,  the  discharges  from  which  are  clay-colored,  and 

Frerichs,  Klinik  der  Leber  Krankheiten,  1858,  pp.  lOY-8,  and  plate  1. 


500 


DISEASES  OF  THE  DIGESTIVE  SYSTE:^!. 


more  or  less  fatty ; and  to  the  urine,  the  chemical  constituents  of  which 
vary  greatly.  It  is  by  the  chemical  analysis  of  this  fluid,  that  new  light 
has  been  endeavored  to  be  thrown  on  our  appreciation  of  the  nature  of 
jaundice.  In  our  attempts  to  arrive  at  results  by  the  chemical  investi- 
gation of  this  fluid,  we  must  first  remember  what  are  the  constituents 
of  bile ; and,  secondly,  how  they  are  to  be  detected. 

The  chemical  constituents  of  bile  are — 1st,  Biliverdine, — a green, 
nitrogenized,  non-crystallizable  coloring  matter  derived  from  the  blood. 
2d,  Two  acids, — the  glycocholic,  which,  with  soda,  is  crystallizable ; and 
the  Taurocholic,  which  is  non-crystallizable.  3d,  Cholesterine, — a fatty 
crystallizable  matter.  4th,  A brown  resinous  matter,  resembling  shoe- 
maker’s wax.  5th,  Sugar.  6th,  Inorganic  matters,  chiefly  soda,  potash, 
and  iron. 

When  the  secretion  of  bile  has  been  suppressed,  that  is,  when  this 
fluid  has  not  been  formed,  it  is  said  that  no  bile  acids  are  to  be  found 
in  the  urine ; not  having  been  formed,  they  do  not  enter  the  blood  and 
are  not  excreted  by  the  kidneys.  It  must  be  confessed,  however,  that 
we  require  more  characteristic  tests  for  the  bed-side  than  those  furnished 
by  Pettinkofer  (p.  Ill),  or  by  the  method  of  Hoppe.  To  me  it  has 
not  appeared,  from  numerous  trials,  that  any  amount  of  skill  and  experi- 
ence will  ever  enable  the  physician  to  come  to  a conclusion  on  this 
point,  when  all  that  has  to  be  determined  is  the  difference  between  a 
rich  brown  and  a purple  color — constantly  passing  as  they  do  into  one 
another — in  order  to  distinguish  the  absence  or  presence  of  an  acid,  on 
which  depends  a conclusion  so  important. 

According  to  Frerichs,  acute  atrophy  of  the  liver  is  to  be  determined 
by  the  presence  of  tyrosine  and  leucin  in  the  urine — two  products 
never  found  there  in  health.  (For  mode  of  detection  see  p.  Ill,  and 
Figs.  112  to  114.)  I have  endeavored  to  ascertain  the  correctness  of 
this  test  in  several  cases  which  entered  the  clinical  wards  during  the 
years  1863-64,  but  only  succeeded  in  obtaining  unequivocal  crystals  of 
leucin  in  one  case.  Here,  also,  I believe  that  unless  the  mode  of  detec- 
tion can  be  simplified,  it  will  be  some  time  before  we  shall  be  enabled 
to  judge  of  the  correctness  of  this  new  diagnostic  sign.  Notwithstand- 
ing the  trouble  I and  my  various  assistants  have  recently  taken  in  en- 
deavaring  to  arrive  at  useful  results,^  by  these  new  modes  of  inquiry, 
the  facts  I have  arrived  at  are  as  yet  too  few  and  uncertain  to  warrant 
publication. 

The  true  method  of  further  investigating  these  matters,  however,  is 
to  extend  chemical  and  histological  knowledge  among  medical  students, 
so  as  to  obtain  a larger  number  of  skilful  workers  at  the  bed-side,  who 
have  time  and  ability  to  grapple  with  the  present  difiiculties  of  such 
questions.  The  profession  at  large  cannot  be  too  grateful  to  those  who 
have  indicated  new  sources  of  information  in  diseases  hitherto  so 
mysterious,  which  I firmly  believe  are  yet  destined  to  yield  most  im- 
portant results. 

* Among  these  I am  much  indebted  to  my  late  resident  physicians,  Drs.  Smart 
and  Duckworth. 


DISEASES  OF  THE  LIVER, 


501 


^'Iase  LXXI.^' — Abscess  of  the  Liver^  bursting  into  the  Right  Thoracic 
Cavity,  and  into  the  Retro-peritoneal  Cellular  Tissue — Pneu- 
monia and  Gangrene  of  Right  Lung — Pneumo-Thorax. 

History. — Robert  Steinkopff,  tet.  45,  native  of  Prussia,  merchant — admitted  Nov. 
5 18G4.  Tlie  patient  states  that  he  was  in  easy  circumstances;  passed  his  time  chiefly 
in  hunting,  and  in  so  doing  he  was  often  accustomed  to  the  free  use  of  spirits;  until 
a year  ago,  when  he  lost  his  property  and  came  to  tliis  country.  lie  was  now  obliged 
10  live  on  very  insufficient  diet,  and  this,  combined  with  great  mental  anxiety,  impaired 
his  strength.  Three  weeks  ago,  after  exposure  to  wet  on  a rainy  day,  he  was  seized 
with  sudden  and  severe  pain  in  the  right  hypochondriac  and  epigastric  regions ; en- 
liu^ement  and  protrusion  of  the  abdomen,  more  especially  when  standing;  diarrhoea 
of  six  thin  and  copious  stools  per  diem,  accompanied  with  much  flatus ; feverish 
attacks,  occurring  every  afternoon  from  3 to  6 o’clock  ; diminished  appetite  and  con- 
stant thirst.  These  symptoms  continued  up  to  the  period  of  admission.  He  left 
Leeds,  where  he  was  first  attacked,  and  went  to  York  and  Newcastle,  whence  he  came 
by  sea  to  Edinburgh,  eight  days  ago.  Since  then  there  has  been  some  oedema  of  the  legs. 

SvMPTOMS  ON  Admission. — Tongue  clean,  fissured  transvcrsly,  bad  taste  in  the 
mouth.  No  appetite;  thirst.  The  epigastrium  is  swollen  ; tympanitic  on  percussion, 
and  very  painful  on  pressure.  Lateral  hepatic  dulness  6 inches  vertically.  The  lower 
border  of  the  organ  may  be  felt  2 inches  below  the  ribs,  which  bulge  very  much  on 
the  right.  Splenic  dulness  normal.  Bowels  moved  from  three  to  seven  times  a day. 
Stools  are  slimy  and  contain  no  blood.  No  dyspnoea.  Slight  cough,  with  scanty 
expectoration.  On  right  side  anteriorly  from  clavicle  to  nipple  vocal  resonance  and 
thrill  much  increased.  Percussion  and  breath  sounds  normal.  Below  the  line  of  the 
nipple  absolute  dulness,  and  complete  absence  of  breath  sounds  and  vocal  resonance. 
Posteriorly,  from  the  level  of  a transverse  line  passing  2^  inches  below  the  spine  of 
the  scapula  downwards,  there  exists  complete  dulness  on  percussion,  with  absence  of 
respiratory  murmurs.  Percussion  over  this  area  causes  great  pain.  Above  this  line 
vocal  resonance  is  bronchophonic.  The  left  side  of  chest  is  normal.  No  friction 
sounds  audible  either  before  or  behind.  Heart  healthy.  Pnlse  108,  weak.  Both 
legs  are  slightly  oedernatous  below  the  knee.  Patient  sleeps  badly  at  night,  and  feels 
very  weak.  Urine  normal  in  color;  no  albumen;  density  1015.  Tr.  Catechu  ^j; 
Mistarain,  Cretcead  % vi,  mUce.  A tahlespoonful  thrice  a day. 

Progress  of  the  Case. — Nov.  Sth. — Friction  heard  on  right  side  immediately 
above  the  nipple  ; none  behind.  Copious  deposits  of  urates  in  urine.  U &pt.  jEth. 
Nit.  3 ii ; Sol.  Amm.  Acetatis  § ss  ; Aquarn  ad  § vi,  M.  A lableapoonful  four  times 
a day.  Nov.  9th. — Friction  heard  more  distinctly  at  same  spot.  Otherwise  as  yester- 
day Hot  poultices  to  he  applied  orer  the  affected  side.  Nov.  \{)th. — Distinct  segophony 
heard  on  the  right  side  posteriorly.  Urine  clear  ; pulse  soft.  Nov.  \2th — At  evening 
visit  last  night,  patient  complained  of  excruciating  pain  in  the  right  side.  7b  have 
3 ss  of  chlorodyne.  Slept  well  last  night  and  feels  refreshed  to-day ; pain  in  the 
side  less  severe.  Friction  and  legophony  persist.  Hot  poultices  to  be  cotdinued,  at 
intervals.  Nov.  \Uh. — Slight  friction  heard  over  the  third  right  costal  cartilage. 
Above  this,  increased  vocal  resonance  and  harsh  breathing.  The  pain  is  nearly  as 
great  as  formerly.  A3gophony  still  audible.  Thirst  is  excessive;  tongue  parched 
and  cracked.  Pulse  96,  soft  and  weak.  Diarrhoea  is  now  reduced  to  two  evacuations 
per  diem.  To  have  wine  § iv,  and  nutrients.  Nov.  Vlth. — Diarrhoea  continues. 
Pulse  110,  weak.  Pain  in  upper  part  of  abdomen  and  the  right  side  still  excessive. 
The  poultices  afford  only  slight  relief.  To  resume  his  chalk  and,  catechu  mixture, 
which  he  had  discontinued  for  a day  or  two.  Nov.  %dh. — Slept  better  last  night 
than  for  some  time  past.  No  friction  audible,  and  aegophony  completely  gone. 
Nov.  227. — This  evening  he  coughed  up  about  12  ounces  of  a reddish  grumous 
m itter.  Nov.  ‘‘ISd. — Friction  again  heard  on  the  right  front,  mixed  with  crepitation, 
accompanying  inspiration.  Pulse  106,  soft  and  weak.  Copious  expectoration  of  the 
thick  red  fluid  continues,  which  under  the  microscope  is  composed  of  blood  and  pus 
corpuscles,  with  numerous  molecules  and  granules.  N'ov.  2&th. — O71  riyht  side  of 
ciiest,  both  in  front  and  behind,  there  is  now  comjflete  dulness  and  absence  of  vocal 
resonance  and  thrill.  Bi-eathing  distant  and  tubular.  Pulse  weak.  Tongue  pale, 
moist  and  furrowed.  Nov.  21th. — Pulmonary  signs  as  yesterday.  Tongue  dry. 

Copious  bloody  expectoration  continues.  Delirious  last  night.  Pulse  very  weak. 

* Recorded  by  Mr.  J.  S.  Torrop,  Clinical  Clerk. 


502 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


Nov.  28<A. — A tympanitic  sound  elicited  on  percussion  over  an  area  about  the  breadth 
of  a crown-piece,  immediately  under  the  right  clavicle.  Nov.  29i!/i. — The  tympanitic 
sound  has  extended  lower  down  to  day.  Pulse  exceedingly  weak.  DiariTia^a  has 
ceased,  and  oedema  of  the  legs  disappeared.  Urine  is  slightly  albuminous.  De- 
cember 2d. — Tympanitic  note  audible  over  the  right  front  to  a distance  of  three  indies 
below  the  right  clavicle.  Over  this  area  there  is  heard  distant  tubular  breathing. 
No  moist  sounds  on  left  front  or  back.  Patient  sleeps  very  badly  at  night,  but  has 
now  no  delirium,  diarrhoea  has  returned,  three  stools  daily.  The  right  leg  and  arm 
have  become  partly  oedematous.  Urine  still  slightly  albuminous.  Continues  to 
expectorate  bloody  sputum.  Pulse  almost  imperceptible.  Gradually  sank,  and  died 
on  the  5th  at  4 a.m. 

Sectio  Cadaveris. — Thirty-three  hours  after  death. 

Thorax. — On  opening  the  right  pleural  cavity,  a quantity  of  air  escaped,  and 
bloody  pus  welled  out.  It  contained  about  four  pints  of  fluid.  Above,  the  right  lung 
was  compressed  and  coated  with  lymph.  Below,  it  was  adherent  to  the  diaphragm, 
infiltrated  with  bloody  pus  to  the  extent  of  one-fourth  of  the  lower  lobe,  and  com- 
municated with  the  pleural  cavity  by  a gangrenous  perforation.  Left  lung  slightly 
congested.  The  pericardium  contained  a little  clear  serum.  Heart  healthy. 

Abdomen. — The  liver  was  much  enlarged,  and  adherent  to  the  diaphragm.  In  the 
substance  of  its  right  lobe  was  a cavity  of  about  the  size  of  a large  cocoa-nut,  full  of 
pus  and  blood  and  partially  disintegrated  hepatic  substance.  It  was  traversed  diago- 
nally by  a bridge  of  hepatic  substance,  about  half  an  inch  thick,  broken  down  in  the 
centre,  as  if  the  excavation  had  been  formed  by  the  union  of  Uvo  separate  abscesses. 
It  communicated  with  the  substance  of  the  lung,  and  with  the  pleural  cavity  by  a 
perforation  through  the  diaphragm,  which  readily  admitted  two  fingers.  It  also  com- 
municated with  an  abscess  situated  between  the  liver  and  diaphragm,  and  with  another 
situated  in  the  retro-peritoneal  cellular  tissue  of  the  right  side.  This  abscess  had 
penetrated  as  far  as  the  upper  and  posterior  margin  of  the  kidney,  and  had  caused 
ulceration  in  a small  portion  of  its  cortical  substance  externally.  The  wall  of  the 
hepatic  abscess  was  composed  of  indurated  substance,  three-quarters  of  an  inch  thick, 
and  of  a fawn  color,  passing  gradually  into  tlie  healthy  hepatic  tissue.  No  trace  of 
echinococci  could  be  found.  The  spleen  was  large,  and  weighed  13  ounces;  waxy. 
The  gall  bladder  contained  a large  quantity  of  pale  yellow  bile.  Other  organs  were 
normal. 

Microscopic  Examination. — The  contents  of  the  hepatic  abscess  consisted  of  pus 
and  hepatic  tissue  in  a state  of  fatty  disintegration.  The  thickened  hepatic  wall  con- 
sisted of  molecular  fibres  densely  aggregated  together,  in  which  no  trace  of  cell-struc- 
ture could  be  discovered. 

Commentary . — The  indurated  wall  of  the  hepatic  abscess  in  this  case 
is  sufficient  to  prove  that  it  is  one  of  those  instances  where  the  disease 
had  progressed  slowly  for  some  time,  and  was  very  chronic,  while  the 
history  shows  it  was  not  accompanied  by  any  symptoms.  The  sudden 
commencement  of  severe  abdominal  pain  three  weeks  before  admission, 
accompanied  by  fever,  probably  indicated  bursting  of  the  hepatic  abscess 
into  the  retro-peritoneal  cellular  tissue.  The  communication  with  the 
right  thoracic  cavity  was  probably  made  shortly  before  admission,  ai  d 
continued  to  extend  until  the  22d  of  November,  when  a perforation  into 
the  lung  having  been  effected,  matter  in  considerable  quantity  passed 
through  the  bronchi  and  was  expectorated. 

Abscess  of  tlie  liver  is  a very  rare  disease  in  Edinburgh,  and  the  pre- 
sent case,  in  which  it  burst  first  into  the  retro-peritoneal  cellular  tissue, 
then  into  the  cavity  of  the  pleura,  and  lastly  into  the  lung  and  bronchi, 
exhibits  unusual  features.  One  other  such  case  is  recorded  by  aring. 
For  the  various  modes,  however,  in  which  the  disease  may  terminate, 
with  the  tabular  results  of  the  cases  collected  by  Kouis,  Morchcad, 
Waring,  and  others,  I must  refer  to  the  excellent  translation  of  Frerichs 
on  the  Liver,  by  Dr.  Murchison,  vol.  ii.  I have  never  had  an  oppor- 


DISEASES  OF  THE  LIVER. 


503 


tunity  of  examining  suppurative  inflammation  of  the  liver  in  an  early 
stage,  nor  is  much  known  of  the  histological  changes  which  precede  the 
formation  of  pus  in  that  organ.  Virchow  supposes  that  new  growths  in 
the  liver  originate  in  the  multiplication  of  its  cells,  and  has  supported 
his  theory  by  supposititious  diagrams  (“  Cellular  Pathology,”  p.  65).  It 
is  not,  however,  in  this  way  that  pathological  difficulties  can  be  solved. 
In  a paper  I received  from  Dr.  Macnamara,  extracted  from  the  Indian 
Annals  of  Medicine  (date  not  stated),  he  alludes  to  the  frequency  of 
abscesses  of  the  liver  following  dysentery,  and  says: — “ The  most  pro- 
minent microscopic  change  I have  been  able  to  discover  in  the  dysen- 
teric liver  is  a granular  degeneration  of  the  cells,  attended  in  the  more 
advanced  stage  with  a deposition  of  intercellular  granular  matter.  This 
granular  change  may  be  equally  present  in  livers  in  which  abscesses 
have  formed,  and  in  those  in  which  there  are  no  indications  of  them. 
The  cells  undergoing  this  degeneration  often  look  scaly,  and  their  edges 
are  generally  ragged  and  disintegrated.  Some  cells  look  in  fact  like  a 
mere  aggregation  of  fine  granular  matter  held  together  by  the  cohesion 
of  the  particles,  and  not  at  all  sustained  by  any  cell  wall.  In  other 
cells,  not  so  advanced  in  degeneration,  the  cell  wall  and  the  nucleus 
may  be  detected,  but  the  latter  looking  as  if  choked  by  the  quantity  of 
granular  substance  deposited  about  it.  In  many  cells  the  most  careful 
examination  has  failed  to  show  me  any  nucleus.  I have  on  three  or 
four  occasions,  when  examining  these  disintegrating  cells,  observed  tliat 
they  appeared  set,  I might  almost  say  scattered,  in  a granular  matrix, 
which  has  seemed  in  more  than  one  instance  to  have  a semifibrillated 
structure.  Such  a precipitate  of  albuminous  molecular  matter  both  inter- 
and  intra-cellular  may  arise  from  repeated  attacks  of  slight  congestion  of 
the  liver,  or  from  a long-continued  engorgement  of  the  organ.”  From 
this  account  it  would  appear  that  in  this,  as  in  all  other  inflammations, 
the  essential  primary  change  is  the  exudation  of  a molecular  matter, 
which  is  intercellular,  and  out  of  which,  doubtless,  the  pus  cells  are 
formed,  although  Dr.  Macnamara  does  not  clearly  state  this.  The  three 
forms  of  abscess  in  the  liver,  viz.,  circumscribed,  diffuse,  and  secondary, 
are  admirably  figured  in  the  great  work  of  Cruvelhier. 

In  the  examination  of  dead  bodies,  I have  frequently  seen  in  the 
liver  indurated  masses,  accompanied  by  puckerings  or  cicatrices  of  the 
surface.  Not  unfrequently  they  have  undergone  the  calcareous  trans- 
formation to  a greater  or  less  extent.  They  are  evidence  of  previous 
exudations,  which,  instead  of  proceeding  to  the  formation  of  abscesses, 
have  been  arrested,  the  animal  matter  absorbed,  the  whole  condensed  and 
hardened.  Such  masses  I have  seen  associated  with  simple  or  inflam- 
matory, with  tubercular,  or  with  cancerous  exudations.  (On  Cancerous 
and  Cancroid  Growths,  1848.)  Dittrich  was  the  first  to  regard  them  as 
syphilitic  (1849),  and  several  pathologists  following  him  have  spoken  of 
them  as  syphilitic  deposits.  It  is  of  course  easy  to  associate  a chronic 
lesion  of  this  kind,  with  a disorder  so  widely  diffused  as  syphilis,  for  the 
simple  reason  that  among  the  multitude  of  persons  affected  with  the  lat- 
ter, a considerable  number  after  death  are  certain  to  present  the  former. 
I have  frequently  seen  them,  however,  in  persons  who  never  had  syphilis, 
and  consider  that  all  that  can  be  maintained  correctly  with  regard  to 
them  is,  that  they  are  the  remains  of  chronic  exudations  into  the  organ, 


504 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


which  have  spontaneously  healed.  We  find  similar  morbid  products  in 
the  lungs,  kidneys,  and  lymphatic  glands,  and  not  only  is  there  no 
necessity  for  associating  them  with  a supposed  dyscrasia,  but  manifest 
injury  might  arise.  The  honor  and  feelings  of  relatives,  for  example, 
might  sufter  by  assuming  that  because  a nodule  of  indurated  matter  with 
puckering  was  found  after  death  in  a person’s  liver,  that  therefore  such 
individual,  male  or  female,  must  have  been  previously  suffering  from 
syphilitic  disease.  It  is  erroneous  generalizations  of  this  kind  that  tend 
so  much  to  bring  discredit  on  our  science  in  courts  of  law.  What  mis- 
chief has  arisen  from  the  idea  that  a corpus  luteum  of  a certain  form  or 
appearance,  must  have  been  connected  with  conception,  or  the  delivery 
of  a child.  Would  it  be  maintained  for  a moment,  if,  in  the  body 
of  a virtuous  lady  of  high  rank,  an  indurated  mass  of  exudation,  with 
puckering,  was  found  after  death,  that  this  had  been  caused  by  the 
syphilitic  disease  ? All  such  pathological  generalizations  cannot  be 
received  with  too  much  caution,  especially  when  we  see,  as  in  the  case 
before  us,  to  what  extent  chronic  hepatitis  may  proceed  without  giving 
rise  to  any  symptoms,  while  there  can  be  little  doubt  that  others  are 
arrested  in  an  earlier  stage,  and  thus  give  origin  to  the  nodules  and  cica- 
trices so  frequently  found  in  the  liver  after  death.  Frerichs  regards  waxy 
degeneration  of  the  liver  as  a result  of  syphilis,  with  which,  however, 
it  has  no  more  special  connection  than  any  other  lesion  of  that  organ. 

Case  LXXII.^ — Impaction  of  a Gall-Stone  in  the  Common  liile-Buct — 
Atrophy  of  the  Substance  of  the  Liver — Jaundice  — Death. 

History. — Mary  Duncan,  aet.  86,  married — admitted  November  24,  1851.  She 
has  lived  in  India  for  some  time,  and  returned  only  a few  months  since.  Three  weeks 
ago,  when  recovering  from  a severe  attack  of  lumbago,  she  experienced  great  pain 
in  the  epigastric  and  right  hypochondriac  regions.  This  was  ushered  in  by  rigors 
and  feverishness,  and  lasted  three  or  four  days.  Its  severity  then  diminished ; but 
jaundice  appeared,  and  has  since  become  more  intense. 

Symptoms  on  Admission. — On  admission,  the  whole  integumentary  surface  pre- 
sented a deep  yellow  color.  Pulse  100,  full.  The  tongue  is  dry,  with  a dark  brown 
coat.  There  is  a disagreeable  taste  in  the  mouth,  impairment  of  appetite,  but  no 
nausea  or  sickness.  The  liver  on  percussion  presents  the  normal  duhiess  of  four 
indies  on  the  right  side.  Pressure  in  the  neighborhood  of  the  gall-bladder  elicits 
pain,  and  there  is  permanent  soreness  diffused  over  the  anterior  portion  of  the  liver 
and  epigastric  region.  The  pain  is  not  spasmodic  in  its  character,  nor  more  severe 
at  one  time  than  at  another.  The  bowels  are  generally  costive ; skin  hot  and  dry, 
urine  like  porter,  staining  linen  yellow,  and  becoming  green  and  then  red  on  the 
addition  of  nitric  acid.  The  abdomen  is  enlarged.  She  has  had  a child  previously, 
and  says  she  is  now  six  or  seven  months  pregnant.  The  treatment  consisted  of 
purgatives  {Pil.  Rhei.  comp.) ; leeches  and  fomentations  to  the  tender  spot  over  the 
liver,  and  diuretics  of  acetate  of  potass  and  sp.  ccther.  nit. 

Progress  of  the  Case. — December  M. — The  bowels  have  been  kept  open  by 
purgatives,  and  the  stools  have  been  well  colored  with  bile.  Leeches  have  been 
applied  twice,  and  the  hepatic  pain  has  been  much  relieved.  She  has  also  been 
taking  small  doses  of  tartrate  of  antimony,  and  muriate  of  morphia.  The  skin,  how- 
ever, continues  dry,  and  is  now  more  deeply  tinged  yellow  than  on  her  admission. 
The  urine  also  is  still  loaded  with  bile.  To-day  vomiting  came  on,  and  she  com- 
plains of  great  languor  and  depression.  Diuretics  to  be  continued ; a blister  to  the 
rigltt  hypochondriac  region  ; and  a powder.,  containing  four  grains  of  calomel  and  one- 
third  of  a grain  of  opium..,  to  be  taken  every  hour  for  six  doses.  The  mercury  produced 
no  physiological  action,  although  continued  in  smaller  doses  and  at  longer  intervals 
for  several  days,  assisted  by  mercurial  frictions  over  the  right  hypochondrium. 

* Reported  by  Mr.  J.  L.  Brown,  Clinical  Clerk. 


DISEASES  OF  THE  LIVER. 


505 


Dec.  1 HA— There  was  slight  diarrhoea,  which  was  checked  by  an  aromatic  cretaceous 
mixture.  Mercurials  were  suspended.  On  the  \2,ih  she  was  evidently  worse ; the  skin 
assumed  a greenish  hue;  she  is  very  feeble,  and  passes  her  stools  in  bed ; pulse  120, 
small.  On  the  Ibth  the  skin  assumed  a tawny  color ; the  stools  are  passed  m bed,  are 
green,  of  a dark  color,  and  of  a very  offensive  cadaveric  smell ; great  prostration  of 
strength;  urine  still  loaded  with  bile ; low  dehrium  at  night.  Died  on  the  18^/i. 

Sectio  Cadaveris. — Thirty  hours  after  death. 


Thorax. — Thoracic  organs  healthy. 

Abdomen.— On  opening  the  abdomen,  bands  of  recently-exuded  lymph  ai’e  found 
firmly  uniting  together  the  peritoneal  surfaces  of  the  gall-bladder,  the  anterior 
margin  of  the  liver,  and  a portion  of  the  omentum,  over  an  extent  the  size  of  the 
palm  of  the  hand.  On  separating  these  adhesions,  the  gall-bladder  and  omentum 
were  found  so  firmly  united,  that  an  aperture  was  formed  in  the  former  the  size  of 
a pea,  through  which  a quantity  of  dark-green  bile  escaped.  The  liver  was  of  its 
normal  size,  and  presented  externally  a dark  olive-green  color.  On  cutting  into 
its  substance,  the  gall-ducts  were  everywhere  dilated  and  thickened,  feome  were 
distended  into  elongated  cavities  above  half  an  inch  in  calibre,  and  they  were  all 
filled  with  thick  dark-green  bile.  The  tissue  of  the  liver  throughout  was  unusually 
soft,  readily  breaking  down  under  the  fingers,  and  uniformly  of  the  same  olive-green 
color  as  the  external  surface.  In  the  common  bile-duct,  about  half  an  inch  from 
its  duodenal  extremity,  a hard  light-yellow  gall-stone,  the  size  of  a small  hazel-nut, 
was  firmly  impacted,  the  duct  both  above  and  below  being  somewhat  thickened  and 
dilated.  No  other  gall-stones  could  be  anywhere  discovered.  The  uterus  and  rec- 
tum were  adherent,  and  in  separating  them  about  a teaspoonful  of  yellow  pus 
escaped.  The  vagina  was  shortened  and  constricted  about  two  inches  from  the 
vulva,  so  as  scarcely  to  admit  a common  quill.  About  an  inch  width  in  the  vagina, 
on  its  inferior  wall,  was  a round  aperture,  the  size  of  a shilling-piece,  with  ragged 
edges,  and  communicating  with  the  rectum.  On  the  superior  wall  of  the  vagina, 
about  half  an  inch  from  the  clitoris,  was  another  rounded 
opening,  about  the  size  of  a sixpenny-piece,  into  which  the 
point  of  the  little  finger  could  be  pushed  and  passed  into 
the  bladder.  The  natural  meatus  urinarius  was  occluded. 

Microscopic  Examination. — On  crushing  a small  piece 
of  the  liver  between  glasses,  and  examining  it  under  a 
power  of  250  diameters  linear,  it  was  found  to  consist  of  a 
multitude  of  fatty  molecules  and  granules,  with  larger 
globules  of  loose  oil.  Many  of  the  cells  seemed  to  be 
broken  down  and  disintegrated,  but  such  as  were  entire  were  more  or  less  distended 
with  bile  pigment. — (Eig.  424.) 


y.O;  <t  oC,,-0, 


Fig.  424. 


Commentary . — The  symptoms  present  in  this  case  on  admission — viz., 
the  jaundice,  local  pain,  the  rigors,  and  fever — were  indicative  of  obstruc- 
tion in  the  common  bile-duct  connected  with  some  inflammatory  action 
going  on  in  the  liver  or  its  neighborhood.  Hence  the  topical  applica- 
tion of  leeches,  and  afterwards  warm  fomentations,  were  ordered.  As 
the  blood  and  urine  were  evidently  loaded  with  bile,  diuretics  and  pur- 
gatives were  also  given  to  assist  the  excretion  of  that  product.  These 
remedies  proving  of  no  avail,  and  the  constitutional  symptoms  increasing, 
mercury,  conjoined  with  opium,  was  actively  administered,  but  failed  to 
produce  its  physiological  or  any  useful  therapeutical  result.  After  death, 
peritonitis  surrounding  the  gall-bladder  and  common  duct  was  dis- 
covered ; but  death  evidently  resulted  from  the  poisoning  of  the  system 
through  the  absorption  of  bile,  the  excretion  of  which  was  prevented  by 
the  firm  impaction  of  a calculus  in  the  common  bile-duct.  The  benefit 
of  mercury  in  such  cases,  though  strongly  recommended  as  a means  of 
altering  the  constitution  of  the  bile,  appears  to  me  very  doubtful , for, 


Fig.  424.  Disintegration  of  the  hepatic  structure  following  obstruction  of  the 
biliary  ducts.  260  diam. 


506 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


supposing  it  to  possess  the  effect  ascribed  to  it,  and  to  act  as  an  altera- 
tive and  cholagogue,  its  action  in  obstruction  of  the  gall-ducts  must  be  to 
distend  them  still  further,  and  thus  increase  the  pressure  on  the  hepatic 
cells,  and  consequently  the  disintegration  of  the  hepatic  texture.  Most 
of  the  examining  class  were  in  favor  of  the  trial  of  mercury  in  tliis 
case;  and  considering  how  uniformly  it  has  hitherto  been  recommended 
by  experienced  practitioners,  I did  not  think  it  right  to  deprive  the 
patient  of  any  chance  which  might  arise  from  its  use.  At  the  time,  I 
expressed  my  want  of  confidence  in  its  virtues,  an  opinion  which  the 
progress  of  the  case  fully  justified.  In  the  present  state  of  science  and 
art  of  medicine,  there  is  no  one  point  in  therapeutics  which  so  urgently 
requires  thorough  re-investigation  as  the  real  value  of  the  medical  pro- 
perties attributed  to  mercury.  I have  tried  podophyllin  as  a purgative 
in  many  cases,  and  found  its  action  to  be  very  uncertain,  sometimes 
purging  in  one,  at  others  requiring  seven  grain  doses.  It  seems  to  have 
no  power  whatever  as  a cholagogue. 

In  this  case  there  was  a partial  disintegration  of  the  cell  elements  of 
the  liver,  and  an  accumulation  of  bile  in  such  of  the  cells  as  remained 
perfect.  This  lesion  is  remarkably  well  described  by  Dr.  Budd,  in  the 
third  chapter  of  his  work,  where  he  treats  of  fatal  jaundice.  It  admits  of 
question,  how  far  this  destruction  of  the  hepatic  cells  may  not,  by  impeding 
the  secreting  power  of  the  organ,  at  length  induce  that  condition  described 
by  Dr.  Alison,  where  the  biliary  princqDles  are  not  eliminated.  It  must, 
I think,  be  certain  that  jaundice,  produced  primarily,  as  in  the  present 
instance,  by  a mechanical  obstruction,  must  be  kept  up  by  this  altered 
condition  of  the  cell-structure.  The  same  disintegrated  structure  of  the 
liver,  occurring  either  with  or  without  obstructive  lesion,  constitutes  what 
Frerichs  calls  acute  atrophy  of  the  organ. 

This  case  was  instructive  to  all  who  observed  it,  with  regard  to  a 
supposed  pregnancy  she  labored  under.  The  abdomen  was  certainly 
somewhat  prominent;  but  the  investigation  of  the  existence  of  this  state 
was  never  gone  into,  for  the  simple  reason,  that  it  no  way  afi'ected  the 
diagnosis  or  treatment.  When  the  woman  was  dying,  however,  the  hus- 
band applied  to  me,  with  a view  of  ascertaining  whether  it  might  not  be 
possible  to  save  the  child.  On  this  point  I requested  the  opinion  of  Dr. 
Simpson,  who,  on  examining  the  w^oman,  declared  her  not  to  be  pregnant. 
This  circumstance,  then,  is  an  illustration  of  how  women  who  have  pre- 
viously had  children  may  be  deceived  as  to  the  existence  of  a subsecjuent 
pregnancy,  and  how  important  it  may  be  for  the  practitioner  to  satisfy 
himself  of  the  reality  or  falsity  of  such  a state.  W hen  formerly  delivered 
in  India,  she  said  instruments  were  employed,  and  that  she  sustained 
some  injury.  This  account  is  rendered  highly  probable  by  the  existence 
of  the  recto-vaginal  and  urethro-vaginal  fistulse,  and  the  remarkable 
vaginal  stricture  found  after  death. 

Case  LXXIII.'^' — Jaundice — Compression  of  the  Ductus  Communis  CJiole- 
dochus  from  a Cancerous  Tumor^  composed  of  Epigastric  and  Lumhar 
Glands — Occlusion  of  Cystic  Duct — Enlargement  of  Gall  Bladder — 
Cancer  of  the  Pancreas — Biliary  Congestion  of  the  Liver — Cancerous 
Exudation  into  various  organs — Slight  Leucocgthemia. 

History. — William  Dodds,  a?t.  23,  ploughman — admitted  December  8th,  1854. 

* Deported  by  Mr.  Robert  Rliiiid,  Clinical  Clerk. 


DISEASES  OF  THE  LIVER. 


507 


He  states  that  four  weeks  ago  he  was  seized  with  pain  in  the  lower  part  of  the  ab- 
domen, accompanied  by  unusual  costiveness.  Some  days  afterwards  he  commeneed 
to  vomit  his  food  a few  hours  after  taking  it.  The  vomiting  continued  for  a fort- 
night, and  then  suddenly  ceased.  But  it  returned  about  four  days  ago  as  before,  and 
has  continued  up  to  the  time  of  admisssion. 

Symptoms  on  Admission. — The  tongue  is  loaded  with  a thick  white  coat,  but 
moist.  Appetite  bad.  After  taking  food  he  has  a feeling  of  great  load  and  disten- 
sion in  his  stomach.  No  flatulence,  but  has  frequent  eructations  of  a watery  fluid, 
which  is  neither  acid  nor  of  disagreeable  taste.  Usually  vomits  it  about  four  o’clock 
A.  M.,  and  for  some  time  afterwards  experiences  considerable  relief;  has  constant 
severe  pain  and  considerable  tenderness  over  the  epigastrium.  A tumor  can  be 
felt  towards  the  pyloric  end  of  the  stomach,  of  a rounded  form.  It  measures  two 
and  a half  inches  vertically,  its  upper  and  lower  margins  being  distinctly  tangible. 
Its  lateral  margins,  however,  cannot  be  determined.  The  hepatic  dulness  in  the  right 
hypochoiidrium  was  normal.  All  the  other  functions  are  healthy.  Diet  to  be  care- 
fully regulated. 

Progress  op  the  Case. — December  10th. — Has  been  much  better  since  admission, 
not  having  vomited  till  this  morning  at  five  o’clock.  He  then  brought  up  a large 
quantity  of  brownish  pultaceous  matter,  which,  on  microscopic  observation,  was 
found  to  consist  of  half-digested  muscular  fibres,  starch  and  oil  globules,  and  epithe- 
lial cells.  Has  considerable  pain  and  tenderness  in  the  epigastrium.  Eight  leeches  to 
he  applied.,  followed  by  warm  fomentations.  Dec.  18/A — There  have  been  remissions 
in  the  epigastric  pain,  which,  however,  still  continues.  The  vomiting  also  has  not 
been  permanent,  having  been  suspended  for  two  days  by  eating  ice,  and  again  on  the 
16th,  by  a morphia  draught.  The  constipation  has  been  relieved  by  domestic  ene- 
mata.  It  was  observed  to-day,  for  the  first  time,  that  the  skin  has  a decided  though 
very  slight  yellow  tinge.  Dec.  23c?. — Since  last  report  has  experienced  great  pain  at 
times  in  the  abdomen  generally,  for  which  he  was  ordered  a draught  at  night  with 
Tr.  Cannabis  Ind.  ; 3ss.  Six  more  leeches  leere  also  applied  on  the  20/7i,  but  with- 
out lessening  his  sufferings.  There  has  been  considerable  fever  with  thirst  and  loss 
of  appetite.  Iced  lemonade  for  drink.,  and  warm  fomentations  to  the  abdomen.,  give 
most  relief.  Yesterday  the  jaundice  was  decidedly  more  pronounced,  and  has 
increased  still  more  to-day.  There  has  latterly  been  constant  vomiting,  shortly  after 
taking  food.  He  is  more  emaciated,  and  the  tumor  formerly  alluded  to  can  now  be 
felt  hard  and  nodulated  through  the  integuments.  The  stools  are  of  a clay  color, 
and  the  urine  loaded  with  bile,  so  as  to  resemble  porter.  Pulse  120,  very  weak.  B 
Pd.  Opii  \’j.  One  to  he  taken  immediately^  and  repeated  in  four  hours  if  there  be  no 
alleviation  of  the  pain.  To  have  wine  §iv  daily.,  and  ice  to  dissolve  in  the  mouth. 
Continue  the  warm  fomentations  to  the  abdomen.,  and  to  inject  slowly  3 iv  of  strong 
beef  tea  into  the  rectum.  From  this  time  he  continued  sinking.  The  skin  assumed  a 
greenish  tinge.  On  the  24th  he  vomited  blood,  and  passed  black  tarry  matter  by 
stool.  Brandy  and  stimulants  were  freely  administered,  but  he  died  Dec.  26th. 

Sectio  Cadaveris — Fifty-one  hours  (flcr  death. 

The  body  considerably  emaciated.  The  vvliole  surface  of  all  the  tissues,  includ- 
ing the  cartilages,  were  stained  of  a greenish-yellow  color. 

Thorax. — Both  lungs  were  emphysematous  anteriorly,  especially  the  left.  Pos- 
terioidy  they  were  engorged,  and  on  section  were  oedematous,  with  scattered  nodules 
of  cancerous  matter  in  their  substance,  of  cheesy  consistence,  but  occasionally  very 
soft,  and  varying  in  size  from  a pepper-corn  to  that  of  a small  hazel-nut.  A con- 
tinuous layer  of  cancerous  matter  also  hero  and  there  surrounded  the  bronchial 
tubes.  From  the  universal  predominance  of  bile-pigment,  these  cancerous  masses 
closely  resembled  to  the  eye  tubercular  matter.  Immediately  under  the  upper  part 
of  the  sternum,  and  over  the  ascending  aorta,  was  a mass  of  lymphatic  glands,  about 
three  inches  long  and  two  inches  thick,  of  a fleshy  color  and  pulpy  consistence, 
easily  breaking  down  under  the  finger,  and  infiltrated  here  and  there  with  a yellowish- 
white  cheesy  deposit,  exactly  resembling  tubercle.  The  bronchial  glands  at  the  root 
of  the  lungs  were  greatly  enlarged,  and  presented  a similar  appearance.  Tire  heart 
was  healthy.  The  ventricles  contained  semi-coagulated  blood,  the  veins  black  fluid 
blood. 

Abdomen. — In  the  cavity  of  the  peritoneum  there  was  about  8 oz.  of  dark- 
brown  clear  scrum.  The  liver  weighed  3 lb.  12  oz.,  was  of  a light  olive-green  color, 
approaching  to  brown,  soft  in  texture,  and  on  section  vras  seen  to  contain  a few 


508 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


whitish-yellow  masses,  varying  in  size  from  a millet-seed  to  that  of  a small  pea,  of 
tolerably  firm  consistence,  'i'he  gall-bladder  projected  about  an  inch  and  a half 
below  the  lower  margin  of  the  liver.  It  was  considerably  enlarged,  and  was  distended 
with  thick  black  bile.  The  cystic  duct  was  completely  closed  a little  above  its  junc- 
tion with  the  hepatic,  which  was  quite  free.  The  calibre  of  the  common  duct  was 
much  diminished ; and  although  a probe  could  be  pushed  through  it,  it  was  evidently 
compressed  by  the  tumor  to  be  described  immediately.  The  spleen  weighed  5 oz., 
and  was  healthy,  with  the  exception  of  a cancerous  mass  in  its  centre,  about  the  size 
of  a coffee-bean,  similar  to  those  in  the  lung.  Surrounding  the  pyloric  end  of  the 
stomach,  and  projecting  from  below  the  liver  towards  the  left  side,  was  an  agglome- 
rated, indurated,  and  nodulated  mass  of  enlarged  and  caneerous  lymphatic  glands,  of 
the  size  and  form  of  a cocoa-nut.  This  was  the  tumor  which,  during  the  life  of  the 
individual,  was  felt  in  the  epigastrium.  It  pressed  upon  and  completely  oecluded 
the  ductus  communis  choledochus.  The  aorta  passed  through  the  left  third  of  this 
m.ass,  and  was  so  compressed  as  scarcely  to  admit  the  little  finger.  On  section,  this 
mass  presented  very  much  the  appearance  of  some  speeimens  of  pudding  stone,  con- 
sisting of  rounded  or  oval  yellowish-white  masses,  varying  in  diameter  from  to  1^ 
inches,  and  united  together  by  highly  congested  areolar  tissue,  of  a deep  purple 
color,  with  here  and  there  extravasations  of  blood  in  its  substance.  The  affected 
glands  were  friable  and  easily  crushed  between  the  fingers,  but  yielded  no  juice  on 
pressure.  The  mesenteric,  mesocolic,  and  lumbar  glands  generally,  were  similarly 
diseased.  The  right  extremity  of  the  pancreas  was  converted  into  a firm  mass  by 
cancerous  exudation,  and  closely  connected  to  the  tumor  just  described,  of  which  it 
formed  an  integral  part.  On  opening  the  stomach,  it  was  seen  to  contain  a quantity 
of  tenacious,  brown,  glairy  mucus,  closely  coherent  to  the  mueous  membrane.  Its 
walls  at  the  pylorus  were  found  thickened  ; and  from  this  point  the  thickening  gra- 
dually diminished,  until  it  ceased  at  a eonvex  margin,  somewhat  irregulrrly  nodulated, 
and  elevated  above  the  rest  of  the  mucous  surface.  The  diseased  portion  occupied 
about  one-third  of  the  area  of  the  oi’gan.  The  mucous  surface  covering  it  was  of  a 
dirty-white  color,  and  was  ulcerated  at  one  point  with  softened  ragged  edges  over  a 
space  the  size  of  a shilling-piece.  Tlie  healthy  two-thirds  of  the  mucous  surface  was 
of  bright  rose-pink  color,  from  vascular  congestion.  The  cut  edge  of  the  pylorus 
was  a quarter  of  an  inch  thick,  dependent  on  hypertrophy  of  the  muscular  coat  to  the 
extent  of  one-sixth  of  an  inch,  and  of  an  infiltration  of  firm  whitish  exudation,  in  the 
submucous  areolar  tissue.  The  intestines,  kidneys,  and  other  organs,  were  healthy. 

Miciioscopic  Examination. — The  whitish-yellow  masses  in  the  lungs  were  prin- 
cipally composed  of  molecular  matter,  but  with  numerous  delicate  nucleated  cells 
apparently  forming.  In  the  bronchial  glands,  the  whitish-yellow  matter  was  com- 
posed of  a few  cancer  cells  only,  evidently  in  a state  of  disintegration,  associated  with 
multitudes  of  fatty  molecules  and  granules.  The  fluid  squeezed  from  the  fleshy  and 
pulpy  matter  from  the  same  glands,  contained,  1st,  numerous  round  and  oval  nueleated 
cells,  about  one-thousandth  of  an  inch  in  diameter  ; 2d,  many  granule  cells  of  varying 
size ; 3d,  multitudes  of  gland  nuclei ; 4th,  blood  corpuscles ; 6th,  a large  quantity  of 
molecular  matter.  » The  pulp  of  the  epigastric  glands  contained,  1st,  large  cancer  cells, 
some  containing  three  included  cells;  2d  a very  few  gianule  cells;  3d,  numerous 
molecules.  The  blood  contained  a decided  increase  of  colorless  corpuscles.  The 
cells  of  the  liver  contained  a quantity  of  biliary  matter,  giving  them,  under  the  micro- 
scope, a bright  yellow  color. 

Commentary . — The  nature  of  this  case  was  tolerably  evident  from 
the  first;  the  epigastric  tumor,  pain,  and  vomiting  after  taking  food, 
indicated  obstruction  of  the  pylorus  produced  by  a cancerous  growth. 
Later,  when  jaundice  appeared,  it  became  clear  that  the  common  duct 
tvas  obstructed.  Treatment  could,  of  course,  only  be  palliative.  On 
dissection,  it  was  singular  to  observe  the  resemblance  which  the  can- 
cerous masses  in  the  lungs  and  in  the  glands  bore  to  tubercle.  Some 
pensons  who  were  present,  indeed,  judging  from  the  youth  of  the  patient, 
their  friable  consistence  and  yellow  color,  maintained  that  the  glands 
were  scrofulous,  and  it  would  have  been  difficult  to  undeceive  them 
without  the  assistance  of  the  microscope.  All  the  tissues  were  tinged 
of  a deep  yellow,  and  the  hepatic  cells  were  gorged  with  bile,  so  that  the 


DISEASES  OP  THE  LIVEK. 


5oa 

absorptioD  of  this  excretion  into  the  blood  must  have  been  very  great. 
The  insensible  manner  in  which  so  much  cancerous  matter  developed 
itself  is  worthy  of  observation,  as  it  was  oidy  four  weeks  before  admis- 
sion that  he  experienced  any  inconvenience.  Then  came  on  the  effects 
of  obstruction — first,  of  the  pylorus,  and,  secondly,  of  the  common  duct — 
from  the  combined  effects  of  which  he  died. 

Case  LXXIV.^ — Jaundice — Cancerous  Tumor  of  the  Pancreas^  com- 
prising the  Ductus  Communis  Choledochus — Dilatation  of  the  Gall- 
bladder^ and  passage  of  Gall-stones  into  the  Gall-bladder — Cancer 
of  the  Liver  and  Kidneys, 

History. — John  M‘Donald,  set.  50,  tailor — admitted  November  29,  1853.  Four 
weeks  ago  he  was  seized  with  a gnawing  pain  in  the  epigastrium.  On  the  13th  he 
was  over-worked,  and  went  home  much  exhausted.  On  the  following  day,  there  was 
drowsiness,  loss  of  appetite,  and  anorexia.  On  the  2'7th,  the  skin  was  slightly  tinged 
yellow.  lie  applied  at  one  of  the  dispensaries,  and  was  then  suffering  from  intense 
grinding  pain  in  the  right  hypochondrium.  One  of  the  clinical  students  who  saw  him 
there  advised  him  to  come  into  the  Infirmary. 

Symptoms  on  Admission. — He  has  no  pain,  no  difficulty  in  taking  food,  though 
it  excites  nausea.  Tongue  slightly  furred ; moist.  No  appetite.  Considerable  thirst. 
Vertical  dulness  of  liver  is  3f  inches.  No  abdominal  tenderness.  No  tumor  to  be 
felt  in  epigastrium.  Bowels  constipated.  Stools  of  a dark  green  color ; but  he  says 
they  were  white  when  the  attack  came  on.  Urine  is  of  a dark  brown  color,  like 
weak  porter,  from  the  presence  of  bile  ; unaffected  by  heat.  Pulse  60,  regular.  Skin 
of  a deep  yellow  color.  Other  organs  and  functions  normal.  B Pd-  Hydrarg.  ; 
Pit.  Rhei  Co.  aa  3 ss.  M.  et  divide  in  pit.  xii.  Two  to  he  taken  every  night. 

Progress  op  the  Case. — December  Sd. — The  stools  are  now  of  a lead  color.  To 
have  gr.  v.  of  Pit.  Hydrarg..^  and  of  Ext.  Taraxaci  every  night.  Dec.  10^/i. — Com- 
plains of  acute  grinding  pain  in  the  region  of  the  liver.  Bowels  have  not  been  open 
for  some  days.  Skin  of  a deeper  yellow.  To  have  gr.  v,  of  Pit.  Rhei  Co.  in  addition 
to  the  others.  Dec.  1 Wi. — Had  an  assafoetida  enema  yesterday.  The  bowels  have 
been  well  opened ; pain  much  relieved.  Stools  still  of  a lead  color.  Omitiant.  Pit. 
B Pil.  Rhei  Co.  3 j ; Calomel.  3j  ; Olei  Cinnamomi  guttas  iv.  M.  et  divide  in  pil. 
xij.  Two  to  be  taken  every  night.  Dec.  14^A. — Is  now  free  from  pain,  but  feels  very 
weak.  Stools  of  a dark  green  color.  Otherwise  the  same.  Cannot  take  food.  B 
Liq.  Potassce  3 ij  ; Sp-  EPther.  Nit.  | ss ; Infus.  Gentian.  Co.,  § v.  M.  Two  table- 
spoonsful  to  be  taken  three  times  a day.  Dec.  Vlth. — Much  weaker.  Takes  no  nourish- 
ment. Skin  of  a dark  green  tint.  Tongue  dry,  and  covered  with  a dark  brown 
crust.  Bowels  open.  Stools  of  a dark  leaden  tint.  Pulse  120,  very  weak.  To  have 
§ vj  of  wine.  Dec.  19th. — Whisky  has  been  liberally  administered ; but  he  continued 
to  sink,  and  died  at  two  o’clock  a.m. 

Sectio  Cadaveris. — Thirty-four  hours  after  death. 

Extreme  jaundiced  appearance  of  the  whole  body,  and  yellowness  of  all  the  tissues. 

Thorax. — With  the  exception  of  slight  emphysema  of  the  lungs,  all  the  thoracic 
organs  were  healthy. 

Abdomen. — On  opening  the  duodenum,  there  was  seen  at  the  point  where  the  com- 
mon duct  enters  it,  a tumor  bulging  inwards,  and  compressing  the  duct.  The  growth 
was  the  size  of  a walnut,  and  presented  all  the  characters  of  scirrhus.  It  was  formed 
in  the  right  extremity  of  the  pancreas ; and  the  rest  of  the  organ  was  indurated,  and 
contained  several  small  cysts  filled  with  a gelatinous  fluid.  The  portion  of  the  com- 
mon duct  which  passed  through  the  tumor  was  an  inch  and  a half  long,  and  barely 
admitted  a small  probe.  Behind  the  constriction,  the  common,  cystic,  and  hepatic 
ducts  were  greatly  enlarged,  the  common  duct  having  a calibre  nearly  equal  to  the 
size  of  the  thumb.  The  gall-bladder  was  much  enlarged,  and  distended  with  dark- 
colored  bile.  It  contained  two  small  gall-stones  of  bile  pigment,  but  none  could  be 
found  in  the  ducts.  The  liver  weighed  3 lbs.  9 oz.,  was  of  a green  color,  with  the 
centres  of  the  lobules  congested.  The  bile-ducts  were  everywhere  dilated  throughout 
its  substance.  Scattered  throughout  the  liver  were  white  cancerous  masses  varying 

* Reported  by  Mr.  Almeric  Seymour,  Clinical  Clerk. 


510 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


in  size  from  a pea  to  that  of  a hazel-nut.  Similar  small  cancerous  masses  existed  in 
the  cortical  substance  of  the  kidneys.  On  opening  the  intestines,  a considerable 
quantity  of  black  blood  was  found  mingled  with  the  faeculent  matter,  botli  in  the 
small  aud  large  intestines.  Other  organs  healthy. 

Microscopic  Examination. — The  cancerous  masses  in  the  pancreas,  and  liver, 
and  kidneys,  contained  numerous  characteristic  cells.  The  hepatic  cells  were  loaded 
with  yellow  bile,  which  became  of  a cherry-red  color  on  the  application  of  Petten- 
kofer’s  test.  They  contained  no  fat. 

Commentary. — It  appeared,  from  careful  examination  of  this  man’s 
case,  that  he  had  suffered  from  two  attacks  of  grinding  pain  in  the  right 
hypochondrium,  such  as  are  commonly  felt  during  the  passage  of  gall- 
stones. After  death,  two  biliary  calculi  were  found  in  the  gall- bladder, 
having  all  the  appearance  of  those  which  are  usually  formed  in  the  liver. 
It  is  almost  certain,  therefore,  that  the  painful  attacks  were  coincident 
with  the  passage  of  these  calculi  from  the  liver  to  the  gall-bladder,  as 
their  escape  into  the  intestines  was  prevented  by  the  constriction  of  the 
common  duct,  by  the  cancerous  mass  in  the  pancreas. 

Since  the  researches  of  Bernard  as  to  the  functions  of  the  pancreas 
were  made  known,  I have  carefully  sought,  in  a great  number  of  cases, 
for  the  passage  of  fatty  matter  in  the  alvine  evacuations,  but  in  vain.  In 
several  instances  of  jaundice,  such  as  the  present,  I have  found  the  head 
of  the  pancreas  diseased;  but  in  none  of  them  did  the  stools  present  the 
characters  described  in  the  cases  of  Bright,  Lloyd,  Elliotson,  and  others. 
It  is  true  that  in  this  case  the  common  duct  was  not  absolutely  obliterat- 
ed, but  it  appeared  to  me  that  the  pancreatic  duct  was  so  involved  in  the 
tumor,  that  its  fluid  secretion  was  incapable  of  passing.  But  as  no 
special  anatomical  investigation  was  made  in  reference  to  this  point,  we 
are  not  entitled  to  suppose  that  the  supply  of  pancreatic  juice  was  entire- 
ly cut  OS'.  In  other  cases,  however,  where  the  common  duct  has  been  ob- 
structed (Case  LXXII.),  or  where,  from  disease  of  the  head  of  the  pancreas, 
the  pancreatic  duct  hasbeen  obliterated  (Cases  LXIY.  and  LXXIII), there 
has  been  no  proof  whatever  that  the  fatty  elements  of  the  food  have  not 
been  emulsionized.  Such  facts  indicate  that  the  function  attributed  by 
Bernard  to  the  pancreas  must  also  be  performed,  under  certain  circum- 
stances by  the  alimentary  canal  alone,  independent  of  that  organ. 

Case  LXXV.'^' — Enlargement  of  the  Liver — Ascites — Albuminuria — 

Recovery. 

History. — David  Harper,  set.  30,  painter — admitted  into  the  clinical  ward  Febru- 
ary 18th,  1852.  Four  months  ago,  was  seized  with  diarrhoea  and  vomiting,  which 
have  continued  more  or  less  ever  since.  The  liver  was  first  observed  to  be  enlarged 
in  the  beginning  of  December  last,  and  it  has  gradually  increased  in  size  up  to  the 
present  time.  He  has  taken  numerous  remedies  to  check  the  diarrhoea  and  vomiting, 
but  with  little  effect. 

Symptoms  on  Admission. — On  admission,  the  liver  is  found  to  extend  from  one 
inch  below  the  right  nipple  above  to  within  an  inch  and  a half  of  the  anterior  supe- 
rior spine  of  the  ilium  below — a depth  of  nine  inches.  From  this  point  its  margin 
could  be  felt  ascending  obliquely  upwards  to  the  most  depending  portion  of  the  ninth 
rib  on  the  left  side,  crossing  about  an  inch  above  the  umbilicus.  There  is  distinct 
fluctuation  to  be  felt  throughout  the  rest  of  the  abdomen,  indicating  ascites.  In  the 
right  lumbar  region  the  enlarged  liver  is  tender  on  pressure.  The  abdomen  measures 
42p  inches  in  circumference  at  its  widest  part.  Spleen  of  normal  size.  Tongue 
moist,  slightly  loaded.  There  has  been  no  vomiting  for  some  days,  but  the  diarrhoea 
is  very  severe.  Says  he  has  frequently  passed  blood  by  stool.  Skin  not  jaundiced, 

* Reported  by  Mr.  J.  A.  Douglas,  Clinical  Clerk. 


DISEASES  OF  THE  LIVED, 


511 


but  rather  dry.  Respiratory,  circulatory,  and  other  systems  normal.  R Pil.  Plumb, 
et  Op  'll  xij.  Sumat  unarn  ter  indies. 

Progress  op  the  Case. — March  4th. — Has  had  occasionally  vomiting  and  diar- 
rhoea since  last  report,  for  which  he  has  been  taking  at  times  the  naphrha  mixture, 
morphia  draughts,  and  gallic  acid.  To-day  the  urine  is  somewhat  scanty,  and 
slightly  coagulable  on  the  addition  of  heat  and  nitric  acid ; spec.  grav.  1024.  1^ 

Acetatis  Potassce  3j;  Sp.  AEth.  Nit.  3 ij  ; Syr.  Aurantii  ?j;  Aquce  3 v.  M.  Sumat 

ter  indies.  March  \ Wi. — To-day  the  urine  was  ascertained  with  the  microscope 
to  contain  numerous  casts  of  the  tubes  and  isolated  epithelial  cells  loaded  with  fatty 
granules.  The  vomiting  and  diarrhoea  continue.  Haheat  snppositorinm  opiatum 
octavd  qudque  hard.  April  Q>th. — The  diarrhoea  was  for  a few  days  somewhat  checked 
by  the  suppositories,  but  gradually  returned,  and  is  now  very  severe ; the  bowels 
having  been  opened  twelve  times  yesterday.  The  urine  has  continued  albuminous, 
and  loaded  with  desquamative  casts  and  fatty  tubes.  To-day  its  spec.  grav.  is  1007. 
There  is  now  great  debility,  and  occasional  stupor  and  drowsiness.  May  l"lth. — The 
drowsiness  has  disappeared.  For  the  last  few  days  has  been  taking  3 j of  the  potass, 
bitart,  with  the  mixture  of  acetate  of  potash  and  nitric  ether,  and  he  now  passes  a 
larger  amount  of  urine,  which  is  free  of  tubular  casts.  The  abdomen  is  less  tense. 
About  the  middle  of  May  the  vomiting  and  diarrhoea  first  abated,  and  was  soon  after 
checked.  In  August  his  health  was  so  much  improved  that  he  was  allowed  to  go 
out  of  the  house  for  the  benefit  of  air  and  exercise.  He  was  readmitted  Septeniher 
1 S/'/i,  having  enjoyed  tolerable  health  in  the  interval,  although  the  hepatic  swelling 
is  about  the  same  size.  He  was  now  ordered,  R Hydrary.  Proto-iodidi,  gr.  vj  ; Pulv. 
Opii  gr.  ij  ; Ext.  Taraxaci  3 ss ; Conserv.  Rosarum  ^y.  v.  Fiant  pil.  xx.  Sumat 
unam  ter  indies.  These  pills  on  the  %)th  produced  salivation,  when  they  were  dis- 
continued, and  an  astringent  gargle  was  ordered.  The  abdomen  now  measures  thirty 
six  inches  in  its  broadest  circumference.  Oct.  iWi. — Complains  of  oppression  on 
walking,  of  shooting  pains  through  the  chest  and  abdomen.  Ascites  seems  once 
more  to  be  increasing.  Tr.  lod'inei  to  he  painted  over  the  abdominal  surface.  Nov. 
'2\st. — Since  last  report  the  liver  has  greatly  diminished  in  size,  and  his  complaints 
have  ceased.  The  urine  presents  a slight  hazy  albuminous  appearance  on  the  addi- 
tion of  heat  and  nitric  acid,  but  is  voided  in  natural  quantity.  Dec.  IZth. — The  liver 
is  now  so  reduced  in  size  that  its  lower  margin  is  only  two  inches  below  the  false  ribs 
in  front,  and  one  inch  on  the  right  side.  All  his  functions  are  apparently  healthy, 
the  urine  healthy,  and  his  strength  appears  perfectly  re-established.  Dismissed. 

Commentary. — The  enlargement  of  the  liver  which  existed  in  this 
man  was  probably  simple  hypertrophy,  which,  by  pressing  upon  the 
large  abdominal  veins,  caused  ascites.  It  is  worthy  of  remark,  that  it 
underwent  a sensible  diminution  after  the  local  application  of  Tr.  of 
Iodine,  having  resisted  mercurial  action  and  various  other  remedies. 
The  occurrence  of  Bright’s  disease,  and  the  presence  of  numerous  desqua- 
mative casts  of  the  tubuli  uriniferi,  more  or  less  loaded  with  fat,  and  of 
albumen  in,  with  diminished  density  of,  the  urine,  were  considered  for- 
midable complications.  But  here,  also,  under  the  use  of  strong  diuretics, 
the  renal  symptoms  subsided,  the  casts  disappeared,  and  the  urine  be- 
came perfectly  healthy.  He  has  since  been  seen  by  the  clerks  walking 
about  the  town,  and  informed  them  that  he  is  quite  well,  and  carries  on 
his  occupation  without  any  inconvenience. 

Case  LXXVI."^ — Fatty  Enlargement  of  the  Liver. 

History. — James  Grant,  set.  29,  l)lacksmith — admitted  October  14th,  1851.  His 
occupation  consists  of  watching  an  ap])aratus  worked  by  steam,  in  a room  of  elevated 
temperature;  ho  has  no  heavy  labor,  though  constantly  standing  on  his  feet;  he 
drinks  whisky  to  a large  amount.  Since  September  1849,  he  has  been  three  times  in 
the  house  for  various  periods,  from  which  he  has  been  as  often  dismissed  relieved. 
The  liver  began  to  enlarge  two  years  ago,  and  has  been  very  slowly  increasing  ever 
since. 

Symptoms  on  Admission. — On  admission,  he  labors  under  slight  diarrhoea,  hav- 
* Reported  by  Mr.  W.  M.  Calder,  Clinical  Clerk. 


512 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


ing  had  two  or  three  stools  daily  for  several  weeks  past.  He  has,  moreover,  a dull 
heavy  pain  in  the  abdomen,  extending  to  the  lumbar  region.  The  belly  is  evidently 
enlarged  at  its  upper  part,  w^here  a firm  tumor  exists,  forming  a protuberance  in  the 
epigastric  region.  The  girth  of  the  abdomen  at  this  place  during  expiration  is  34 
inches.  The  hepatic  dulness  extends  from  two  inches  below  the  right  nipple  down  to 
a transverse  lirie  drawn  one  inch  above  the  superior  spine  of  the  ilium.  The  whole  of 
the  right  and  part  of  the  left  hypochondriac  regions  are  dull  on  percussion.  The  tym- 
panitic sound  of  the  stomach  is  audible  in  front,  the  organ  being  evidently  pushed 
forward  by  the  enlarged  liver  behind  it.  The  whole  surface  of  the  tumor  feels 
smooth,  and  presents  no  tenderness.  The  splenic  dulness  m.easures  6^  inches  verti- 
cally ; skin  dry : no  oedema  of  the  legs ; general  appearance  pale  and  cachectic ; occa- 
sionally he  has  frequent  desire  to  micturate,  but  the  urine  has  always  presented  its 
normal  characters ; considerable  breathlessness  on  exertion,  but  the  lungs  and  heart, 
on  examination,  were  apparently  quite  healthy ; other  functions  well  performed.  He 
was  ordered  a mixture  containing  the  Iodide  of  Foiassivm^  six  grains  of  which  were 
to  be  taken  three  times  a day.  Frictions  with  the  Unguent,  lodinei  were  also  to  be 
employed  daily. 

Progress  of  the  Case. — Tov/ards  the  end  of  October,  the  bowels  became  regular, 
and  his  general  health  was  somewhat  improved.  Frequent  micturition,  with  discharge 
of  pus  in  the  urine  now  came  on,  which  subsided  in  a few  days.  From  this  time, 
although  the  size  of  the  liver  underwent  no  diminution,  his  bodily  strength  gradually 
improved.  He  occasionally  had  slight  return  of  looseness  in  the  bowels,  wdiich  w^as 
checked  by  appropriate  remedies.  The  difficulty  of  breathing  after  exertion  also 
slowly  left  him ; and  he  was  dismissed  greatly  relieved,  January  26th,  1852. 

Commentary. — Fatty  liver  was  first  sliown  by  Mr.  Bowman  to  depend 

on  the  secretion  of  a large  quantity  of 
oil,  which  is  stored  up  in  the  hepatic 
cells.  These  cells  are,  under  such  cir- 
cumstances, frequently  enlaiged,  and 
contain  oil  varying  in  amount  from  a 
few  granules  to  a large  mass,  which 
occupies  the  whole  of  their  cavities. 
Not  unfrequently  livers,  which  to  the 
naked  eye  appear  healthy  enough, 
may  still  be  demonstrated  under  the 
microscope  to  contain  an  unusual  num- 
ber of  fat  granules,  and  there  can  be  little  doubt  that  considerable  varia- 
tions may  "exist  in  this  respect  quite  compatible  with  a state  of  health. 
Almost  all  stall-fed  animals  that  do  not  labor,  possess  a large  amount  of 
fiit  in  their  hepatic  cells.  It  is  only  \^here  the  organ  is  much  enlarged, 
altered  in  color,  and  pressing  upon  neighboring  viscera,  that  its  fatty 
degeneration  can  be  said  to  interfere  with  the  vital  processes. 

Fatty  degeneration  of  the  liver  has  been  observed  to  be  very  common 
in  drunkards  who  are  continually  taking  alcoholic  liquids.  Of  13  indi- 
viduals who  died  from  Delirium  Tremens,  6 had  very  fatty  liver,  in  3 
the  organ  contained  little,  in  2 none  at  all,  and  in  2 there  was  cirrhosis 
(Frerichs).  In  such  cases  the  quantity  of  carbon  taken  in  the  torm  of 
spirits  being  too  great  in  amount  to  be  excreted  from  the  lungs  as  car- 
bonic acid,  and  from  the  liver  as  bile,  is  stored  up  in  the  liver  as  fat. 
In  tropical  climates,  the  same  pathological  condition  comes  on  under  dif- 
ferent circumstances.  A high  temperature,  and  a rarefied  atmosphci  e, 
indispose  persons  to  take  bodily  exercise;  and  Europeans,  instead  of 

Fig.  425.  Hepatic  cells  in  various  stages  of  fatty  degeneration.  On  the  right  of 
the  figure,  yellow  granular  pigment  is  also  contained  in  the  cells,  which  were  taken 
from  a cirrhosed  liver.  250  diam. 


Fig.  425. 


DISEASES  OF  THE  LIVEF.. 


513 


living  according  to  the  simple  manner  of  the  natives,  too  often  continue  to 
consume  the  food  habitual  to  them  in  their  native  country.  But  the  ex- 
cretory power  of  the  lungs  being,  at  the  same  time,  diminished,  the  excess 
of  carbon  in  the  tissues  and  food  is  thrown  upon  the  liver,  and  there  con- 
verted into  fat.  Dr.  Macnamara  * found  that,  among  the  first  regiment 
of  European  Bengal  Fusileers,  during  seven  years,  the  mortality  among 
the  officers  was  11  per  cent,  and  among  the  men  80  per  cent,  so  that  the 
whole  of  the  fighting  men  of  the  regiment  were  changed  about  once  in 
every  ten  years.  From  the  circumstance  that  the  great  majority  of  these 
men  were  young,  healthy,  and  vigorous,  when  tliey  left  home,  and  other 
circumstances,  he  attributes  the  deaths  to  high  feeding,  indulgence  in 
spirits,  and  to  slothful  habits,  causing  fatty  degeneration  of  the  textures. 

The  maimer  in  which  the  livers  of  geese  are  made  fatty  at  Strasburg 
is  as  follows : — The  geese  are  confined  in  close  cages,  in  a heated  atmo- 
sphere, and  largely  supplied  with  food.  Want  of  exercise  and  heat  dimi- 
nish the  respiratory  functions,  and  cause  that  of  the  liver  to  be  disorder- 
ed; and  the  result  is  enlargement  of  the  organ  from  accumulation  of  fat. 
In  the  case  before  us,  the  cause  of  the  disease  seems  to  have  been  exactly 
the  same.  A man  is  kept  stationary  watching  a steam-engine,  in  an  ele- 
vated temperature,  consuming  his  usual  food,  and  indulging  in  alcoholic 
drinks.  Fatty  liver  is  also  common  in  phthisis  pulmonalis.  Here  the 
excreting  function  of  the  lung  is  more  or  less  interfered  with,  and  the  car- 
bonaceous matters,  not  separated  as  usual  by  this  channel,  are  stored  up 
in  the  liver  in  the  form  of  fat.  The  hepatic  disease  is  especially  observed 
in  those  consumptive  patients  who,  while  they  are  capable  of  assimilating 
a certain  amount  of  food,  are  prevented  by  languor,  breathlessness,  or 
other  causes,  from  taking  exercise.  According  to  Frerichs,  of  117  cases 
of  pulmonary  tuberculosis,  examined  after  death,  there  were  17  which  pre- 
sented fatty  liver  in  the  highest  degree,  whilst  there  were  62  others  with 
the  hepatic  cells  loaded  with  oil-globules.  On  the  contrary,  in  other  dis- 
eases of  the  pulmonary  organs,  ho  found  fatty  liver  to  occur  very  seldom. 

This  view  of  the  pathology  of  fatty  liver  has  been  objected  to  on  the 
following  grounds : — 1st,  That  the  connection  between  fatty  liver  and 
disease  of  the  lungs  is  not  general;  2d,  That  there  is  no  evidence  that  a 
fatty  liver  does  not  excrete  bile  as  usual ; and  3d,  That  as  a considerable 
portion  of  bile  is  absorbed  into  the  blood  to  be  excreted  from  the  lungs, 
the  liver  must  be  considered  as  preparing  material  for  tliese  organs. 
Hence  it  is  argued,  that  it  would  be  a strange  compensation  if  the  func- 
tions of  the  liver  were  to  be  increased,  while  that  of  the  lung  is  dimin- 
ished by  disease  (Biidd).  But  if  fatty  liver  be  not  always  conjoined 
with  diseased  lung,  it  will  be  found  associated  with  some  circumstance 
which  diminishes  the  function  of  that  organ,  in  relation  to  the  work  it  is 
called  upon  to  perform ; for  instance  the  diminished  exercise  and  great 
heat  of  tropical  climates.  Further,  although  it  be  granted  that  the  liver 
may  in  health  prepare  carbonaceous  matters  for  pulmonary  excretion,  it 
must  be  clear,  that  if  the  lungs  cannot  accomplish  this  function,  such 
matters  must  be  thrown  back  or  retained  in  the  liver,  and  constitute  a 
powerful  cause  of  fatty  degeneration  of  that  organ.  On  the  whole,  there- 
fore, we  must  regard  excess  of  carbonaceous  matters  in  the  system,  and 
the  diminution  of  pulmonary  action,  as  the  chief  causes  of  fatty  degencra- 
33  * Indian  Annals  of  Medical  Science,  1855,  p.  170. 


514 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


tion  of  the  liver ; a view  which  has  the  merit  of  pointing  out  to  us  as 
remedies  a diminished  diet,  a temperate  climate,  appropriate  exercise,  and 
an  endeavor  to  promote  the  functions  of  the  lungs  and  of  the  skin. 

There  is  another  structural  alteration  of  the  liver,  whicli,  from  its 
color  and  general  resemblance  to  bees’-wax,  has  been  called  “ waxy,” 
and  sometimes  “brawny  ” liver.  This  disease  has  been  confounded  with 
fatty  liver,  but  an  examination  of  their  minute  structure  shows  that  the 
hepatic  cells  present  a very  different  character  in  this  condition.  Instead 
of  being  enlarged  and  filled  more  or  less  with  oil-globules,  they  arc 
colorless,  shrunken,  and  for  the  most  part  destitute  of  contents,  and  the 
nucleus  disappears.  (See  Fig.  319.)  I have  previously  described  this 
lesion  as  one  of  the  forms  of  albuminous  degeneration.  (See  p.  249.) 
Its  clinical  history  will  be  given  under  the  head  of  Phthisis.  (See  case 
of  Margaret  Clark.) 

Case  LXXVII.'^ — Cirrhosis  with  Atrophy  of  the  Liver— Ascites. 

History. — John  Harper,  aet.  28,  farmer,  from  Caithness — admitted  June  24th, 
1852.  Six  years  ago,  after  recovering  from  measles,  his  health  was  greatly  deranged. 
He  was  weak,  and  perspired  profusely  at  night,  or  when  performing  any  unusual  exer- 
tion, A short  time  afterwards,  he  was  exposed  to  cold  and  wet,  and  he  observed  that 
the  abdomen  gradually  enlarged,  and  dyspnoea  supervened.  On  two  occasions  para- 
centesis abdominis  was  performed  ; at  the  first  operation  a quart,  and  at  the  second  a 
pint,  of  fluid  was  removed,  without  producing  much  relief.  He  has  had  considerable 
pain  in  the  epigastric  region  at  times,  and  latterly  the  appetite  has  been  diminished, 
and  the  bowels  costive. 

Symptoms  on  Admission. — On  admission,  the  abdomen  is  slightly  srvollen,  and 
evidently  contains  fluid.  Round  the  umbilicus  it  measures  39  inches.  Ko  anasarca. 
The  hepatic  dulness  extends  three  inches  downwards  on  the  right  side,  commencing 
two  inches  under  the  nipple.  Tongue  is  furred ; appetite  diminished  ; no  epigastric 
pain  or  uneasiness ; bowels  irregular,  but  at  present  costive.  There  is  slight  dulness 
on  percussion  under  the  right  clavicle,  with  harsh  inspiration,  prolonged  expiration, 
and  increased  vocal  resonance ; urine  scanty,  depositing  lithates.  The  other  functions 
are  well  performed,  and  he  appears  to  be  a strong,  well-nourished  person. 

Progress  of  the  Case. — The  treatment  consisted  of  diuretics  {8p.  ^ther.  Nit. 
mid  Tr.  Digitalis)  and  sudorifics  {Pulv.  Doveri) ; but,  feeling  the  confinement  of  the 
Hospital  to  disagree  with  him  after  his  usual  active  occupations,  he  insisted  on  going 
out,  which  he  did  July  6th. 

Commentary. — The  dimiinshed  extent  of  the  hepatic  dulness,  the 
ascites,  and  the  chronic  nature  of  the  disease,  point  out  this  case  to  be 
one  of  cirrhosis.  This  morbid  change  in  the  liver  consists  of  the  forma- 
tion of  fibrous  tissue  between  the  lobules  of  the  organ,  whereby  its  secret- 
ing cells  are  compressed  and  atrophied.  As  a further  result,  the  large 
venous  trunks  are  also  compressed,  and  their  commencing  ramifications 
so  congested  that  effusion  into,  or  dropsy  of,  the  peritoneal  cavity  is  in- 
duced. Notwithstanding  the  extensive  organic  changes  which  are  fre- 
quently observed  in  this  disease,  danger  is  not  so  much  to  be  apprehended 
from  them  as  from  the  ascites,  which,  by  distending  the  abdomen  and 
compressing  the  lungs  and  liver,  so  interferes  with  those  important  organs 
as  to  destroy  life. 

Case  LXXVHII.f — Cirrhosis  with  Enlargement  of  Liver — Hypertrophy 
of  Spleen — Slight  Leucocythemia — Jaundice — Constriction  of  Arch 
and  descending  Aorta. 

History. — James  Kerr,  let.  28,  a laborer — admitted  July  22,  1852.  This  iran 

* Reported  by  Mr.  John  Matthews,  Clinieal  Clerk, 
f Reported  by  Messrs.  Douglas  and  Dewar,  Clinical  Clerks. 


DISEASES  OF  THE  LITER. 


515 


first  had  jaundlea,  with  swelling  of  the  abdomen,  between  four  and  five  years  ago ; 
and  since  tlien  lie  h.is  been  several  times  in  the  Infirmary,  The  treatment  has  con- 
sisted of  various  alteratives  internally,  with  the  occasional  application  of  the  Tr. 
lodinei,  blisters,  and  leeches  externally.  The  swelling,  however,  has  continued  to 
increase  very  slowly,  and  for  the  last  two  years  he  has  been  incapacitated  fi“om  work- 
ing. The  blood  fur  some  time  has  contained  an  excess  of  fibrin,  and  a slight  increase 
of°the  colorless  corpuscles ; and  he  has  been  troubled  at  intervals  with  attacks  of 
epistaxis  and  occasional  diarrhoea.  For  two  years  past  there  has  been  an  increased 
impulse,  with  a rough  blowing  murmur,  loudest  with  the  first  sound  under  the  manu- 
brium of  the  sternum. 

Symptoms  on  Admission. — On  admission  the  hepatic  dulness  commences  an  inch 
below  the  right  nipple,  and  extends  down  to  the  umbilicus,  measuring  twelve  inches 
vertically.  The  splenic  dulness  reaches  from  the  lower  margin  of  the  fifth  rib  to  a 
transverse  line  drawn  an  inch  below  the  umbilicus,  and  measures  eight  inches  verti- 
cally. The  liver  presents  a protuberance  anteriorly,  which  extends  in  the  form  of  a 
ridge,  four  inches  broad,  from  the  epigastrium  backwards  towai'ds  the  false  ribs.  The 
girth  of  the  abdomen  over  this  ridge  is  4i  inches.  The  interior  border  of  the  spleen 
and  liver  can  be  distinctly  felt  through  the  parietes  of  the  abdomen.  The  heart’s 
action  and  sounds  are  normal.  An  increased  pulsation  is  distinctly  visible  at  the 
root  of  the  neck,  and  can  be  felt  above  the  clavicles  and  under  the  top  of  the  sternum. 
Here  there  is  aloud  rough  murmur  synchronous  with  the  systole  of  the  heart,  and  ac- 
companied by  a distinct  impulse.  Tnere  is  a slight  cough,  with  a little  mucous  expec- 
toration, but  auscultation  and  percussion  of  the  lungs  reveal  nothing  abnormal.  Urine 
rather  .scanty,  high-colored,  spec.  grav.  lOifi,  contains  some  biliary  matter,  and  de- 
posits on  cooling  a pretty  copious  pinkish  sediment  of  lithates.  The  integuments  and 
conjunctivae  are  still  tinged  of  light  bile-yellow  color.  There  is  considerable  tender- 
ness over  the  liver  in  the  right  hypochondrium.  lie  says  slight  epistaxis  returns  about 
once  a week.  The  bowels  are  open  daily ; no  diarrhoe;i.  After  vadking  or  unusual 
exertion  oedema  of  the  legs  comes  on.  On  examining  the  blood  microscopically,  the 
colorless  corpuscles  are  not  so  numerous  as  when  he  was  last  in  the  house.  Four 
leeches  to  he  applied  to  the  right  hypochondrium. 

Progress  OF  THE  Case. — This  man  left  the  house  in  August.  He  was  readmitted 
Novemlier  9th,  having  in  the  interval  suffered  from  an  attack  of  pleurisy  on  the  right 
side.  Latterly  he  has  been  in  the  Dundee  Hospital,  and  says  that  five  weeks  ago  he 
pissed  considerable  quantities  of  dark  grumous  matter  from  the  bowels.  In  other 
respects  his  condition  is  the  same  as  formerly  reported.  November  IH/i. — Vomited 
about  nine  or  ten  ounces  of  blood.  29</i. — Haematemesis  returned  yesterday  after- 
noon with  great  violence,  and  at  intervals  he  brought  up  in  all  132  ounces  of  blood. 
His  strength  is  now  greatly  diminished-,  pulse  loi,  full.  The  abdominal  swelling 
and  aortic  signs  as  formerly  reported  ; but  the  breathing  is  labored,  with  dyspnoea  at 
night,  considerable  cough,  and  muco-purulent  expectoration.  No  dulness  on  per- 
cussion over  lungs ; but  sibilant  and  sonorous  rales  are  heard  at  the  base  of  the  right 
lung  on  auscultation.  From  this  period  his  general  health  evidently  began  to  fail. 
Ascites  first  came  on,  followed  by  oedema  of  the  legs  and  general  anasarca.  The 
dyspnoea  became  more  urgent,  with  a sense  of  oppression  in  the  chest,  and  there  M’as 
occasional  vomiting  of  blood.  On  the  21st  of  December  there  was  considerable 
haematemesis,  and  discharge  of  blood  by  stool,  which  v-as  followed  by  exhausting 
diarrhoea.  He  died  December  25th. 

Sectio  Cadaver  is. — Fifty -three  hours  after  death. 

Body  generally  anasai-cous. 

Thorax. — Extensive  chronic  adhesions  between  the  pleurae  on  the  right  side.  On 
the  left  side  about  four  ounces  of  serum  in  the  pleural  cavity.  Lungs  oedematous. 
Slight  emphysema  of  the  left  lung  anteriorly.  Posteriorly  both  lungs  congested,  and 
here  and  there  compressed.  The  ascending  portion  of  the  aortic  arch  was  of  normal 
size,  but  its  transverse  and  descending  portions,  as  well  as  the  descending  aorta 
generally,  were  unusually  small  in  calibre,  so  that  the  little  finger  could  with  difficulty 
be  introduced.  In  structure  the  vessel  was  healthy,  but  in  consequence  of  this  forma- 
tion a pouch  was  formed  immediately  above  the  sigmoid  valves.  About  two  ounces 
of  serum  in  the  pericardium.  The  heart  healthy. 

Abdomen, — About  twenty  ounces  of  serum  in  the  peritoneal  cavity.  The 
stomach  was  about  half-full  of  brownish-black  blood,  containing  soft  coagula. 
Mucous  coat  healthy.  Brunner’s  glands  much  enlarged,  about  the  size  of  millet- 


516 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


seeds.  The  intestines  everywhere  healthy.  Mesenteric  glands  slightly  enlarged. 
Liver  weighed  nine  pounds  one  ounce,  was  of  a pale  gamboge  color  throughout* 
speckled  here  and  there  with  rounded  masses,  the  size  of  a pea,  having  a darker 
ochrey  tint.  On  section,  it  offered  considerable  resistance  to  the  knife,  and  the 
fresh-cut  surface  presented  a dense,  whitish-yellow,  fibrous  structure,  \vith  the 
lobules  of  the  orgaii  atrophied  and  embedded  in  it,  and  of  various  tint’s  of  yellow 
varying  towards  white.  In  short,  the  last  stage  of  cirn:osis.  Spleen  weighed  3 lb. 
6 oz.,  and  is  enlarged  from  simple  hypertrophy.  Kidneys,  larynx,  cesophao-us  and 
other  organs  healthy.  ® ’ 


Mickoscopic  Examination. — On  making  a thin  section  of  the  liver  with  a 
Valentin’s  knife,  and  examining  it  with  a power  of  250  diameters,  the  appearance 
was  seen  represented  in  the  woodcut  (Fig.  426).  The  stroma  of  the  organ  was 


Fig.  426. 

composed  of  fibrous  substance^  surrounding  and  compressing  the  hepatic  lobules, 
many  of  which  presented  pale  cells,  more  or  less  filled  with  yellowish  pigment ; in 
some  the  cells  were  more  or  less  fatty,  and  in  others  waxy.  Here  and  there  the 
spaces  were  empty,  the  contents  having  apparently  lost  their  cohesion,  or  having  been 
dragged  out  by  the  knife. 

Commentary . — The  lesion  which  I presumed  to  exist  in  the  liver  of 
this  man  during  his  life  was  that  of  a simple  hypertrophy,  a disease  fre- 
quently associated  with  enlarged  spleen  and  excess  of  colorless  corpuscles 
in  the  blood.  But  on  dissection,  the  liver  presented  all  the  structural 
characters  of  the  last  stage  of  cirrhosis,  associated  with  great  increase  of 
size  in  the  organ.  The  fibrous  structure  especially  was  very  large  in 
amount,  the  lobules  much  compressed,  and  so  altered,  that,  while  the 
cells  in  many  of  them  were  loaded  with  pigment,  some  had  undergone 
the  fatty,  and  others  the  waxy,  degeneration.  The  cirrhosis  must  have 
occasioned  some  obstruction  to  the  perfect  excretion  of  bile,  as  the 
jaundice,  though  slight,  was  uniform  for  more  than  four  years.  There 
had  also  been  epistaxis,  haematemesis,  and  frequent  diarrhoea,  symptoms 
very  common  in  connection  with  enlarged  liver  and  spleen,  and  pro- 
bably dependent  on  the  congested  condition  of  the  gastro-intestinal 
mucous  membrane,  produced  by  pressure  on  the  portal  veins.  For  a 
long  time  he  suffered  no  inconvenience  from  the  abdominal  swelling, 
except  from  its  bulk  and  occasional  tenderness,  unless  indeed  dyspnoea 
be  taken  into  consideration,  which  was  attributed  partly  to  an  aneurismal 

Fig.  426.  Structure  of  a thin  section  of  the  liver  in  the  last  stage  of  cirrhosis. 

250  diam. 


DISEASES  OF  THE  LIVER. 


517 


dilatation  of  the  aortic  arch.  A dilatation  in  point  of  fact  did  exist,  and 
a certain  obstruction  was  occasioned,  from  the  state  of  the  parts  described, 
sufficient  to  produce  all  the  physical  signs  and  functional  symptoms  of 
aneurism  of  the  aorta.  The  origin  of  the  excessive  hemorrhages  is  in- 
volved in  mystery,  the  most  careful  examination  of  the  body  having 
failed  to  detect  lesion  of  any  vessel,  or  of  any  part  of  the  mucous  mem- 
brane. Some  years  ago  I opened  the  body  of  a man  whose  stomach  was 
found  filled  with  a firm  coagulum  of  blood,  so  that,  when  the  organ  was 
opened,  it  could  be  turned  out,  presenting  a cast  of  its  interior,  weighing 
between  two  and  three  pounds.  Yet  the  most  minute  inspection  did  not 
enable  me  to  discover  the  slightest  lesion  to  which  such  extensive 
hemorrhage  could  be  attributed.  Such  lesion,  however,  must  have 
existed ; for  no  one  can  now  conceive  the  possibility  of  blood  corpuscles 
passing  through  the  vascular  walls  by  transudation,  as  was  formerly 
imagined  We  may,  I think,  theoretically  ascribe  them  to  the  excessive 
congestions  occasioned,  and  to  the  rupture  of  capillaries  which  escape 
detection  after  death.  Another  fact  worthy  of  observation  in  the  case  of 
Kerr  vvas,  that  the  excess  of  colorless  corpuscles  in  the  blood  (leucocy- 
themia),  which  existed  when  he  first  came  under  my  notice,  had  entirely 
disappeared  during  the  last  few  months  of  his  life. 

The  treatment  in  cirrhosis  must  be  purely  palliative,  and  directed  to 
diminish  the  ascites  by  means  of  diuretics  and  diaphoretics.  The  ques- 
tion of  drawing  off  the  fluid  by  paracentesis  is  one  which  may  arise,  in 
case  the  swelling  is  very 


great,  and  the  embarrass- 


ment to  the  pulmonary  and 
renal  organs  extreme.  Even 
then,  although  temporary 
relief  may  be  obtained  by 
the  operation,  there  is 
every  reason  to  believe 
that,  in  the  majority  of 
cases,  life  is  in  no  way 
prolonged. 

In  1853,  I was  induced 
by  the  great  suff’erings  aris- 
ing from  distension,  in  the 
case  of  a man  named  Stew- 
art, to  sanction  the  opei-a- 
tion,  which  was  followed 


by  peritonitis  and  death. 


Fi?.  427. 

On  examination  afterwards,  the  surface  of 
the  liver  was  found  very  roughened  from  extreme  hob-nailed  cirrhosis. 
It  occurred  to  me  that  peritonitis  might  have  been  induced  by  suddenly 
bringing  such  a surface  in  contact  with  the  opposite  peritoneum,  after 
evacuation  of  the  fluid,  and  that  during  the  friction  necessarily  caused  in 
the  acts  of  respiration  the  inflammation  might  have  been  excited.  Whe- 
ther this  supposition  be  correct  or  not,  I have  since  contented  myself,  in 
extreme  cases,  with  drawing  off  half  the  fluid  from  the  abdomen,  by 

Fig.  427.  Peri-lobular  fatty  or  nutmeg  liver,  a.  Fatty  degeneration  around  the 
lobules  ; b and  c.  Centres  of  the  lobules  with  the  vessels  congested. — ( Wedl.) 


518 


DISEASES  OF  THE  DIGESTIVE  SYSTEIiI. 


paracentesis,  a practice  wliicli  has  equally  succeeded  in  causing  temporary 
relief,  without  exciting  any  bad  consequences. 

A condition  of  the  liver  is  frequently  seen,  and  which  has  been  called 
the  nutmeg  liver ^ from  the  resemblance  it  presents  to  the  fresh-cut  surface 
of  a nutmeg.  That  is  to  say,  it  exhibits  bright  red  or  brown  points,  sur- 
rounded by  a whitish  or  slightly  yellow  substance.  On  making  thin 
sections  of  such  a liver,  it  will  be  seen,  that  whilst  the  vessels  of  tlie 
lobules,  and  especially  their  central  parts,  are  distended  with  blood,  the 
cells  at  the  margins  of  the  lobules  have  undergone  the  fatty  degeneration. 
It  has  been  supposed  by  some  that  this  condition  is  an  incipient  cirrhosis, 

by  others  an  incipient 
fatty  degeneration  ot‘ 
the  organ.  Certain 
it  is  that  in  such  cases 
the  fatty  cells  are 
formed  at  the  cir- 
cumference of  the 
lobule,  in  immediate 
relation  to  tlie  portal 
capillaries,  which  are 
loaded  wuth  blood. 
It  has  been  called  in- 
terlobular fatty  de- 
generation, but  is  in 
fact  fatty  degenera- 
tion of  the  cells  at 
the  circumference  of 
the  lobule.  Wedl 
has  pointed  out  that  in  some  rare  forms  of  this  lesion  there  is  a deposit 
of  pigment  in  the  cells  nearest  the  hepatic  capillaries,  and  occupying  the 
centre  of  the  lobule,  without  any  fatty  degeneration  whatever.  Pigment 
may  also  occur  in  the  veins  themselves.  At  other  times  the  fatty  and 
pigmentary  degenerations  of  the  liver  may  be  more  or  less  combined,  the 
former  existing  at  the  periphery,  and  the  latter  at  the  centre  of  the 
lobule.  We  have  no  clinical  history  of  these  forms  of  nutmeg  liver, 
nor,  sd  far  as  is  yet  known,  do  they  occasion  any  symptoms  susceptible 
of  being  recognised  in  the  living  body.  (Figs.  427,  428.) 

Case  LXXIX,'^ — Cancerovs  JExudation  into  the  Liver — Cancerous  TTlcero- 
iion  of  GJ.wphagus — Simple  Stricture  of  Pylorus — Profuse  Ilccmate- 
niesis — Aneurism  of  Thoracic  Aorta^  lursting  into  the  left  Pleura. 

History. — Thomas  Stewart,  aet.  54,  bookseller — admitted  November  28,  1849. 
States  that  about  six  years  ago  he  had  an  attack  of  haemoptysis,  but,  with  this 
exception,  he  always  enjoyed  good  health,  till  about  four  months  ago,  At  that 
time  his  appetite  began  to  fail,  and  he  felt  sick  after  eating,  occasionally  vomiting 

* Reported  by  Mr.  Hugh  Balfour,  Clinical  Clerk. 

Fig.  428.  Pigmented  nutmeg  liver,  a.  Lobule  with  the  central  vein  divided  at  -f-, 
containing  amor|)hous  pigment ; i.  Lobule  with  the  central  vein  healthy  ; c.  The 
central  vein  filled  with  pigment.  The  radiated  central  pigment  is  owing  to  its  being 
deposited  in  that  portion  of  the  hepatic  cells  nearest  the  capillaries. — ( Wedl).  90 
diam. 


DISEASES  OF  THE  LIVER. 


519 


his  food.  Since  then  the  sickness  has  been  increasing,  and  about  three  or  four 
weeks  ago,  he  began  to  vomit  blood.  He  has  also  been  affected  with  pain  in  the 
throat  on  attempting  to  swallow,  and  a sense  of  constriction  in  the  oe.sophagus, 
opposite  the  superior  border  of  the  sternum.  He  states,  that  he  can  very  seldom 
take  food  without  exciting  vomiting  ; but  occasionally,  when  he  succeeds  in  retaining 
it  for  half  an  hour,  the  sense  of  sickness  passes  off.  He  further  states,  that  he  vomits 
blood  mixed  with  clots  of  dark-brown  masses.  This  does  not  occur  after  eating,  but 
generally  between  three  and  live  in  the  morning;  occasionally,  however,  it  occurs 
during  the  day,  and  is  then  preceded  by  a lit  of  coughing.  He  has  been  losing  flesh 
lately  to  a great  extent,  and  is  now  very  thin,  having  formerly  been  of  a stout  and 
robust  habit  of  body. 

Symptoms  on  Admission. — On  admission,  he  appears  pale  and  emaciated.  Com- 
plains of  great  general  weakness.  Tongue  much  furred,  and  the  superior  surface 
fissured.  He  has  pain  and  constriction  on  attempting  to  swallow.  Is  sick,  and 
generally  vomits  after  every  meal,  and  this  whether  his  diet  bo  solid  or  fluid. 
Vomits  a great  deal  of  florid  blood,  mixed  with  dark  grumous  masses,  and  clots  of  a 
black  color.  On  examining  this  fluid  under  tlie  microscope,  it  is  seen  to  consist 
chiefly  of  blood  corpuscles  and  epithelial  scales ; no  cancer  cells  can  be  detected. 
He  states  that  on  Friday  last  (Nov.  23),  he  vomited  about  half  a gallon  of  blood,  and 
on  the  following  day  even  a larger  cpiantity.  There  is  great  tenderness  over  the 
region  of  the  stomach ; and,  on  examination,  a hard  lobulated  oval  tumor  is  dis- 
covered on  the  right  side  of  the  epigastric  region,  measuring  four  inches  transversely, 
and  two  inches  from  above  downwards.  The  appetite  is  bad,  and  has  been  getting- 
worse  of  late.  Bowels  usually  regular.  He  complains  of  cough,  which  has  existed 
for  about  four  months ; no  dyspnoea.  On  percussion,  the  chest  sounds  well,  exeept 
that  there  is  dulness  over  the  lower  third  of  the  left  lung  posteriorly.  On  ausculta- 
tion, the  expiration  is  prolonged  anteriorly,  and  crepitation  is  heard  over  the  part 
where  dulness  is  elicited  on  percussion.  Pulse  90,  of  tolerable  strength.  Complains 
of  occasional  palpitation,  and  the  impulse  of  the  heart  is  somewhat  increased  ; but  on 
auscultation,  the  heart’s  sounds  are  normal.  Urine,  sp.  gr.  1020,  natural  in  quantity, 
not  coagulable ; deposits,  on  cooling,  an  abundant  lateritious  sediment  of  lithate  of 
ammonia.  Complains  of  giddiness,  and  is  unable  to  walk  well,  owing  to  weakness. 
Four  leeches  to  be  applied  over  the  tumor  in  epigastrium.  ^ Pulv.  Opii  gr.  ij ; 
Ettract.  Hijoscgam.^  gr.  xii.  M.  et  divide  in  pil.  iv.  One  to  he  taken  morning  and 
evening.  B dPaplithce  Medicin.  3 i ; 3Iist.  Camphorce  ^ iij.  3f.  Half  an  ounce  to  be 
taken  everg  three  hours. 

Progress  op  the  Case. — December  Is^. — Pain  and  tenderness  are  somewhat  re- 
lieved by  the  leeches.  Still  vomits,  but  not  to  so  great  an  extent  as  formerly.  From 
this  time  he  went  on,  with  occasional  exacerbations  and  remissions,  but  on  the  whole 
became  manifestly  weaker.  Every  now  and  then  he  vomited  large  quantities  of  florid 
blood,  and  on  one  occasion  the  quantity  amounted  to  thirty-six  ounces  Gallic  acid 
and  acetate  of  lead  and  opium  were  given  at  these  times.  After  each  attack  of 
haematemesis,  for  some  hours  small  quantities  of  blood  came  welling  up  into  his 
mouth,  and  were  expectorated.  On  December  14^A,  it  is  noted  that  the  weakness  is 
increasing,  and  appetite  diminishing.  He  was  then  ordered  eight  ounces  of  wine  daily., 
and  beef-tea  enemata.  Vlth. — Extremely  weak,  and  quite  unable  to  take  food,  evi- 
dently sinking.  18th. — Died  this  morning  at  four  a.m. 

Seetto  Cadaver  is. — Twenty-one  hours  after  death. 

The  body  was  livid  and  greatly  emaciated.  On  reflecting  the  integuments  from 
the  thorax  and  abdomen,  a nodulated  portion  of  the  liver,  nearly  separated  from  the 
rest,  very  movable,  containing  a large  mass  of  cancerous  exudation,  and  measuring 
four  by  two  inches  across,  projected  as  a distinct  tumor  into  the  epigastrium,  and  was 
evidetktly  the  same  swelling  as  had  been  felt  during  life,  through  the  integu- 
ments. 

Thorax. — The  cavity  of  the  left  pleura  contained  about  a pound  and  a half  of 
recently  coagulated  blood.  The  pericardium  contained  about  six  ounces  of  clear 
straw-colored  serum.  Heart  much  contracted.  The  whole  of  the  thoracic  viscera, 
together  with  the  trachea,  and  great  vessels,  were  removed  en  masse.  The  blood 
in  the  pleura  was  then  seen  to  have  issued  from  between  the  lobes  of  the  left  lung, 
through  a laceration  of  the  pleura,  at  the  external  and  back  part  of  that  organ.  The 
aorta  being  slit  up,  was  found  to  be  somewhat  rough  internally.  At  the  outer  part 
of  the  arch,  where  it  joins  the  descending  aorta,  the  left  side  of  the  vessel  was  per- 


520 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


forated  by  a nearly  circular  aperture,  two  inches  in  diameter,  with  smooth  edges, 
which  led  into  an  aneurismal  sac,  the  size  of  a large  cocoa-nut,  filled  with  a soft 
coagulum.  The  aneurismal  sac  pressed  and  encroached  on  the  left  lung  inferiorly, 
and  communicated  with  the  pleural  cavity  through  a recent  ragged  laceration  in 
the  pleura  costalLs,  three  inches  in  length.  Here  and  there,  immediately  round  the 
sac,  the  lung  Avas  infiltrated  with  blood,  and  greatly  softened.  In  these  places  it  was 
very  thin,  and  presented  several  perforations,  through  which  hemorrhage  into 
the  lung  must  have  taken  place.  No  communication  could  be  discoveied  between 
the  aneurismal  sac  and  the  stomach  or  oesophagus.  The  whole  arch  of  aorta  was 
Slightly  dilated  ; the  valves  healthy.  Between  the  thoracic  aorta  and  the  oesophagus 
there  Avere  tAvo  masses  of  glands,  greatly  enlarged  from  cancerous  infiltiation.  The 
oesophagus  itself  Avas  ulcerated  about  its  middle,  and  the  enlarged  glands  before 
mentioned  projected  into  its  cavity.  This  ulceration  surrounded  the  tube  internally, 
and  extended  about  three  inches  from  above  doAvnwards,  presenting  a soft  pultaceous 
surface,  the  result  of  disintegrated  cancerous  exudation.  The  lung  presented  through- 
out a number  of  small  irregularly-shaped  masses  of  exudation,  not  larger  in  most 
instances,  than  four  or  five  lines  in  diameter,  and  resembling  masses  of  crude  tubercle, 
but  somewhat  softer,  and  slightly  redder  in  color.  There  Avere  also  one  or  two  larger 
masses,  nearly  globular  in  form,  from  one-fourth  to  three-fourths  of  an  inch  in 
diameter,  of  soft  consistence,  yielding  a cream-colored  juice,  and  marked  aa  ith  one  or 
two  red  vessels  and  reddish  points.  The  bronchial  glands  Avere  infiltrated  Avith  black 
matter,  and  mostly  contained  masses  of  cancerous  exudation  simitar  to,  but  smaller 
than,  those  in  the  lung. 

Abdomen. — The  peritoneum  covering  the  diaphragm,  as  well  as  that  in  the  pelvis 
and  several  other  places,  showed  fungus-like  projections  and  nodules  of  irregular 
form — the  largest  tAvo  inches  in  diameter — flattened  on  their  surface,  of  a yellowish- 
Avhite  color,  mottled  Avith  numerous  red  vessels  externally.  Internally  they  were  of  a 
similar  color  and  appearance — crossed  by  fibres,  Avhich  included  matter  of  the  con- 
sistence and  geneial  appearance  of  boiled  ground  idee.  In  the  pelvic  cavity,  at  its 
most  depending  parts,  there  were  about  tAvo  ounces  of  bloody  pus  and  lymph,  in- 
filtrated Avith  blood,  and  here  and  there  these  existed  in  small  patches  on  the  surface 
of  the  intestines  and  parietal  peritoneum.  The  liver  Avas  much  enlarged,  and  Aveighed 
six  jiounds  ten  ounces.  It  contained  numerous  nodular  masses,  which  on  the  surface 
Avere  cup-shaped.  The  largest  Avere  nearly  four  inches  across,  and  were  usually 
softened  in  their  centre.  On  section  they  presented  the  ordinary  appearance  of 
encephaloma  of  the  liver,  Avith  the  exception  that,  in  many  places,  their  substance 
AA'as  partly  diffluent,  and  on  section  excavations  or  cavities  Avere  left  in  the  mass. 
Some  of  them  contained  a creamy  yellowish  fluid,  mixed  with  red,  and  others  olive- 
colored  serum,  with  a large  amount  of  flocculent  and  granular  pinkish  debris.  Here 
and  there,  also,  masses  of  reticulum  were  infiltrated  among  the  Avhitish  and  greyish 
cancerous  exudation.  The  liA^er  itself  Avas  pale  faAvn-colored  and  very  fatty.  The 
stomach  was  perfectly  healthy;  but  there  Avas  a simple  stricture  at  the  pylorus, 
Avhich  with  difficulty  admitted  the  introduction  of  the  little  finger,  and  Avhich 
depended  on  hypertrophy  of  the  areolar  tissue  betAveen  the  miuscular  and  mucous 
coats.  The  intestines  Avere  extremely  contracted ; the  colon  not  being  above  one- 
half  inch  in  diameter.  Kidneys  pale,  containing  numerous  small  cysts.  The 
epithelium,  however,  Avas  nearly  healthy,  exhibiting  under  the  microscope  only  a 
small  quantity  of  granular  matter.  The  mesenteric  and  lumbar  glands  were 
healthy. 

Microscopic  Examination. — A small  portion  of  the  white  and  tolerably  con- 
sistent cancerous  exudation  in  the  liver  presented  numerous  cancer  cells,  varying 
greatly  in  size  and  shape,  but  none  exceeding  the  l-50th  of  a millimetre  in  its 
longest  diameter.  Many  were  nucleated,  and  several  Av^ere  evidently  breaking  up 

and  disintegrating.  They  were  associated  Avith  some  free  nuclei,  and  a multitude  of 
molecules  and  granules — (Fig.  346).  The  reticulum  was  Avholly  composed  of  fatty 
molecules  and  granules — (Fig.  347).  The  broken-down  matter  on  the  surfiAce  of  the 
oesophagus,  Avhere  it  was  ulcerated,  closely  resembled  that  represented  in  Fig.  345, 
but  Avas  eA^en  more  disintegrated.  The  milky  juice  squeezed  from  the  glands,  between 
the  thoracic  aorta  and  the  oesophagus,  presented  large  cancer  cells,  Avhich  presented 
the  various  appearances  characteristic  of  their  undergoing  the  fatty  degen  eration — 
(Fig.  346). 

Commentary . — During  life,  the  pain  in  the  stomach,  the  vomiting  after 


DISEASES  OF  THE  LIVER. 


521 


fojJ,  tlie  black  bloody  coagula  rendered,  and  the  distinct  nodulated  and 
somewhat  movable  tumor  in  the  epigastrium,  left  little  doubt  in  the 
minds  of  all  those  who  examined  the  case,  that  we  had  to  do  with  cancer 
of  the  pylorus.  On  examination  after  death,  however,  the  tumor  which 
had  previously  been  felt,  was  found  to  be  a nodule  of  cancerous  exuda- 
tion developing  itself  in  the  liver,  a part  of  which  had  been  pushed  for- 
ward so  as  to  occasion  the  swelling.  As  the  rest  of  the  liver  was  entirely 
hid  under  the  ribs,  it  was  not  possible  to  have  suspected  this  occurrence 
during  life.  The  simple  stricture,  however,  that  really  existed  in  the 
pylorus,  conjoined  with  the  pressure  exercised  by  the  tumor  on  the 
valve,  caused  the  vomiting  that  formed  the  principal  feature  of  the  disease. 

The  appearance  of  the  matters  rendered  by  the  mouth,  proved  that 
they  must  have  come  from  the  stomach  : because,  although  a considerable 
quantity  of  red  blood  was  evacuated,  this  was  commonly  mingled  with 
rusty  brown,  and  even  perfectly  black,  coagula.  Besides,  on  one  occa- 
sion, he  was  actually  seen  by  the  clerk  to  render  the  blood  by  the  act  of 
vomiting;  and  the  same  thing  was  repeatedly  observed  by  the  nurse. 
At  first,  then,  I considered  that  the  cancer  of  the  stomach  had  ulcerated 
internally,  and  poured  out  the  blood  evacuated  ; but,  latterly,  from  the 
large  quantities  discharged,  my  suspicions  were  fixed  on  the  presence  of 
an  aneurism  pressing  on  the  lung,  and  communicating  with  the  trachea, 
in  which  case  he  must  have  swallowed  the  blood.  This  supposition 
seemed  to  be  confirmed  by  the  existence  of  limited  dulness  on  the  left 
side,  and  by  crepitation — an  almost  invariable  concomitant  of  aneurism 
so  situated. 

On  attempting,  after  death,  to  ascertain  by  what  means  the  blood 
entered  the  stomach,  I could  not  find  any  direct  communication  between 
the  aneurism  and  that  viscus,  or  the  oesophagus.  It  may  have  resulted 
from  the  blood,  in  the  first  instance,  having  been  infiltrated  into  the 
substance  of  the  lung,  then  passed  through  the  bronchi,  trachea,  and 
larynx,  into  the  pharynx,  and  so  been  swallowed.  More  probably,  how- 
ever, it  was  caused  by  intense  portal  congestion,  producing  hemorrhage 
from  the  capillaries. 

This  man  presented  in  a very  marked  degree  the  so-called  peculiar 
cachectic  aspect  of  malignant  disease.  I have  always  noticed  that  this 
aspect  is  best  marked  in  individuals  laboring  under  cancer  of  the  stomach, 
so  situated  as  to  interfere  with  the  process  of  nutrition.  It  is  stated  in 
the  report  that  he  had  previously  been  stout  and  fat — a condition  I have 
pointed  out  in  another  place^  to  be  favorable  to  the  development  of 
cancer  generally.  I am  inclined  to  think  that  this  malignant  aspect,  so 
much  dwelt  on  by  practitioners,  is  the  mere  result  of  emaciation  from 
interference  with  the  nutritive  processes,  or  from  pain  and  want  of  sleep, 
and  is  in  no  way  distinctive  of  cancer  in  organs  where  such  effects  are 
not  occasioned. 

Cancer  of  the  liver  may  occur  in  two  forms — 1st,  That  of  distinct 
nodules,  which  have  been  so  well  described  by  Baillie  and  Farre  ; 2d, 
More  or  less  infiltrated  in  minute  grains  throughout  the  hepatic  tissue. 
The  former  is  by  far  the  most  common,  and  when  it  presents  projections 
from  the  surface  of  the  organ,  these  constitute  the  only  positive  proof 
during  life  of  its  being  affected  with  cancer.  In  some  rare  cases  I have 
* On  Cancerous  and  Cancroid  Growths.  Edinburgh,  1849 


522 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


seen  these  two  forms  run  into  one  another.  Softening  of  the  cancerous 
masses  was  well  observed  in  the  case  just  recorded,  as  well  as  its  trans- 
formation into  the  fatty  substance  which  forms  the  so-called  reticulum. 
Dr.  Ogle*  has  recorded  a case  in  which  a cancerous  mass  in  the  liver 
presented  on  section  the  remarkable  form  of  a cyst  with  thick  walls, 
closely  resembling  a small  cocoa-nut  full  of  fluid.  The  walls  exhibited 
the  usual  appearance  and  structure  of  encephaloma,  and  the  fluid  which 
occupied  the  centre  was  slightly  turbid  and  contained  shreddy  particles  of 
cancer  and  some  fatty  matter.  In  the  majority  of  cases  of  cancerous 


Fig.  429. 

liver  other  organs  of  the  body  are  similarly  affected,  rendering  the 
disease  more  or  less  complicated.  (See  Cases  LXXIII.  and  LXXXV.) 
The  treatment  must  be  entirely  palliative. 

Case  LXXX  f — Hydatid  Cyst  of  the  Lker  diagnosed  hy  means  of  the 
3Iicroscope — Its  Puncture — Discharge  of  Echinococci — Pecovery. 

History. — Lawrence  Anderson,  set.  56,  a tailor,  admitted  June  21,  1864,  has  lived 
well  and  been  somewhat  intemperate.  Two  years  ago  first  became  aware  of  swelling 
in  the  epigastrium.  Six  or  nine  months  ago  had  occasionally  nausea  on  rising  in  the 
morning  and  on  going  to  bed,  but  no  vomiting.  Ilis  bowels  have  been  costive  for 
many  years.  He  has  never  had  jaundice.  His  appetite  has  always  been  good. 
Never  met  with  any  injury  likely  to  affect  the  liver.  He  has  been  in  the  habit  of 
eating  pork  both  fresh  and  salted,  but  always,  as  he  says,  well  prepared.  Has 
never  been  out  of  Scotland. 

Symptoms  on  Admission. — He  complains  of  no  pain,  nor  of  any  inconvenience, 
with  the  exception  of  a tumor  in  his  abdomen.  It  presents  a smootli  rounded  swcll- 

* Trans,  of  Patholog.  Society,  vol.  ix.  p.  238. 

I Reported  by  Mr.  Wm.  Frank  Smith,  Clinical  Clerk. 

Fig.  429.  Remarkable  carcinomatous  cyst  in  the  liver ; a,  part  of  diaphragm. — 
( Ogle.)  Half  the  real  size. 


DISEASES  OF  THE  LIVEPw 


523 


ing,  elastic  to  the  feel,  occupying  the  epigastric  and  right  hypochondiiac  regions, 
having  its  greatest  prominence  an  inch  to  the  left  of  the  median  line  of  the  body,  and 
at  that  point  projecting  about  an  inch  from  the  normal  level  of  the  surface.  It  seems 
to  form  a part  of  the  liver.  There  is  a slight  vertical  groove  to  be  felt  between  the 
external  two-thirds  and  the  inner  third.  The  greatest  vertical  hepatic  dulness  on 
percussion  is  5^  inches.  It  has  no  tenderness,  no  pulsation,  no  fluctuation;  all  the 
functions  are  normal. 

Progress  of  the  Case. — On  the  22d  June,  iodine  was  painted  over  the  tumor. 
On  the  28th,  the  patient  left  the  hospital  for  a time.  Cn  his  return,  July  Yth,  the 
tumor  had  evidently  approached  nearer  the  surface  ; it  was  more  prominent  and  more 
elastic.  There  are  no  further  symptoms.  July  Ihth. — An  exploratory  puncture  was 
made  with  a grooved  needle,  and  in  the  viscid  serum  brought  back  there  were  seen 
under  the  microscope  several  booklets  of  echinococci,  with  fat  granules  and  crystals 
of  cholesterine.  July  l<6th. — At  two  p.m.  a crucial  incision  was  made  over  the  most 
prominent  part  of  the  tumor,  and  the  flaps  having  been  dissected  back,  an  eschar  was 
made  witli  potassa  fusa  in  the  subjacent  cellular  tissue.  Dilute  acetic  acid  was  used 
to  allay  the  subsequent  pain,  and  chloroform  employed  during  the  operation  itself. 
July  23d — A slough  about  half  an  inch  deep  has  been  formed  ; this  was  further 
deepened  by  the  introduction  to-day  of  a small  piece  of  potassa  fusa.  July  2oth. — A 
trocar  and  canula  (bore  about  ^inch)  was  passed  through  the  slough  into  the  middle 
of  the  tumor.  With  some  difficulty,  and  by  using  the  scoop  at  the  end  of  a director, 
about  1 oz.  of  a viscid  substance  was  drawn  out,  consisting  of  broken  hydatid  sacs 
and  serum.  The  sacs  varied  in  size  from  a large  grape  to  a pea,  some  of  the 
smaller  ones  were  unruptured.  There  was  no  retraction  of  the  tumor  from  the 
parietes  ; no  bleeding  ; no  purulent  discharge.  July  2Qth. — After  the  operation 
he  felt  considerable  pain  and  great  restlessness.  At  5 p.m.  to  have  Tr.  Opii  TTtxxv ; 
at  \\  P.M.  Tl^xl.  Liq.  MovqJi.^  and  3 i 07i  the  'poultice.  During  the  ivight.^  two q)illsj 
each  containing  1 gr.  of  opium.  July  ^()th. — The  opening  has  been  dilated  and  kept 
open  by  tents  of  lint,  and  from  4 to  8 oz.  of  sanguinolent  viscous  matter,  crow’ded 
with  hydatid  cysts,  discharged  daily.  He  has  no  pain,  and  was  transferred  to 
Dr.  Haldane’s  ward.  There  he  continued  five  weeks,  fragments  of  cysts  and  serum 
being  discharged  the  whole  time,  and  he  then  returned  to  bis  native  place,  Dunferm- 
line. 

Re-admitted  January  3f7,  1865. — He  says  that  tvhen  he  left  the  hospital  last  Sep- 
tember he  suffered  from  pain  across  the  loins  ; he  was  in  a very  weak  condition,  and 
was  unable  to  walk  without  the  support  of  a stick.  The  discharge  continued  profuse 
for  the  next  five  weeks ; and  he  continued  in  a very  weak  and  exhausted  condition  ; 
but  at  this  time  a portion  of  tough  membrane,  about  six  inches  in  length,  and  folded 
like  a sac,  was,  in  the  course  of  eight  days,  gradually  discharged  from  the  wound; 
and  from  this  moment  the  discharge  rapidly  ceased,  and  in  the  course  of  three  weeks 
the  wound  was  quite  healed.  He  was  then  able  to  work  at  his  tailoring  for  five  or  six 
hours  a day  without  any  discomfort — his  appetite  improved  considerably,  and  he 
rapidly  gained  strength,  so  that  he  felt  as  well  as  ever  he  did,  and  could  walk  ten  or 
twelve  miles  in  the  day  with  perfect  case.  At  present  he  appears  strong,  and  in 
good  condition.  Appetite  very  fair.  There  is  neither  pain,  tenderness,  nor  any  pain 
or  protuberance  in  the  abdominal  cavity.  Hepatic  dulness  measured  in  a vertierd 
line  4-^  inches.  The  surface  of  the  liver  appeared  smooth,  and  the  skin  moved  readily 
over  it,  except  at  the  position  of  the  former  puncture,  which  is  marked  by  a linear 
cicatrix  an  inch  in  length  transversely. 

Commentary . — The  rounded  and  peculiar  elastic  feel  of  this  hepatic 
tumor  having  led  to  the  suspicion  of  its  being  caused  by  hydatids,  I 
directed  an  exploratory  puncture  to  be  made.  In  the  gelatinous  serum 
removed  in  the  groove  of  tlie  needle,  several  booklets  of  echinococci 
were  detected  with  the  microscope,  and  the  diagnosis  was  thus  established 
on  a certain  basis.  After  careful  consideration  it  was  determined  to 
attempt  its  radical  cure,  by  evacuating  the  tumor,  and  to  this  end  Re- 
camier’s  practice  was  adopted,  and  an  eschar  formed  slowly  with  potassa 
fusa,  to  secure  adhe.sion  of  the  parietal  walls  of  the  abdomen.  This 
being  effected,  the  hydatid  cyst  was  opened,  as  stated  in  the  report. 
The  operation  was  performed  and  the  most  intelligent  care  bestowed  on 


524 


DISEASES  OF  THE  DIGESTIVE  SYSTEJI. 


this  case  throughout,  by  niy  then  resident  physician,  Dr.  Duckworth. 
At  the  coinmenceinent  of  the  autumn  vacation  he  was  transferred  to  the 
care  of  another  physician  in  the  Infirmary,  under  whom  he  remained  for 
five  weeks,  the  hydatids  continuing  to  come  away  from  the  opening.  Ii 
Djcemb:‘r  I learnt  from  Dr.  Dewar  of  Dunfermline,  that  this  man  was 
rutming  about,  carrying  on  his  usual  occupation,  quite  well.  He  showed 
himself  at  the  Hospital,  January  3,  1865,  and,  as  stated  in  the  report, 
the  entire  cyst  having  sloughed  out,  and  the  opening  cicatrized,  he  has 
regained  perfect  health.  For  the  practical  history  of  this  subject  I 
must  refer  you  to  the  works  of  Bright,  Budd,  and  Frerichs. 

The  mystery  that  so  long  reigned  over  the  production  of  hydatids 
in  the  animal  body  is  now  removed.  (See  Intestinal  worms.)  The 
habits  of  the  Scotch  people  as  to  diet  perhaps  explain  the  infrequency 
of  internal  parasites  among  them.  Certainly  no  case  can  well  be  more 
rare  than  that  of  a hydatid  cyst  in  the  liver.  In  Iceland,  on  the  other 
hand,  it  is  known  to  be  one  of  the  most  common  and  fatal  diseases  met 
with.  Looking  at  the  great  risk  which  all  who  are  afieclcd  must  run,  I 
have  little  hesitation  in  thinking  that  the  practice  followed  by  such  good 
results  in  the  case  above  recorded,  is  the  one  which,  as  a general  rule, 
should  be  adopted  as  early  as  possible,  when  the  diagnosis  is  clearly  ar- 
rived at. 


DISEASES  OF  THE  INTESTINES. 

Case  LXXXI.'^ — Diarrlma — Recovery. 

HrsTORT. — Mary  Gordon,  aet.  21,  a thin,  weak-looking  woman,  lately  employed  as  a 
herring-curer — admitted  in  the  afternoon  of  July  26th,  1855.  She  has  for  the  last  two 
days  been  much  exposed  to  cold  and  wet,  and  early  this  morning  was  seized  with  vio- 
lent pain  in  the  epigastric  and  lumbar  regions,  accompanied  by  shivering,  sickness,  and 
vomiting.  At  nine  o’clock  the  bowels  were  freely  opened,  and  since  then  she  has  had 
several  fluid  stools,  with  griping  pain  in  tlie  abdomen,  and  violent  tenesmus.  The 
matters  discharged  from  the  bowels  she  describes  as  watery,  mingled  with  slime.  She 
has  taken  some  brandy,  which  caused  slight  relief. 

SvMPTO.\is  ON  Admission. — On  admission  the  tongue  is  white,  appetite  impaired, 
great  thirst,  no  nausea  or  vomiting  at  present,  no  tenderness  over  stcmach  or 
abdomen.  Bowels  still  loose;  the  matter  discharged  consists  of  a dirty  yellow 
fluid,  in  which  masses  of  mucus  are  floating.  No  blood  or  pus.  Pulse  84,  full. 
Says  she  has  occasional  palpitations.  Countenance  slightly  flushed.  Considerable 
lumbar  pain.  Urine  healthy.  Other  functions  well  perlormed.  B Cjon  3j 

Co)if.  Aromat.  3j  ; Alist.  Cretce  comp.  § iij  ; M.  Half  an  ounce  to  be  taken  every 
three  hoars 

Progress  of  the  Case. — July  2&th. — To-day  feels  weak,  but  the  diarrhoea 
ceased  after  the  second  dose  of  the  mixture.  July  2^th. — Still  very  exhausted.  To 
have  nutrients  with  wine  | ij  daily.  She  rapidly  recovered,  and  was  discharged 
August  2d. 

Case  LXXXII.j — Diarrhoea — Recovery. 

History. — Frederick  Lyons,  aet.  4 — admitted  December  19th,  1854.  The  mother 
says  he  has  been  fed  regularly,  if  not  plentifully,  and  up  to  two  months  ago^  he  was 
quite  healthy.  He  was  then  sent  to  school,  ever  since  which  he  has  had  diarrhoea, 
the  bowels  being  generally  open  five  or  six  times  a day.  He  has  been  losing  strength 
up  to  the  present  time. 

Symptoms  on  Admission, — The  child  is  now  very  thin  is  always  picking  his  nose. 
Tongue  clean.  Abdomen  tumid  and  tender  on  pressure  Has  had  six  stools  within 

* Reported  by  Mr.  Simon  Mutakisna,  Clinical  Clerk, 
f Reported  by  Mr.  Arthur  W Moore,  Clinical  Clerk. 


DISEASES  OF  THE  INTESTINES. 


525 


the  last  twenty-four  hours,  of  fluid  consistence  and  chiy  color.  Pulse  9fi,  weak.  Has 
never  been  known  to  pass  worms.  Other  symptoms  normal.  Haheat  01.  Ricini  3 ij. 
Nutritious  diet.  To  remain  in  bed. 

Progress  of  the  Case. — Diarrhoea  diminished.  Stools  of  a more  healthy  color. 
Takes  rice  and  milk  greedily.  From  this  time  he  rapidly  recovered.  All  diarrhoea 
h id  ceased  on  the  24th.  On  the  27th  he  was  allowed  to  get  up  ; there  was  then  no 
tomlerness  of  abdomen,  and  the  tumidity  had  nearly  disappeared.  Discharged  well, 
January  8th. 

Commentary. — The  cases  of  diarrhoea  here  recorded  are  examples  of 
the  two  most  common  forms  of  this  disorder,  the  one  originating  from 
exposure  to  wet  and  cold,  the  other  from  irregularities  in  diet.  In  the 
first  case  the  discharge  was  checked  by  opium  and  chalk,  in  the  second 
by  a mild  aperient,  proper  nourishment,  and  rest. 

Many  varieties  of  diarrhoea,  or  excessive  discharge  from  the  bowels, 
have  been  described  by  systematic  writers,  but  pathologically  they  may 
all  be  referred  to  two  causes,  namely  : — 1st,  A disturbance  of  the  healthy 
conditions  of  the  blood,  leading  to  increased  eliminating  action  of  the 
intestinal  mucous  membrane,  in  various  acute  inflammatory  diseases — 
when  it  may  be  critical — as  after  exposure  to  cold  or  wet,  occasioning 
suppressed  transpiration.  2d,  From  irritating  substances  in  the  canal 
itself,  derived  from  food  or  drink;  from  an  increased  amount  of  bile  or 
other  secretion ; from  structural  disease  of  the  mucous  membrane,  as  in 
dysenteric,  tubercular,  or  typhoid  ulcerations  ; from  worms  or  foreign 
bodies  impacted  in  the  gut,  etc.  etc.  The  indications  for  treating  those 
two  forms  of  diarrhoea  are  very  ditferent.  In  the  first  it  may  be  sana- 
tive in  itself,  and  only  symptomatic,  or  the  natural  termination  of  a 
general  disorder  which  it  would  sometimes  be  injurious  and  even  danger- 
ous to  check.  In  the  second,  the  diarrhoea  is  always  hurtful  if  long  con- 
tinued, and  our  hopes  of  correcting  it  will  mainly  depend  on  our  capa- 
bility of  removing  the  local  irritating  cause. 

Thus  if,  as  very  commonly  ha])pens,  improper  diet  be  the  cause,  this 
must  of  course  be  better  regulated.  If  any  special  irritating  substance 
has  been  taken,  and  occasions  griping  with  tenesmus,  a simple  w^arm- 
water  injection,  slowly  introduced,  so  as  to  distend  and  wash  out  the 
rectum,  may  at  once  remove  it.  If  not,  a dose  of  castor-oil,  followed  hy 
an  antacid  and  anodyne  mixture,  such  as  the  compound  chalk  mixture, 
with  a little  Tr.  opii,  generally  succeeds.  To  this,  if  the  discharge  con- 
tinue, the  various  astringents  may  be  added,  and  given  by  the  mouth  or 
by  the  rectum.  Quietude  is  a very  necessary  part  of  the  treatment,  and 
confinement  to  bed  in  all  severe  cases  is  of  the  greatest  importance. 
When  diarrhoea  is  symptomatic  of  deranged  liver,  of  intestinal  ulcera- 
tions, of  worms,  or  other  irritating  cause,  the  treatment  resolves  itself 
into  the  appropriate  method  of  removing  the  original  disorder. 

The  opposite  disease  to  diarrhoea  is  constipation,  which  is  diminished, 
difficult,  or  suspended  discharge  from  the  bowels.  This  also  may  be  the 
result  of  constitutional  or  local  causes,  and  give  rise  to  indications  for 
treatment  directed  to  overcome  the  one  and  remove  the  other.  In  most 
cases,  however,  there  is  torpor  and  diminished  nervous  energy  affecting 
the  contractility  of  the  intestinal  muscular  coat.  The  influence  of  voli- 
tion also  in  producing  or  overcoming  constipation  is  most  marked.  If 
the  call  of  nature  be  not  promptly  attended  to,  it  may  not  be  repeated 
for  some  time,  and  thus  irregularity,  and  at  length  constipation  induced. 


526 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


If,  on  the  other  hand,  an  effort  be  made  daily,  at  a certain  hour,  no  better 
means  exist  for  overcoming  the  disorder.  Everything,  therefore,  that 
tends  to  prevent  retiring  to  the  closet  daily  favors  constipation.  For 
this  reason  I have  observed  it  to  be  very  common  among  English  people 
travelling  abroad,  where  cleanliness  and  comfort  in  this  matter  are  so 
little  attended  to.  Purgatives,  although  necessary  to  overcome  tem- 
porary obstructions  and  give  immediate  ease,  do  not  tend  in  themselves 
to  remove  the  causes  of,  and  therefore  seldom  permanently  cure,  a con- 
stipation. The  best  means  for  accomplishing  this  are  appropriate  diet, 
the  use  of  particular  kinds  of  food,  such  as  brown  bread,  stewed  fruits, 
etc. ; exercise,  baths,  pleasure-excursions,  a course  of  saline  waters,  etc. 
etc.  In  constipation,  as  in  diarrhoea,  should  any  structural  disease  or 
mechanical  impediment  exist,  its  treatment  must  be  regulated  according 
to  the  circumstances  of  the  disease  of  which  it  is  symptomatic. 

The  use  of  purgatives  in  intestinal  disease  is  a subject  of  great  im- 
portance, and  one  which  appears  to  me  to  have  been  much  misunder- 
stood. It  has  been  supposed,  for  instance,  that  a good  alvine  evacua- 
tion once  a day  is  necessary  to  the  healthy  state  of  the  body,  and  that 
an  individual  who  only  has  such  an  evacuation  once  in  two  days,  and 
sometimes  in  three,  is  constipated.  This  idea  has  led  to  the  habitual 
use  of  purgatives,  and  is  the  principal  cause  of  the  enormous  number  of 
aperient  pills  annually  sold  with  government  stamps  in  this  country. 
The  fact  is,  that  many  persons  naturally  never  have  a motion  above  once 
ill  two  or  three  days,  and  retain  their  health  quite  well.  The  rule  ought 
to  be,  that  in  all  such  cases  purgatives  are  unnecessary,  unless  incon- 
venience or  some  decided  symptom  follow  retention  of  the  ffeces. 
Again,  it  has  been  supposed  that  purgatives  are  antiphlogistic,  and  so 
far  has  their  administration  been  deemed  beneficial,  that  there  is  scarcely 
a disease,  the  treatment  of  which  at  one  time  was  not  commenced  by  a 
smart  aperient,  with  a view  of  cleansing  out  the  bowels,  in  order  to  have 
a clear  field,  as  it  were,  for  future  operations.  But  purgation  can  in  no 
way  benefit  a distant  part  actually  inflamed,  whilst  its  employment  at 
the  commencement  of  many  diseases,  and  more  especially  of  typhus  and 
peritonitis,  is  positively  injurious.  The  chief  uses  of  purgatives  are  to 
overcome  temporary  obstructions,  to  remove  irritating  substances;  to 
solicit  the  flow  of  bile  and  other  secretions  at  the  upper  part  of  the 
canal,  and  to  excite  watery  discharges  in  certain  eases  of  dropsy.  For 
this  purpose  the  practitioner  must  be  acquainted  with  the  properties  of 
the  different  kinds  of  purgatives,  and  choose  such  only  as,  when  pro- 
perly administered,  will  best  effect  his  object.  Everything  like  routine 
practice  should  be  avoided. 

Case  LXXXITI."^ — Acute  Dysentery — Recovery. 

History. — Timothy  Flynn,  ret.  14,  a hawker — admitted  November  26th,  1852. 
States  that  on  the  22d  inst.,  when  in  Perth,  he  was  suddenly  seized  with  looseness  of 
the  bowels,  gi'iping  pains  in  the  abdomen,  and  tenesmus  not  preceded  by  shivering. 
He  attributes  the  attack  to  having  breakhisted  on  oatmeal  porridge,  a kind  of  food  to 
which  he  was  not  accustomed,  although  he  has  been  much  exposed  to  wet,  cold,  and 
fatigue.  On  the  first  day  of  his  illness,  the  calls  to  stool  occurred  several  times  in  an 
hour.  On  the  following  day  he  observed  that  he  was  passing  blood  with  the  faeces, 
and  sometimes  nothing  but  small  quantities  of  thick  bloody  matter  of  tough  consistence 

* Reported  by  Mr.  Wm.  Calder,  Clinical  Clerk. 


DISEASES  OF  THE  INTESTINES. 


521 


like  glue.  Notwithstanding  these  symptoms,  he  walked  from  Perth  to  Edinbui-gh, 
the  frequent  bloody  stools  continuing,  but  the  pain  gradually  abating. 

SrMPTOMS  ON  Admission. — Tongue  is  dry  in  the  centre,  the  tip  and  edges  being 
clean  and  moist.  Appetite  much  impaired ; thirst  moderate.  Thinks  he  has  had 
twelve  stools  during  the  last  twenty-four  hours,  which  were  mixed  with  blood.  Has 
still  tenesmus  and  much  straining.  Complains  of  a constant  and  rather  sharp  pain 
at  the  lower  part  of  the  abdomen,  which  is  greatly  increased  on  pressure,  and  follows 
the  course  of  the  sigmoid  flexure  and  rectum.  This  pain,  he  says,  appeared  on  the 
second  day  of  his  illness,  a few  hours  before  the  appearance  of  the  blood.  Pulse  92, 
small  and  soft.  Urine  diminished  in  quantity,  but  healthy.  Other  functions  well 
performed.  7>.  Catechu  ? ss ; Sol.  Mur.  Morph.  3 j ; Mist.  Crel(M  comp,  ad 

5 viij,  J/.  Smnat  3 j tertid  qudque  hord. 

Progress  of  the  Case. — The  bowels  have  been  opened  twelve  or  fourteen  times 
since  yesterday’s  visit.  Pain  still  very  severe  in  the  left  iliac  fossa.  A considei’able 
quantity  of  blood  and  mucus  in  the  stools.  Applicent.  hirudines  xij  parti  dolenti. 
Lijiciatur  Enema  Amyli  cum  Tr.  Opii  3 i-  November  2Sth. — Six  stools  since  yester- 
day, very  watery,  with  traces  of  blood.  No  tenesmus,  Continuetur  Mist.  Nov.  ZOth. 
— Six  stools,  more  faeculent,  and  without  blood.  From  this  time  he  rapidly  recovered, 
and  was  dismissed  quite  well,  December  9th, 

Case  LXXXIY.^ — Suh-Acute  Dysentery — Recovery. 

History. — John  M‘Gee,  set.  38,  a mason’s  laborer — admitted  June  29th,  1853. 
Says  that  last  summer  he  was  confined  to  his  house  for  twenty-six  weeks,  in  conse- 
quence of  severe  bowel  complaint;  and  has  been  subject  to  diarrhoea  every  now  and 
then  ever  since.  He  returned  to  his  work  last  February,  but  was  again  obliged  to 
desist  nine  weeks  ago  in  consequence  of  the  sevei’ity  of  the  bowel  complaint  and 
weakness.  Three  v^eeks  since  he  observed  the  stools  to  be  tinged  with  blood.  Six 
days  ago  he  vomited  a tenacious  mass  of  the  appearance  of  white  of  egg.  He  has 
been  much  addicted  to  the  use  of  ardent  spirits,  and  is  very  intemperate.  The  medi- 
cines he  has  taken  have  been  of  little  benefit. 

Symptoms  on  Admission, — Tongue  smooth  and  moist  anteriorly,  but  somewhat 
loaded  at  the  base.  Appetite  tolerably  good.  No  fever.  There  is  tenderness  on 
pressure  over  the  abdomen  generally,  and  frequently  griping  pains.  Has  about 
thirteen  stools  a day,  which  are  thin,  of  pale  yellow  color,  containing  a quantity  of 
pus.  Pulse  80,  weak.  Other  systems  healthy.  Pll.  Plumb.  Acet.  Sumai  unam 
quartd  qudque  hord.  Habeat  suppositor.  cum  Mur.  Morph,  gr.  ss  vapere.  July  Is^. 
— Increased  pain  in  the#  abdomen.  Applicent.  hirudines  vj.  July  2d. — No  change. 
Complains  of  thirst.  Intermit.  Pil.  Plumb.  H Confect.  Aromat.  3 ss ; Pol.  2Iur. 
Morph.  3 iss ; Tr.  Catechu  3 vj  ; Mist.  CreUe  § v.  M.  A table-spoonful  to  be  taken 
every  four  hours.  Habeat  Enema  Amyli  cum  Tr.  Opii  min.  xl.  H Lactis  recentis 
§ x;  Aq.  Colds  § viij.  M.  To  be  used  as  drink.  July  Mh. — Has  now  only  six  stools 
in  the  twenty-four  hours.  Complains  of  dysuria,  and  has  only  passed  nineteen 
ounces  of  urine  daily  for  three  days.  Pp.  Hither.  Nit.  3 ss ; Pot.  Acet.  3 ij  ; Pyr. 
Aurant.  3 j ; Aquee  3 ivss,  M.  A table-spoonful  to  be  taken  three  times  a day.  July 
1th. — Has  now  only  three  or  four  stools  daily,  which  are  fmculent.  No  dysuria. 
Urine  more  copious.  Considerable  uneasiness  in  the  epigastric  region.  Omit.  3Iist. 
diuretica.  Applicet.  Emp.  Lyttce  (3  x 4)  epiyastrio.  Habeat  Enema  Opiatum  ves- 
pere.  July  2oth. — Since  last  report  has  had  about  three  stools  on  an  average  daily. 
He  feels  much  stronger.  Aug.  Is^. — Has  had  occasional  exacerbations  of  fever,  with 
thirst,  accompanied  by  increased  looseness,  which  have  been  checked  by  the  Pil. 
Plumb.  Opiat.  From  this  date  he  continued  slowly  gaining  strength,  taking  occa- 
sional exercise,  but  subject  now  and  then  to  relapses,  for  which  he  was  ordered 
tannin  with  opium,  and  occasional  suppositories.  Gradually  the  pus  disappeared 
from  the  stools,  which  became  more  faeculent  and  regular.  He  was  dismissed  quite 
well,  September  20th. 

Case  LXXXV.j — Chronic  Dysentery — Ascites  and  (Edema  of  the  Legs 
— Leucocythemia — Cirrhosis  of  the  Liver — Cancer  of  the  Lung. 

History. — Thomas  Crease,  sot.  28,  single — admitted  May  2Yth,  1857.  Has  been 
of  intemperate  habits.  Sinee  November  1856,  has  been  troubled  with  violent  cough 
— sputum  being  tinged  with  blood  ; voice  hoarse ; feet  and  legs  more  or  less  swollen. 


* Reported  by  Mr.  J.  D.  Maclaren,  Clinical  Clerk, 
f Reported  by  Messrs.  John  Lowe  and  Stewart  Lockie,  Clinical  Clerks. 


528 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


hot  and  tender,  especially  around  the  ankles.  This  attack  dated  from  a definite  day 
which  he  could  not  name  in  November  1856,  after  exposure  to  cold  while  crossing 
at  Queensferry.  He  was  under  treatment  in  the  Infirmary  from  March  6th  to  April 
28th,  1857 ; there  were  present  during  that  time  cough,  with  bloody  or  rusty 
sputum,  which,  however,  occasionally  became  frothy  and  mucous;  a doughy  and 
oedematous  condition  of  the  feet,  and  latterly  of  the  hands ; an  unusual  temperature 
of  skin,  and  a pulse  more  or  less  thrilling  and  hard.  There  was  no  diarihoea.  After 
leaving  hospital  he  was  for  four  weeks  under  quack  treatment ; getting  steaks,  ale, 
and  bi’andy  almost  ad  libitum.  No  relief  was  obtained  ; the  heat  of  skin,  thirst,  and 
exhaustion  continued,  and  the  bowels  became  loose.  The  cough  became  less  trouble- 
some, and  the  expectoration  scanty. 

Symptoms  on  Admission. — Percussion  note  is  rather  fiat  on  the  right  side  of 
thorax  anteriorly,  and  over  the  upper  half  on  same  side  posteriorly.  The  respiratory 
murmurs  are  very  feeble.  When  audible  they  are  harsh ; no  sibilus  nor  moist  rale ; 
vocal  resonance  increased  under  right  clavicle ; no  dyspna  a ; no  cough  nor  sputum 
to-day.  Cardiac  impulse  weak;  the  transverse  dulness  is  noimal;  the  sounds  are 
normal.  The  pulse  126,  rather  full  and  hard.  The  tongue  is  covered  with  fur; 
thirst  great,  appetite  bad.  Abdomen  on  palpitation  is  natural ; no  dulness  on  per- 
cussion, nor  tenderness  on  pressure.  The  bowels  are  reported  loose,  but  patient 
does  not  complain  of  their  frequency.  Urine  is  quite  natuial.  The  skin  over  the 
body  generally  is  of  an  unusually  high  temperature  and  dry.  No  lesion  of  the  neivous 
system ; is  exhausted,  and  is  mentally  despondent.  As  ordered  vine  ( § iij)  and  mime 
diaphoretics. 

Progress  op  the  Case. — May  81st. — Sputum  rather  frothy,  semi-transparent 
gelatinous,  slightly  tinged  with  blood;  pulse  114;  febrile  condition  the  same;  the 
diarrhoea  has  not  ceased.  Jeme  8d. — Diarrhoea  continues ; faeces  of  a light  yellow 
color  and  pea-soup  consistence,  of  an  extremely  faeculcnt  odor,  presenting  on  n icro- 
scopic  examination  no  blood  discs  nor  other  abnormial  bodies.  Ordered  an  astringent 
and  chalk  mixture.  June '1th. — Febrile  s}miptcms  continue;  ordered  8 grains  of  ejuir 
nine  thrice  daily.  The  diarrhoea  slightly  abated  ; continue  the  astringent  mixture. 
June  nth. — Diarrhoea  continues  with  much  tenesmus;  frequent  calls  (from  6 to  8 
times)  at  night  to  stool ; evacuations  at  each  time  are  scanty ; stools  watery,  let 
him  have  an  opiate  suppository  at  night.^  and  after  every  stool  let  the  follcuing  enema 
he  administered : — Plumb.  Acetat.  Dj  ; Aep  Distill.  § iss ; Sol.  Mur.  Morph.  3 ss. 
June  IMh. — Patient  expresses  himself  as  better,  and  the  febrile  excitement  is  dimi- 
nished. June  lAth. — The  diarrhoea  has  not  ceased  ; the  injections  cause  pain,  and  are 
speedily  ejected ; they  are  now  discontinued  ; orelered  half  ounce  of  the  decoction  of  the 
Inelian  Bad  thrice  daily.  June  Pith. — In  addition  to  the  decoction.,  let  him  have,  thrice 
daily,  one  of  the  following  powders  : — D P^dv.  Cretce  prep.  3 ij  ; Confect.  Arcmat  Vj  ; 
Pedv.  opii  gr.  iij.  M.  et  divide  in  chartulas  duodccirn.  July  ‘id. — Febrile  symptoms 
and  diarrhoea  much  diminished  ; skin  cooler;  pulse  86,  of  miOderate  strength  ; oedema 
of  the  lees  is  much  less  than  formerly.  On  the  4:th,  he  becomes  worse;  on  the  hth, 
feels  better ; on  the  8th,  diarrhoea  again  more  severe,  and  febrile  symptom,s  renewed. 
On  the  ^th,  the  blood  was  microscopically  examined,  and  an  increase  of  white  cor- 
puscles was  detected  (from  20  to  25  being  visible  in  one  field),  and  the  red  discs  ar- 
ranged themselves  in  irregular  masses.  On  the  ll^A,  the  powders  and  decoction  are 
discontinued,  and  a mixture  of  Kino,  Catechu,  and  Simaruba  was  given.  On  the 
lo.Ai,  the  diarrhoea  being  persistent,  the  use  of  the  powders  is  resumed,  and  at  night 
an  astringent  injection.  On  the  15^/i  and  17/A,  is  better;  on  the  20/7i,  is  worse  and 
seldom  off  the  stool;  on  the  21.s7,  is  better,  having  had  only  three  stools;  on  the 
24^A,  has  six  stools,  skin  being  burning  hot,  pulse  120,  hard,  and  appaiently  strong, 
but  patient  complains  of  great  debility.  July  i^th. — Great  thirst ; pain  over  abdo- 
men, which  is  relieved  by  a turpentine  epithera.  Abdomen  is  tense,  with  skin 
white,  glistening,  and  dry ; percussion  very  tympanitic  anteriorly ; is  slightly  dull 
over  the  flanks.  July  i8th. — Patient  is  extremely  weak ; faeces  are  passed  in  bed. 
Urine  is  examined  and  found  non-albuminous ; has  been  delirious  this  moining. 
July  29//n — No  return  of  the  delirium;  swelling  of  abdomen  increased;  the  diairhaa 
and  febrile  state  continue;  pulse  112,  very  weak;  great  thirst.  July  8Qih. — Died 
this  morning  at  9.30  a.m. 

Sectio  Cadaveris. — Forty -eight  hours  after  death. 

Body. — Moderately  emaciated ; oedema  of  feet  and  legs ; face  with  a peculiar  fever- 
ish expression. 

Thorax. — Heart  was  quite  natural.  The  two  upper  lobes  of  right  lung  healthy  ; 


DISEASES  OF  THE  INTESTIXES. 


529 


the  lower  lobe  felt  heavy,  presenting  a rounded  prominence  about  three  inches  in  dia- 
meter projecting  from  its  surface.  On  section  it  was  found  to  be  a mass  of  soft 
cancer,  of  an  oval  form,  about  the  size  of  a fist ; greyish  or  pinkish-white  in  color, 
with  some  opaque  yellow  patches  (reticulum)  intermixed  with  it.  It  readily  broke 
down  under  pressure,  and  part  had  already  undergone  softening.  In  its  neighbor- 
hood were  two  other  masses  of  similar  character,  about  the  size  of  small  marbles.  In 
the  lower  lobe  of  the  left  lung  there  was  a cancerous  mass  of  the  size  of  a filbert ; 
otherwise  the  lung  was  healthy.  The  bronchial  glands  were  natural. 

Abdomen. — The  peritoneum  contained  nearly  a gallon  of  a somewhat  opalescent 
serum.  The  liver  was  of  small  size,  and  presented  a coarsely  granular  surface.  On 
section  it  was  found  in  a moderately  advanced  state  of  cirrhosis ; it  weighed  2 lbs.  8 
oz.  The  spleen  was  quite  natural,  and  weighed  6 ounces.  Kidneys  healthy.  Stomach 
normal.  The  coats  of  the  small  intestines  were  generally  thickened  and  oedematous, 
but  there  was  no  trace  of  ulceration.  The  mucous  membrane  of  the  large  intestines 
was  found  extensively  ulcerated,  chiefly  in  the  transverse  and  descending  colon.  There 
were  a few  ulcerations  in  the  caecum  and  upper  part  of  the  rectum ; they  ceased  alto- 
gether about  3 inches  above  the  anus.  The  calibre  of  the  intestine  was  diminished. 
The  ulcerations  were  of  a very  chronic  character,  there  being  no  increased  vascularity 
of  the  surrounding  mucous  membrane.  They  were  generally  arranged  in  a linear 
direetion,  parallel  to  the  long  axis  of  the  gut.  Many  were  nearly  cicatrized,  present- 
ing in  the  base  and  margin  an  aecumulation  of  dark-colored  pigment.  There  were 
pretty  numerous  slate-colored  cicatrices,  indicating  the  position  of  former  ulcers. 
No  other  lesion  was  found. 

Microscopic  Examination. — The  cancerous  exudation  in  the  lungs  contained 
numerous  cancer  cells  in  all  stages  of  development.  Some  of  them  were  very  large, 
and  contained  from  three  to  five  secondary  cells.  Several  of  them  contained  clear 
collections  of  fluid,  as  represented  Fig.  294. 

Commentary. — The  three  cases  now  related  present  the  same  disease 
in  different  degrees  of  severity.  In  the  first,  there  is  every  reason  to 
suppose  that,  though  severe,  it  was  not  extensive.  In  the  second,  it  was 
more  chronic,  but  ultimately  the  patient  got  well.  In  the  third,  it  went 
on  to  such  extensive  ulceration,  kept  up  such  constant  irritative  fever, 
and  so  interfered  with  nutrition,  as,  conjoined  with  the  other  lesions 
under  which  the  man  labored,  to  cause  death ; on  dissection  afterwards 
it  was  seen  that  he  had  had  chronic  disease  of  the  liver,  which  had  caused 
ascites  and  oedema  of  the  extremities.  On  this  had  supervened  the  in- 
fiamination  of  the  lower  bowel,  especially  of  the  colon,  which  had  pro- 
ceeded to  ulceration,  extending  over  a considerable  portion  of  the  mucous 
membrane.  In  many  places  the  ulcers  had  healed,  while  in  others  there 
was  exhibited  a tendency  to  cicatrization ; and  it  is  very  possible  that 
a recovery  might  have  occurred  in  this  case,  as  in  the  one  which  pre- 
ceded it,  but  for  the  hepatic  disease,  which,  by  keeping  up  constant 
congestion  of  the  portal  system,  and  therefore  of  the  intestinal  venous 
capillaries,  must  have  opposed  itself  to  all  successful  efforts  at  cure  of 
the  ulcers.  The  masses  of  cancer  developed  in  the  lower  portion  of  the 
hings,  and  which  gave  rise  to  many  of  the  symptoms  of  pneumonia, 
especially  cough  and  bloody  expectoration,  cannot  be  said  to  have  had 
any  influence  in  producing  the  fatal  termination. 

In  the  case  of  Crease  I employed,  as  an  astringent,  a decoction  of  the 
unripe  fruit  of  the  Indian  Bael,  commonly  called  the  Bengal  Quince. 
It  is  said  to  contain  tannin,  both  free  and  in  a combined  state,  an  aromatic 
principle,  mucilage,  and  a small  amount  of  a bitter  substance  supposed  to 
be  sedative.  The  decoction  must  be  used  fresh,  and  is  prepared  by  sim- 
mering two  ounces  of  the  unripe  fruit  in  a pint  of  water  down  to  a 
fourth,  of  which  from  one  to  three  table-spoonfuls  constitute  a dose.  In 
the  case  of  a gentleman  under  my  care,  whose  obstinate  diarrhoea  had 
34 


530 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


resisted  all  the  usual  means,  this  decoction  checked  the  disorder  perman- 
ently after  a few  doses;  and  I have  since  given  it  wdth  great  advantage 
in  similar  cases.  In  the  case  of  Crease  it  was  of  no  benefit  whatever. 
Indeed  it  cannot  be  supposed  that  where  actual  ulcerations  exist  over  a 
considerable  portion  of  the  mucous  surface  of  the  colon,  any  remedies 
can  produce  an  impression  on  the  alvine  discharges.  These  are  the 
result  of  the  organic  lesion,  so  that  medicines  merely  directed  to  the 
symptoms,  unless  they  favor  cicatrization,  cannot  operate  with  effect. 
This  requires  time,  general  health  of  body,  avoidance  of  irritating  food 
and  mental  excitement,  quietude,  a good  atmosphere,  pure  water,  etc. 
etc. — in  short,  local  agents  must  be  combined  with  all  those  general 
remedies  and  hygienic  conditions  calculated  to  improve  the  vital  powers, 
and  favor  regeneration  of  tissue. 

Diarrhoea  and  dysentery  pass  into  one  another;  a great  variety  of 
lesions  may  induce  the  first,  but  the  last  is  considered  to  be  a true  in- 
flammation of  the  large  intestines.  Hence  the  symptoms  of  dysentery 
are  local  pain,  accompanied  by  fever,  and  attended  with  a discharge  from 
the  bowels,  first  of  blood  and  then  of  pus.  The  blood  results  from  rup- 
ture of  the  capillaries  consequent  upon  their  congestion,  and  is  mingled 
with  the  mucous  discharge.  Fluid  exudation  is  at  first  poured  out  on 
the  surface  and  passes  away  from  the  bowels  with  the  excess  of  mucus 
and  blood,  but  subsequently  purulent  matter  is  thrown  off  from  the 
ulcerated  surface  of  the  mucous  membrane. 

The  character  of  the  faecal  evacuations  should  be  carefully  attended 
to,  not  only  in  dysentery,  but  in  all  forms  of  intestinal  disease.  In 
health  the  faecal  evacuation  consists  of  a soft  solid  mass,  forming  a mould 
of  the  outlet  at  the  anus.  It  is  mingled  with  bile,  and  presents  a dark 
brown  color.  Its  odor,  though  faecal,  is  not  putrid.  As  a general  rule, 
the  more  the  alvine  evacuation  departs  from  its  normal  consistence, 
color,  and  odor,  the  more  violent  is  the  cause  which  occasions  the 
change.  Thus,  as  regards  consistence,  the  dischai'ge  from  the  bowels 
may  be  fluid,  though  faeculent,  sometimes  resembling  pea-soup,  the 
characteristic  stools  of  active  typhus.  The  discharge,  again,  may  be 
watery  through  an  excessive  amount  of  serum,  resulting  from  congestion 
of  the  vessels,  or  occasioned  by  saline  and  drastic  cathartics.  In  cholera 
the  discharge  resembles  rice-water,  and  is  largely  mingled  with  pure 
desquamated  epithelium.  It  may  consist  of  shreds  of  glairy  mucus, 
which  is  very  common  in  females  with  uterine  disease,  and  sometimes  of 
masses  of  recently  coagulated  exudation,  or  a substance  like  white  of 
egg.  In  color  it  may  be  paler  than  natural,  to  such  a degree  as  to  be 
clay-colored  or  almost  white,  indicating  a diminished  quantity  of  bile. 
It  may  be  red,  reddish-brown,  grass-green,  or  absolutely  black,  from  the 
presence  of  blood,  and  according  as  blood  has  been  poured  into  the  in- 
testine more  or  less  near  its  outlet,  or  as  chemical  changes  have  occurred 
in  it  before  being  discharged.  In  other  cases  it  may  be  of  a dark  leaden 
hue,  or  of  a dirty  yellow  more  or  less  resembling  pus.  If  pus  and  blood 
appear  in  the  stools  almost  pure,  then  these  fluids  have  been  poured  out 
not  far  from  the  orifice ; the  more  they  are  mingled  with  faeculent  or 
fluid  matter  the  more  is  their  origin  distant.  Constant  fluid  stools  of  a 
uniform  color  arc  generally  derived  from  the  small  intestines.  As  to 


DISEASES  OF  THE  INTESTINES. 


531 


odoi’j  the  more  offensive  and  putrid,  the  greater  is  the  indication  of 
absence  of  bile  in  some  cases,  and  prostration  of  the  vital  powers  in 
others.  In  the  examination  of  the  feces  the  microscope  will  be  found 
of  the  greatest  service.  (See  p.  90.) 

The  morbid  anatomy  of  dysentery  and  of  enteritis  generally  is  a most 
extensive  subject,  for  vdiich  I must  refer  you  to  the  various  special  works 
which  treat  of  it.  It  will  suffice  to  say  that  the  seat  of  the  exudation  is 
for  the  most  part  the  areolar  texture  below  the  basement  membrane,  but 
pressing  principally  on  the  mucous  surface,  and  giving  rise  to  hemor- 
rhages, ulcerations,  purulent  discharges,  etc.  If  the  disease  be  chronic, 
the  muscular  coat  becomes  hypertrophied,  causing  thickening  and  rigidity 
of  the  intestinal  tube.  If  violent  gangrene  occur,  the  mucous  surface 
after  death  presents  a deep  red  color,  which  is  caused  by  congestion 
of  the  vessels;  sometimes  bright  green  patches  are  mingled  with  the  red, 
and  result  from  alteration  in  the  color  of  extravasated  blood;  then  again, 
brown  or  blackish  sloughs  may  be  observed  from  decomposition  of  the 
injured  texture.  Typhoid  enteritis  will  be  subsequently  described  (See 
Fever.)  Tubercular  enteritis  is  a common  complication  of  phthisis, 
generally  hurrying  on  the  fatal  result.  Cancerous  enteritis  is  by  no 
means  uncommon. 

The  structural  changes  observed  in  the  mucous  membrane  in  cases 
of  diarrhoea  and  dysentery  are — 1st,  Degeneration  of  the  epithelium  ; 
2d,  Congestion  of  the  vessels  and  hemorrhage;  3;i,  Exudation;  4th,  Mor- 
bid changes  in  the  various  glauds;  5th,  Waxy  degeneration. 

1.  The  readiness  with  which  the  epithelium  is  separated  from  the 
basement  membrane  of  the  intestinal  mucqus  membrane  varies  much  in 
different  animals.  For  instance,  I have  found  it  to  be  easily  separable 
in  dogs,  while  in  cats  it  is  very  firmly  adherent.  This  circumstance  ex- 
plains, to  a certain  extent,  the  different  ideas  put  forth  by  experimental- 
ists as  to  the  function  of  the  epithelium  in  digestion.  Some  maintain 
that  it  is  cast  off  so  as  to  admit  of  endosmose  through  the  naked  villus ; 
whilst  others  maintain  that  endosmose  is  carried  on  through  the  agency 
of  the  epithelial  cells 
themselves  in  which 
I believe  to  be  the  cor- 
rect doctrine.  In  man 
the  epithelial  cells  are 
easily  separated,  and 
their  separation  consti- 
tutes a morbid  state  of 
great  importance,  be- 
cause if,  as  I suppose, 
they  be  the  organs  of 
primary  assimilation, 
their  removal  must 
interfere  with  nutri- 
tion. This  I consider 
to  be  one  of  the  reasons  why  chronic  diarrhoeas,  and  more  especially 

Fig.  430.  Vascular  congestion  and  sugillation  of  the  mucous  membrane  of  the 
small  intestine  in  cholera,  a and  6,  Congested  tortuous  vessels  in  villi,  which  are 
deprived  of  epithelium ; c.  The  veins  only  congested  in  four  villi ; </,  Extravasation  of 
blood  below  the  basement  membrane,  and  around  the  glands  of  Lieberkuhn. — ( Wedli) 

50  diam. 


Fig.  430, 


532 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


cholera,  in  which  disorder  the  rice-water  stools  consist  chiefly  of  serum, 
containing  desquamated  epithelium,  are  so  prostrating  to  the  economy. 
Of  course  the  interference  with  nutrition  so  occasioned  will  be  in  propor- 
tion to  the  extent  of  mucous  membrane  affected. 

2.  Great  congestion  of  the  vascular  plexus,  which  ramifies  in  the 
villi  and  around  the  glands,  is  one  of  the  most  common  appearances  seen 
after  death  in  the  intestinal  mucous  membrane ; it  is  often  associated 
with  extravasations  of  blood  more  or  less  extensive.  This  lesion  may 
be  conjoined  with  all  the  others  to  which  this  texture  is  liable,  and  is  at 
once  visible  both  to  the  naked  eye  and  on  microscopic  observation.  In 
all  cases  of  acute  diarrhoea,  dysentery,  and  in  cholera,  this  morbid 
change  may  be  recognised. 

3.  Exudation  may  occur  below  the  basement  membrane,  infiltrating 
the  areolar  texture  between  it  and  the  mucous  coat,  occupying  the  villi 
and  surrounding  the  various  glands ; or,  more  rarely,  it  may  appear  on 
the  surface  of  the  mucous  membrane,  presenting  adherent  coagula. 
In  the  former  case  it  undergoes  the  usual  transformations,  giving 
rise,  according  to  circumstances,  to  purulent  collections,  fibrous  growths, 
or  ulcerations  varying  in  extent,  which  may  or  may  not  ultimately 
cicatrize.  In  the  latter  case  the  coagulated  exudation  rarely  presents 

a fibrillated  structure,  but  rather  a dense  ag- 
gregation of  fibrinous  amorphous  substance, 
which  disintegrates  or  passes  into  pus.  \Yith- 
in  the  villi  it  often  assumes  an  opaque  brown- 
ish color,  and  passes  into  granule  cells,  while 
the  blood,  which  has  been  extravasated  or  ar- 
rested in  the  vessels,  is  transformed  into  black 
pigment.  (Fig.  431,  h,  c,  and  d). 

4.  The  morbid  changes  in  the  various 
glands  have  been  more  especially  studied  in 
relation  to  typhoid  fever,  under  which  head  I 
shall  again  refer  to  them.  There  can  be  no 
doubt,  however,  that  the  glands  of  Brunner 
and  Lieberkuhn,  as  well  as  those  of  Peyer, 
are  constantly  undergoing  alterations,  pro- 
bably similar  to  those  so  well  described  by  Dr. 
Fig.  431.  Handfield  Jones  in  the  stomach,  although  few 

histological  and  clinical  researches  have  as  yet  been  made  regarding 
them.  In  children,  in  whom  the  intestinal  mucous  membrane  is  active 
and  easily  irritated,  the  shut  sacs  of  Peyer  are  often  unusually  large 
(Fig.  432.) 

5.  Waxy  degeneration  of  the  villi  and  mucous  membrane,  generally 
extending  over  a greater  or  less  portion  of  the  surface,  may  now  be  re- 
garded as  a fruitful  source  of  constant  diarrhoea.  This  I have  ascertained 
to  exist  in  many  cases  of  leucocythemia,  with  a similar  degeneration  in 
various  organs,  especiall}?^  the  spleen,  liver,  and  kidneys.  In  such  cases 
uncontrollable  diarrhoea  is  a leading  symptom.  The  thin  translucent 
tissue  under  such  circumstances  appears  to  favor  the  transmission  of 

Fig.  431.  a,  Granular  mass,  in  recent  exudation  on  the  surface  of  the  intestinal 
mucous  membrane  ; A,  summit  of  a villus,  containing  black  pigment,  at  -f-,  in  a ves- 
sel ; c.  Summit  of  a villus,  containing  a brown  exudation ; d,  Another  villus,  with  the 
exudation  transformed  into  granule  cells  and  masses. — ( Wedl.)  250  diam. 


DISEASES  OF  THE  INTESTINES. 


533 


serous  fluids  through  it,  as  we  shall  see  is  remarkably  the  case  in  certain 
forms  of  Bright’s  disease. 

The  treatment  of  ordinary  dysentery,  such  as  we  meet  with  in  this 
country,  may  be  gathered  from  the 
cases  Tecorded.  It  consists — 1st,  In 
careful  regulation  of  the  diet,  which 
should  be  nutritive  but  unirritatiug; 

2d,  In  confinement  to  bed ; 3d,  In 
the  use  of  antacids  and  astringents 
to  check  the  discharges ; and  4th, 

In  the  employment  of  leeches,  fo- 
mentations, and  poultices  locally, 
and  of  opium  internally  to  relieve 
pain  and  diminish  irritability.  It 
should  not  be  forgotten,  however, 
that,  although  in  consequence  of  in- 
flammation there  may  be  abundant 
diarrhoea,  this  may  be  conjoined  with 
a true  constipation ; in  other  words,  the  excrement  which  it  is  necessary 
for  the  body  to  throw  out,  may  be  retained  in  the  caecum  or  upper  part  of 
the  canal,  in  consequence  of  the  contraction  or  irritability  of  the  canal 
lower  down.  Hence  it  is  necessary  occasionally  to  administer  a small  dose 
of  castor-oil  or  other  mild  aperient,  to  secure  the  passage  of  effete  matter 
from  the  system,  a point  in  practice  requiring  great  care  and  experience. 

Whenever  dysentery  is  violent  and  epidemic,  I have  long  been  per- 
suaded that  the  former  antiphlogistic  treatment,  followed  by  calomel,  etc., 
was  opposed  to  a sound  pathology  in  this  as  in  all  other  inflammations. 
I was,  therefore,  much  gratified  to  observe*  that  Dr.  W.  L.  Lindsay, 
physician  to  the  Ballarat  Hospital,  has  recently  treated  no  less  than  63 
cases  simply  by  means  of  rest  and  nutrients,  with  the  result  of  invari- 
able success. 

Derangements  of  the  alimentary  canal  constitute  the  great  majority 
of  children’s  diseases.  In  them  this  portion  of  the  economy  is  actively 
engaged,  not  only  in  developing  itself,  but  in  producing  by  means  of 
digestion  and  assimilation,  an  excess  of  nutritive  materials  for  the  blood. 
During  these  processes  of  evolution,  the  functions  of  the  alimentary 
canal  are  especially  liable  to  be  disordered,  and  frequently,  as  a result 
of  the  irritations  thereby  occasioned,  various  convulsive  or  diastaltic 
affections  arise.  In  all  such  cases  the  practitioner  should  endeavor  to 
remove  local  irritations  and  support  nutrition.  The  former  object  is 
best  accomplished  by  antacid  medicines,  especially  chalk  and  magnesia, 
and  occasionally  a mild  aperient,  such  as  castor-oil ; the  latter,  by 
careful  attention  to  the  diet,  procuring  a healthy  nurse,  etc.  The  con- 
stant flow  of  saliva  during  dentition,  the  vomitings  from  over  distension 

* Australian  Medical  Observer,  October  1864. 

Fig.  432.  An  enlarged  Peyerian  sac  from  the  colon  of  a child,  a.  Glands  of  Lie- 
berkuhn ; 6,  Muscular  layer ; c,  Sub-mucous  tissue ; d,  Transverse  muscles ; e, 
Serous  membrane;  /,  Depression  of  mucous  membrane  over  the  sac,  g. — [Kolliker.) 

60  diam. 


534 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


of  tlie  stomach,  and  occasional  diarrhoea  in  weak  children,  are  often 
salutary  discharges,  which  only  require  watching  and  hygienic  regulation, 
and  will,  it  is  hoped,  no  longer  be  mistaken  for  symptoms  of  an  active 
inflammation  which  requires  antiphlogistic  remedies 

Case  LXXXVI.* — Ohstruction  of  the  large  Intestine — Cancer  of  Stomachy 
Liver ^ Peritoneum  generally^  and  Meseyiteric  Glands. 

History. — James  Sturgeon,  ost.  21,  tax-collector — admitted  into  the  Clinical  Ward 
of  the  Royal  Infirmary,  September  14,  1853.  He  noticed  for  the  first  time  last  Janu- 
ary that  his  appetite  had  diminished,  and  he  was  greatly  troubled  with  flatulence, 
vomiting,  and  constipation.  These  symptoms  continued  until  three  months  ago, 
when  the  abdomen  became  swollen,  and  gradually  so  distended,  that  he  applied  to  Dr. 
Alison,  under  whose  treatment  the  vomiting  nearly  disappeared.  He  then  noticed 
several  hard  lumps  in  the  abdomen,  varying  in  size  from  a walnut  to  a hen’s  egg. 
These  since  then,  have  continued  to  increase  in  size,  and  have  become  very  painful  on 
pressure. 

Progress  of  the  Case, — Ocioher  1%ih. — Since  his  admission  the  appetite  has  been 
gradually  failing,  and  he  has  become  daily  thinner  and  weaker.  He  has  experienced 
considerable  pain  in  the  abdomen,  combined  with  a feeling  of  tightness  and  constric- 
tion there.  It  has  always  felt  tense,  and  contained  more  or  less  fluid,  but  until  a 
fortnight  ago,  the  tumors  formerly  mentioned  could  be  felt  very  distinctly,  separated 
from  the  walls  of  the  abdomen  by  a thin  layer  of  fluid.  The  bowels  have  been  greatly 
constipated.  The  treatment  has  consisted  in  the  administration  of  diuretics  of  every 
kind,  with  strong  purgatives,  cnemata,  warm  fomentations  to  the  abdomen,  and 
occasionally  anodyne  draughts  at  night.  On  taking  charge  of  this  patient  to-day,  I 
found  his  condition  as  follovrs  : — Great  emaciation  ; complexion  of  a cachectic  waxy 
appearance  ; skin  cold  and  dry ; tongue  moist,  with  a brownish  fur  ; breath  offensive ; 
very  little  appetite ; only  occasional  vomiting ; and  no  thirst.  Bowels  have  not  been 
opened  for  four  days,  a draught  of  castor-oil  with  a drop  of  croton-oil  having  m.erely 
brought  away  a few  hard  lumps  of  fajces  of  a dark  color.  Purgatives  do  not  cause 
griping.  The  abdomen  is  greatly  enlarged,  and  tense,  but  with  a distinct  feeling  of 
fluctuation.  No  tumors  can  now  be  felt,  but  during  inspiration  distinct  friction  can  be 
felt  by  the  hand,  and  heal'd  by  means  of  the  stethoscope.  Pressure  causes  a 
trifling  obscure  amount  of  pain,  but  his  chief  complaint  is  from  the  sense  of  constric- 
tion. The  pulse  is  70  ; regular  and  feeble.  A murmur  is  audible  with  the  first  sound 
of  the  heart,  at  the  base ; action  is  regular ; no  palpitation.  There  is  drj  cough  and 
slight  dyspnoea.  The  respiratory  sounds  are  feeble,  but  otherwise  seem  natural.  Urine 
healthy.  Prom  this  time  he  gradually  sunk.  (Edema  appeared  in  the  inferior  ex- 
tremities; vomiting  became  more  severe,  and  at  length  constant,  whenever  food  or 
drink  was  taken.  All  kinds  of  medicines  failed  even  as  palliatives ; emaciation  became 
extreme,  and  he  sank  November  5,  the  bowels  having  been  obstinately  closed  for  ten  days. 

Sectio  Cadaveris. — Forty  hours  after  death. 

Thorax. — Pulmonary  tissue  everywhere  spongy  and  crepitant.  On  the  superior 
lobe  of  the  left  lung  there  were  two  cicatrices,  and  on  the  right  pulmonary  pleura  there 
were  similar  patches,  more  widely  scattered,  extending  over  the  whole  of  superior,  mid- 
dle, and  inferior  lobes.  Purulent  mucus  was  easily  pressed  from  several  of  the  bronchi. 
No  carcinomatous  nodules  were  found  in  the  pulmonary  tissue,  but  the  whole  intercos- 
tal pleura  was  studded  over  with  small  irregular  plates  of  cancerous  exudation,  bearing 
a considerable  resemblance  to  the  eruption  of  small-pox.  Heart  small ; muscular  sub- 
stance pale  fawn-colored.  The  pericardium  shows  on  its  external  surface  numerous 
cancerous  nodules  from  the  size  of  a pin’s  head  to  that  of  a small  flattened  coffee  bean. 
Bronchial  glands  at  the  root  of  lung  swollen,  some  of  them  the  size  of  a pigeon’s  egg ; 
all  infiltrated  with  cancer,  and  some  mingled  with  black  pigment. 

Abdomen. — The  liver  was  smooth  on  its  surface.  Inferiorly  and  laterally  it  was 
closely  adherent  to  the  diaphragm,  the  pleural  surface  of  which  was  covered  by  lami- 
nae of  cancerous  matter.  On  stripping  off  the  diaphragm  the  peritoneal  covering  of 
the  liver  was  seen  infiltrated  with  cancer,  in  some  places  to  the  depth  of  half  an  inch. 
Substance  of  liver  presented  the  usual  appearance  of  the  white  tubercle  of  Farre ; it 

* Reported  by  Mr.  Wm.  Calder,  Clinical  Clerk. 


DISEASES  OF  THE  INTESTINES. 


535 


was  pale,  soft,  and  very  fatty.  The  spigelian  lobe  of  the  liver,  the  omentum,  epigastric 
glands,  spleen,  and  pancreas,  were  united  togetlier,  and  formed  a large  irregular  whitish 
mass  extending  across  the  abdomen,  and  weighing  4 lbs.  This  mass  formed,  on  the 
right  side,  a dense  wedge  pressing  in  the  right  iliac  fossa  upon  the  ascending  colon  im- 
mediately as  it  leaves  the  caecum ; this  bowel  was  filled,  but  not  distended,  with  firm 
yellow  fieces,  but  the  ascending,  descending,  and  transverse  colon  were  empty  and 
collapsed.  The  peritoneum  covering  the  intestine  was  dotted  all  over  with  nodular 
projecting  masses,  varying  in  size  from  a millet  seed  to  a hazel  nut,  in  color  from  white 
to  deep  red,  and  even  almost  black,  and  in  consistence  from  soft  pulpy  matter  to 
nodules  considerably  indurated.  The  whole  of  the  abdominal  peritoneum  was  closely 
covered  with  similar  irregular  nodules,  for  the  most  part  of  soft  consistence,  with  here 
and  there  a little  coagulated  blood.  There  were  two  gallons  of  sanguineous  serum  in 
the  peritoneal  cavity.  Spleen  small  but  healthy ; it  was  closely  adherent  to  the  dia- 
phragm above  and  the  cancerous  mass  below,  and  on  section  seemed  to  be  surrounded 
by  a thin  layer  of  cancer  infiltrated  in  the  peritoneum  superiorly  while  inferiorly  the 
cancerous  mass  all  around  it  is  1^^  inch  in  thickness.  Stomach  imbedded,  and  also 
compresse<l,  in  the  cancerous  mass,  which  was  everywhere  adherent  to  its  peritoneal 
surface.  Its  mucous  membrane,  as  well  as  that  of  the  alimentary  canal,  was  quite 
healthy.  On  section  of  the  mass  it  presented  the  uniform  appearance  of  white  lard, 
giving  to  the  finger  a feeling  of  considerable  firmness.  It  yielded  no  cancerous  juice, 
but  was  friable,  readily  breaking  down  under  pressure. 

Microscopic  Examination. — The  whole  of  the  cancerous  exudation  on  the  peri- 
toneum exhibited  numerous  cancer  cells,  in  some  places  mingled  with  fibres,  in  others 
associated  with  numerous  oil  granules  and  granular  cells.  The  white  masses  on  the 
pleurae  were  principally  composed  of  fibres,  but  on  the  addition  of  acetic  acid  might 
be  seen  to  be  crowded  with  cancer  nuclei. 

Commentary. — In  this  case  it  was  observable  that  the  vomiting  did 
not  occur  regularly  after  taking  food,  and  that  the  ejected  matters  con- 
sisted of  the  ingesta,  and  were  never  mixed  with  recently  extravasated  or 
altered  blood.  This  indicated  that  no  ulcer  or  erosion  of  the  stomach 
had  taken  place.  That  the  peritoneum  and  mesenteric  glands  were  the 
principal  textures  involved,  was  indicated  by  the  nodular  swellings  felt, 
and  the  friction  sound  audible  over  the  peritoneum,  and  the  abdominal 
distension  from  accumulation  of  fluid.  The  continued  constipation  also 
indicated  some  mechanical  contraction  of  the  gut,  obviously  owing  to 
cancerous  deposition  in  some  way  pressing  on  or  constricting  it, — all 
which  suppositions  were  proved  to  be  correct  on  examination  of  the  body 
after  death. 

Case  LXXXVII.^' — Strangulation  of  the  Small  Intestine  from  Inguinal 
Hernia — Gangrene^  Ulceration^  ayid  F erf  oration  of  the  Intestine — 
Feritonitis. 

History. — Margaret  Bruce,  let.  47 — admitted  September  25th,  1848.  Says  that  she 
has  occasionally  had  a swelling  in  the  left  groin  for  the  last  nine  years,  that  has  always 
gone  away  on  lying  down  and  applying  warm  fomentations.  On  the  18th,  while  car- 
rying a large  bucket  of  water  up  stairs,  she  felt  something  give  way  in  the  left  groin. 
On  the  following  morning  she  suddenly  awoke  with  rigors,  shortly  followed  by  nausea 
and  vomiting.  The  left  groin  also  felt  painful,  and  she  perceived  a tumor  there  the 
size  of  a man’s  fist.  Purgatives  were  now  taken  without  causing  any  action  of  the 
bowels.  The  vomiting,  however,  became  more  intense,  and  the  matter  ejected  more 
of  a dark-brown  color.  In  this  condition  she  has  continued  ever  since. 

Symptoms  on  Admission. — On  admission  she  lay  on  her  back,  with  the  thighs  flexed 
on  the  abdomen.  The  countenance  was  sharp,  sallow,  and  expressive  of  great  suffering. 
Extremities  cold.  Pulse  1 20,  small  and  weak.  Respiration  difficult,  especially  during 
inspiration.  Percussion  and  auscultation  of  the  chest  elicit  nothing  abnormal.  Tongue 
white,  but  red  at  the  top  and  edges.  Bowels  have  not  been  opened  for  eight  days,  and 


Reported  by  Mr.  T.  N.  Fanning,  Clinical  Clerk. 


536 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


there  is  frequent  vomiting  of  matter  like  coffee.  Skin  of  abdomen  is  hot  and  dis- 
tended, and  she  complains  of  great  pain  in  the  umbilical  and  left  iliac  regions  on  the 
slightest  touch.  A ttuctuating  tumor,  the  size  of  an  orange,  occupies  the  left  groin, 
over  Poupart’s  ligament.  Urine  scanty  but  normal.  Menstruation  has  been  irregular. 
Other  functions  normal.  Mr.  S}une  was  consulted,  who  opened  the  tumor,  from  which 
there  was  evacuated  about  § v of  foetid  serum,  mixed  with  dirty  yellow  purulent  mat- 
ter. Warm  fomentatiou 8 to  he  applied  to  the  abdomen.  To  have  one  grain  of  opmm 
in  the  form  of  pill  immediately.  In  the  evening  the  symptoms  were  the  same,  with  the 
exception  of  the  abdominal  pain,  which  was  more  violent,  and  appeared  as  if  she  was 
cut  with  a sharp  instrument.  Has  had  three  injections  of  warm  water,  which  return 
unaltered.  To  have  Pulv.  Opii  gr.  ij.  every  hour. 

Progress  oe  the  Case. — September  26i'/n — No  change.  The  opium  produces  no 
effect  whatever.  Strong  beef  tea  to  be  taken  in  small  quantities.  To  eat  as  much  ice 
as  she  pleases.  September  With. — Vomiting,  abdominal  pain,  and  intestinal  obstruction 
continue.  Abdomen  considerably  swollen.  Sore  in  the  left  groin  looks  very  unhealthy. 
Thirst  and  dryness  of  the  lips  and  fauces  are  much  relieved  by  the  pieces  of  solid  ice. 
Has  taken  opium  in  three-grain  doses  every  second  or  third  hoxir.,  which  has  caused  ap- 
parently no  effect  whatever.  September  Wth. — V omited  matters  to-day  are  distinctly 
feculent.  The  abdomen  above  the  umbilicus  and  in  left  flank  is  greatly  swollen,  very 
tender,  and  tympanitic ; over  the  right  lower  third  it  is  collapsed.  A dirty  sanious 
discharge  is  poured  from  the  wound  in  left  groin.  Pulse  1 1 0,  very  small  and  weak. 
Tongue  brown  and  dry.  Quite  sensible,  but  much  exhausted.  Utters  low  moans,  and 
complains  principally  of  dryness  of  mouth  and  throat,  which  continues  to  be  relieved 
by  the  ice.  Bowels  continue  closed.  To  have  a table-spoonful  of  voine  and  beef -tea 
every  hour,  and  | viij  of  beef  tea  injected  into  the  bowels  slowly,  night  and  morning. 
Pulv.  Opii  gr.  iij,  to  be  given  only  at  night.  September  %Qth. — The  discharge  from  the 
groin  to-day  is  feculent,  as  well  as  the  vomited  matters.  Complains  of  no  pain,  but 
there  is  commencing  delirium.  Pulse  100,  scarcely  to  be  felt.  Prostration  extreme. 
Distension  of  abdomen,  and  other  symptoms  the  same.  Died  October  l6‘^. 

Sectio  Cadaveris. — Thirty-six  hours  after  death. 

Body  pale  and  emaciated.  'Over  Poupart’s  ligament  was  an  oval  ulcer,  measuring  an 
inch  and  a half  in  its  longest  diameter,  which  was  slightly  oblique  from  above  down- 
wards. Its  base  was  superficial,  of  a brownish  black  color,  and  feculent  odor. 

Thorax. — Slight  chronic  adhesions  between  pleurse  on  right  side.  Lungs  somewhat 
emphysematous  anteriorly.  Thoracic  organs  otherwise  healthy. 

Abdomen. — On  opening  the  abdominal  cavity,  the  liver,  stomach,  and  intestines 
superiorly,  were  seen  to  be  covered  by  a uniform  membranous  expansion  of  lymph. 
The  remainder  of  the  intestines  and  the  uterus  were  matted  together,  and  bound  down 
to  the  left  side  of  the  pelvis,  leaving  a considerable  cavity  in  the  right  side,  which  was 
occupied  by  about  a pint  of  dirty  reddish-brown  fluid,  possessing  a strong  feculent 
odor.  On  separating  the  intestines,  a knuckle  of  the  ileum,  in  its  upper  third,  wns 
found  to  be  strangulated  in  the  left  inguinal  ring  presenting  externally  to  it,  and  form- 
ing the  base  of  the  ulcer,  two  soft  prominent  projections.  On  the  summits  of  these 
were  two  ragged  ulcers  perforating  the  gut.  Into  the  superior  of  these  a probe  only 
passed  a few  lines ; into  the  inferior  it  readily  passed  into  the  dilated  and  upper  por- 
tion of  the  intestine.  The  duodenum,  jejunum,  and  three  or  four  feet  of  the  ileum,  up 
to  the  point  of  strangulation,  were  greatly  distended  with  flatus  and  fluid  feces,  resem 
bling  that  found  in  the  right  side  of  the  peritoneal  cavity.  The  small  and  large  intes- 
tines below  the  strangulation  were  collapsed  and  apparently  contracted.  About  eight 
inehes  from  the  strangulation,  in  the  upper  part  of  the  gut,  was  an  ulcer  the  size  of  a 
halfpenny,  with  two  perforations  in  its  centre,  each  about  the  size  of  a goose’s  quill, 
through  which  fluid  feces  had  escaped  into  the  peritoneal  cavity.  For  about  eighteen 
inches,  extending  from  the  strangulation,  the  ileum  was  of  a dark  mahogany,  and  in 
the  centre,  as  well  as  near  the  strangulation,  of  a claret  color,  evidently  gangrenous. 
The  rest  of  the  intestines  and  other  abdominal  organs  were  healthy  in  texture.  The 
gall-bladder  was  distended  with  tenacious  bile,  having  the  appearance  of  tar. 

Commentary . — In  this  case  the  intestine  had  been  strangulated  in 
the  inguinal  ring  seven  days  previous  to  admission,  and  the  symptoms  on 
her  coming  into  the  house  were  not  only  those  of  intestinal  obstruction, 


DISEASES  OF  THE  INTESTINES. 


537 


but  of  peritonitis  also.  Purgatives  bad  been  administered  before  she 
came  in.  Mr.  Syme  recognised  an  abscess,  which  was  opened  without 
causing  relief,  external  to,  and  covering  the  hernia.  In  the  evening, 
peritonitis,  with  symptoms  of  perforation,  were  more  unequivocally  pro- 
nounced, and  the  case  became  hopeless.  Large  doses  of  opiLim  failed  to 
relieve  the  pain.  Ileus  was  established  on  the  1 1th,  and  an  artificial 
anus  on  the  13th  day,  without  relief — gangrene  and  perforation  of  the 
intestine  having  caused  escape  of  faeces  into  the  peritoneum,  and  of  course 
death. 

The  two  cases  previously  given  exemplify  two  modes  in  which  the 
intestinal  canal  may  become  permanently  obstructed — viz.,  by  morbid 
growths  compressing  it  from  without,  and  by  the  strangulation  of  a her- 
nial protrusion.  An  instance  of  internal  obstruction  from  a band  of 
lymph  acting  as  a ligature,  and  constricting  the  gut,  will  be  found  un- 
der the  head  of  Ovarian  Dropsy.  (Case  of  Jessie  Fleming.)  A variety 
of  other  causes  may  also  occasion  permanent  obstruction,  such  as  invagi- 
nation, accumulation  of  fmces  or  foreign  bodies,  and  calculi  impacted  in 
the  tube,  inflammation,  gangrene,  paralysis,  etc.  In  most  of  these  cases 
distension  of  the  upper  and  corresponding  collapse  of  the  inferior  portion 
of  the  intestine  occur,  followed  at  length  by  ulceration  or  rupture,  occa- 
sioning fatal  peritonitis.  Yomiting  is  a common  symptom  of  permanent 
obstruction,  and  when  the  disease  is  far  advanced,  the  faeces  are  propelled 
backwards,  and  rendered  by  the  mouth,  constituting  ileus,  as  in  Case 
LXXXVII. 

The  pathology  of  this  anti-persistaltic  action  of  the  tube  has  been 
much  discussed,  more  especially  as  to  whether  it  be  owing  primarily  to 
spasmodic  contraction,  or  to  paralysis.  In  all  such  cases  it  has  been 
found  that  one  portion  of  the  intestine  has  been  over-distended,  and 
another  collapsed,  and  this  even  though  a mechanical  obstruction  does 
not  exist.  A portion  of  the  tube  may  be  inflamed,  and  even  gangrenous, 
giving  rise  to  ileus,  without  the  passage  being  actually  closed.^  In  these 
cases  the  cause  of  the  obstruction  producing  ileus  is  not  easy  to  deter- 
mine ; but  the  reasoning  of  Abercrombie  on  this  point  has  always  ap- 
peared to  me  so  good,  that  I shall  quote  it  in  his  own  words.  “ If  we 
suppose,  then,  that  a considerable  tract  of  the  canal  is  in  a collapsed  state, 
and  that  a mass  of  alimentary  matter  is  propelled  into  it  by  the  contrac- 
tion of  the  parts  above,  the  series  of  actions  which  will  take  place  will 
probably  be  the  following: — When  a portion,  which  we  shall  call  No.  1, 
is  propelling  its  contents  into  a portion  No.  2,  the  force  exerted  must  be 
such  as  both  to  propel  these  contents,  and  also  to  overcome  the  tonic 
contraction  of  No.  2.  The  portion  No.  2 then  contracts  in  its  turn,  and 
propels  the  matter  into  No.  3 ; this  into  No.  4,  and  so  on.  Now,  for 
this  process  going  on  in  a healthy  manner,  it  is  necessary  that  each  por- 
tion shall  act  in  consecutive  harmony  with  the  other  portions  ; but  there 
appear  to  be  several  ways  in  which  we  may  suppose  this  harmony  to  be 
interrupted  ; (1st),  If  the  portion  No.  1 has  contracted  and  propelled  iLs 
contents  into  No.  2,  and  No.  2 does  not  contract  in  its  turn,  the  function 

* See  Abercrombie  on  Diseases  of  the  Stomach  and  Abdominal  Viscera. — Cases 
XXX.  xxxi.  and  xxxvii. 


538 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


of  the  whole  will  be  to  a certain  extent  interrupted,  and  the  contents  will 
lodge  in  No.  2 as  in  an  inanimate  sac.  The  parts  above  continuing  to 
act  downwards,  one  of  two  results  will  now  take  place ; either  the  parts 
above  will  be  excited  to  increased  contraction,  and  the  matters  will  be 
forced  through  into  No.  3,  independently  of  the  action  of  No.  2,  and  so 
the  action  be  continued;  or,  new  matter  being  propelled  into  No.  2,  this 
will  be  more  and  more  distended,  until  an  interruption  of  a very  formi- 
dable nature  takes  place  in  the  function  of  the  canal.  (2),  If,  in  the 
series  of  actions  now  referred  to.  No.  2 contracts  in  its  turn,  while  some 
obstacles  exists  to  the  free  dilatation  of  No.  3,  it  is  probable  the  motion 
may  be  so  inverted,  that  the  contraction  of  No.  2 may  dilate  No.  1,  and 
that  the  action  may  thus  be  communicated  backwards.  In  the  state  of 
parts  here  referred  to,  varieties  may  occur,  which  appear  to  give  rise  to 
important  ditferences  in  the  phenomena.  The  obstruction  to  the  dilata- 
tion of  No.  3 may  exist  in  various  degrees ; in  a smaller  degree,  it  may 
not  prevent  it  from  acting  in  harmony  with  other  parts,  when  the  quan- 
tity of  contents  is  small,  and  only  a small  degree  of  dilatation  is  re- 
quired; but,  when  there  is  an  increased  distension  of  the  parts  above, 
either  from  increase  of  solid  contents  or  from  some  accidental  accumula- 
tion of  flatus,  then  a greater  degree  of  expansion  may  be  required  than 
No.  3 is  capable  of,  and  in  this  manner  interruption  may  take  place  to 
the  harmonious  action  of  the  canal.  It  is  probably  in  this  manner  that, 
in  connection  with  slight  organic  affections  of  the  canal,  we  find  the 
patient  liable  to  attacks  of  pain  and  other  concomitant  syn  ptoms,  which 
at  first  occur  only  at  long  and  uncertain  intervals,  but  at  length  termi- 
nate in  fatal  ileus.’’ 

In  the  summer  of  1853,  a valuable  lesson  was  presented  to  us  in  the 
case  of  a man,  John  Johnstone,  who  had  long  been  subject  to  inguinal 
hernia,  and  in  whom,  as  the  result  of  strangulation,  violent  vomiting 
and  abdominal  pain  had  existed  for  three  days  previous  to  admission. 
On  the  third  day,  he  went  to  a medical  man,  who  sent  him  into  the 
medical  ward,  not  having  discovered  the  hernia.  This  was  simply  the 
result  of  non-examination  (see  p.  28,  Eule  4),  and  strongly  inculcates 
the  duty  of  carefully  feeling  and  investigating  into  the  disease,  rather 
than  hurriedly  acting  upon  the  prominent  symptoms  referred  to  by  the 
patient.  It  so  happened  that  the  hernia  disappeared  three  hours  after 
admission  spontaneously,  before  I saw  the  man,  who  from  that  moment 
recovered. 

The  treatment  of  intestinal  obstruction,  however  it  originates,  must 
always  be  a matter  of  anxious  consideration.  At  first,  it  is  more  or  less 
difficult  to  determine  whether  there  be  only  an  obstinate  constipation, 
which  may  be  overcome  by  purgatives,  or  whether  there  be  a mechanical 
obstruction,  rendering  them  useless  and  perhaps  dangerous.  Under 
these  circumstances,  I think  one  full  purgative  at  least  should  always 
be  given  as  a rule,  for  the  simple  reason,  that  not  only  may  its  action 
overcome  many  forms  of  simple  obstruction,  but  because  without  it  no 
one  can  determine  whether  or  not  there  is  an  obstruction  at  all.  As 
soon,  however,  as  it  becomes  evident  with  what  we  have  to  do,  all  attempts 
to  stimulate  the  action  of  the  canal  from  above  should  cease,  and  we  must 
have  recourse  to  anodynes  to  diminish  spasm,  lessen  irritability,  and, 


INTESTINAL  WORMS. 


530 


if  possible,  cause  relaxation.  Surgical  means  may  be  bad  recourse  to, 
if  the  nature  of  the  case  admit  of  them,  and  operations  performed  with  a 
view  of  relieving  the  straugulatioD  or  extracting  any  impacted  mass ; 
and  the  colon  may  be  dilated  with  oil,  air,  or  other  fluid,  by  means  of 
long  tubes.  These  important  points,  however,  are  so  purely  surgical, 
that  I need  not  dwell  upon  them  here. 


INTESTINAL  WORMS. 

The  observations  of  recent  helminthologists,  but  more  especially  of 
Siebold,  Van  Beneden,  Dujardin,  Leuckart,  Steenstrup,  and  Blanchard, 
have  cleared  away  the  mystery  which  so  long  hung  over  the  origin  of 
tape-worms  and  other  entozoa.  It  seems  now  determined  that  tape- 
worms are  only  further  stages  of  development  of  Cysticerci,  as  flukes  arc 
only  further  stages  in  growth  of  certain  Cercarige.  This  important  fact 
is  a result  of  the  researches  now  everywhere  prosecuted  with  so  much 
zeal  by  anatomists  and  physiologists  in  embryology,  and  from  which  it 
has  resulted  that  many  animals  hitherto  considered  altogether  distinct 
species,  bear  the  same  relation  to  each  other  as  a caterpillar  does  to  a 
butterfly. 

Professor  Siebold  first  pointed  out  that  the  Cysticerciis  fasciolaris 
found  in  the  liver  of  the  mouse,  reaches  its  ultimate  stage  of  develop- 
ment in  the  intestines  of  the  cat,  and  is  there  transformed  into  the 
Tcenia  crassicollis.  This  fact  was  confirmed  by  a careful  series  of 
observations  made  by  Dr.  Henry  Nelson,  who,  in  his  Thesis  presented  to 
this  University  in  1850,  carefully  traced  and  figured  all  the  various 
stages  which  the  tape-worm  of  the  cat  passes  through.  Each  joint  of 
this  worm  is  estimated  to  contain  125,000  ova,  which  gives  for  the  entire 
animal  about  12,500,000.  These  minute  bodies  pass  off  by  the  faeces  in 
incalculable  numbers,  and  enter  the  body  of  the  mouse  mixed  with  its 
food  or  drink,  or  by  licking  its  furry  coat,  to  which  they  adhere.  From 
the  alimentary  canal  of  the  mouse  they  may  enter  the  liver  of  that 
animal  in  three  ways  : 1st,  They  may  ascend  the  bile-ducts.  2dly,  They 
may  pass  through  the  coats  of  the  intestine,  and  penetrate  the  adjoining 
portion  of  the  liver.  3dly,  They  may  bore  their  way  into  one  of  the 
mesenteric  veins,  and  be  carried  by  the  blood  along  the  vena  porta  to  the 
liver.  Dr.  Nelson  considers  the  last  to  be  the  most  correct  view, 
for,  as  he  shows,  the  ova  are  furnished  with  temporary  teeth,  which  en- 
able them  to  pierce  the  tissues.  That  they  do  not  perforate  the  intestine, 
and  so  get  into  the  liver,  is  shown  by  the  fact  that  they  are  most  devel- 
oped on  the  surface  of  that  organ,  and  least  so  in  its  interior.  Neither 
are  they  found  especially  in  the  biliary  ducts,  like  the  Bistomata. 
Hence  the  blood-vessels  seem  to  be  the  channel  of  their  introduction — 
an  idea  still  further  supported  by  facts,  the  number  of  which  is  rapidly 
augmenting,  which  demonstrate  the  presence  of  entozoa  in  various  stages 
of  development  in  the  blood  itself.  Arrived  at  the  liver,  these  ova  are 
transformed  into  Cysticerci  fasciolares^  and  would  never  proceed  further 
in  development  in  the  mouse;  but  being  eaten  by  the  cat,  they  become 
tape-worms,  and  are  developed  into  Tccnm  crassicolles. 


540 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


This  series  of  observations  renders  it  probable  that  all  the  various 
kinds  of  Tsenia  are  only  different  Cysticerci  in  advanced  stages  of  devel- 
opment. Dr.  Nelson  points  out  that  “the  head  of  the  Cysticerciis  cellu- 
losus  resembles  in  every  respect  that  of  the  Tcbnia  solium  of  man.  The 
two  figures  given  by  Bremser  are  identical,  if  we  allow  for  stretching 
of  the  neck  in  the  latter.  Both  have  a double  circle  of  hooks,  and  al 
though  the  Tceuia  solium  is  sometimes  found  without  any  teeth,  Bremser 
has  fully  proved  that  this  is  the  result  of  age,  and  not  the  original  con- 
dition. He  also  observed  that  as  the  worm  increased  in  age,  one  row  of 
the  double  corona  first  fell  off,  and  was  after  a time  followed  by  the  other, 
leaving  the  worm  thus  unarmed.  The  size  of  the  head  in  both  is 
similar,  as  also  are  the  attenuated  neck  and  the  gradually  increasing 
body.”  Besides,  man  feeds  on  animals  in  which  these  Cysticerci  are 
common,  especially  on  the  pig  and  sheep  ; and  it  has  been  observed  that, 
in  countries  where  meat  is  often  eaten  raw,  as  in  Abyssinia,  tape-worms 
are  very  common.  The  reason  of  the  rare  occurrence  of  Taenia  in  civi- 
lised countries,  is  probably  owing  to  the  cooking  of  food,  which  destroys 
the  vitality  of  the  Cysticerci.  Very  thorough  curing  or  salting  meat  also 
appears  to  produce  the  same  effect.  However,  it  may  easily  be  con- 
ceived, that  owing  to  meat  being  very  underdone,  or  to  the  tenacity  of 
life  ill  certain  of  these  creatures  (and  many  of  them  resist  a high  tem- 
perature w'ithout  injury),  they  may  occasionally  escape  the  action  of  the 
teeth,  arrive  living  in  the  human  stomach,  and  be  converted  into  young 
Tasnim. 

These  ideas  with  regard  to  the  origin  of  tape-worms  have  been  con- 
verted into  certainties  by  the  experiments  of  Hr.  Kuchenmeister,  first 
recorded  in  the  Prague  Vierteljalirschrift  (Band  i.  1852,  p.  126).  He 
fed  dogs  and  cats  upon  parts  of  animals  which  contained  different  kinds 
of  Cysticerci,  and  subsequently  found  the  tape-worms  into  which  these 
had  been  transformed  in  various  stages  of  development,  according  as  the 
life  of  the  animal  who  had  eaten  the  Cysticerci  had  been  more  or  less 
prolonged  afterwards.  Every  precaution  seems  to  have  been  used  in 
these  experiments,  one  of  which  may  be  cited  : — An  old  dog,  during  a 
period  of  from  six  to  eight  weeks,  was  frequently  purged  with  castor-oil, 
so  as  to  prevent  the  possibility  of  tape-worms  being  present.  On  the 
18th  of  March,  1851,  he  ate  food  containing  ten  Cysticerci ; on  the  25th 
he  ate  as  many  more;  and  on  the  1st  of  April,  several  others  which 
were  not  numbered.  On  the  10th  of  April,  the  dog  was  killed,  and 
thirty-five  Taenim  were  found  in  the  intestines,  of  which  five  wmre  from 
124  to  390  millimetres  (from  about  5 to  15  inches)  in  length,  and  possess- 
ed from  130  to  160  joints.  There  were  six  others,  from  25  to  96  mil- 
limetres (1  to  5 inches)  in  length,  having  from  40  to  60  joints.  There 
were  21  others,  which  measured  from  8 to  16  millimetres  (^  to  ^ an 
inch)  in  length,  in  which  the  joints  were  so  indistinct  that  the}^  could  not 
be  counted.  Lastly,  there  were  three,  measuring  from  4 to  5 milli- 
metres (^th  of  an  inch)  in  length,  in  which  the  joints  could  scarcely  be 
distinguished.  Considering  the  power  of  construction  and  elongation 
possessed  by  these  worms,  their  length  was  not  so  decided  a character  of 
their  stage  of  development,  as  the  size  of  the  head  and  hooks,  which 
corresponded  to  the  three  periods  in  which  the  C}^sticerci  had  been 


INTESTINAL  WORMS. 


541 


swallowed.  Similar  results  have  since  been  obtained  in  cats;  and  even 
in  a man — a condemned  criminal — to  whom  Kucbenmeister  gave  Cys- 
ticerci  in  broth,  and  found  tape-worms  in  his  intestinal  canal  after  death. 

On  feeding  dogs  upon  the  liver  of  a mouse,  containing  the  G. 
fasciolaris,  Or.  Kucbenmeister  never  found  Taeniae  in  the  intestines. 
But  when  he  fed  cats  on  the  same  liver,  the  intestines  contained  the 
Tmnia  crassicoUis.  This  observation  indicates  that  not  only  are  certain 
Cysticerci  transformed  into  certain  Taeniae,  but  the  former  can  only 
undergo  this  transformation  in  certain  habitats,  or  in  peculiar  animals. 
Although  the  present  amount  of  our  knowledge  does  not  enable  us  to 
state  from  what  kinds  of  Cysticerci  many  species  of  Taeniae  are  formed, 
it  seems  probable  from  the  observations  of  Siebold,  Nelson,  and 
Kucbenmeister,  that  the  Cijsticercm  fasciolaris  of  the  mouse  is  trans- 
formed into  the  Tcenia  erassicoUis  of  the  cat ; the  C.  pisiformis  of  hares 
and  rabbits  into  the  T.  crasucem  of  the  fox ; the  C.  temiicollis  of  rumi- 
nantia  and  squirrels  into  the  T.  serrata,  so  common  in  the  dog ; and  the 
C.  cellidoms  of  the  pig,  sheep,  and  rabbit,  into  the  Tcenia  solium  of  man. 
It  is  also  tolerably  certain,  from  the  observations  of  Eschricht,  that 
the  Botliriocephalm  latus  found  in  man  in  certain  countries,  especially 
in  Russia,  is  the  further  development  of  a species  of  Ligula^  which 
exists  in  large  numbers  in  the  flesh  of  the  dorse,  and  other  fish  of  the 
northern  seas. 

Numerous  instances  have  occurred,  especially  in  India,  where  men 
encamped  on  the  borders  of  a lake  have  subsequently  been  attacked  by 
tape- worm,  evidently  in  consequence  of  the  water  they  consumed  con- 
taining the  ova  of  the  worm.  The  parasite  also  has  been  known  to  infect 
Hindoos  who  have  eaten  no  flesh.  There  can  be  little  doubt,  therefore, 
that  the  numerous  ova  of  tape-worms  voided  by  animals  may  enter  the 
intestines  of  man  with  the  food  or  drink,  and  there  be  transformed  into 
Taeniae.  This  direct  mode  of  entry  must  not  be  overlooked  while  inves- 
tigating the  undoubted  origin  of  the  worm  from  its  cystic  stage  of  trans- 
formation in  the  tissues  of  other  animals.  Dr.  Fleming  considers  that 
the  frequency  of  measly  pork  in  Ireland  is  due  to  the  pig  being  reared 
in  the  peasant’s  cabin,  where  it  has  commonly  a dog  for  its  companion, 
which  animal  is  almost  always  infected  with  tape-worm,  and  must  void  a 
multitude  of  minute  ova  that  find  ready  access  to  the  aliment  of  the  other. 

Experiment  shows,”  he  says  “ that  the  ‘ measle  ’ is  generated  in  the 
muscle  of  the  pig  by  feeding  it  with  ripe  joints  of  the  dog’s  tape- worm 
(the  Tcenia  serrata,  now  considered  to  be  the  same  as  the  Tcenia  solium  or 
human  tape- worm),  and  that  the  same  tape-worm  is  developed  in  the 
intestines  of  a dog  fed  with  fresh  measly  pork.  The  measle  is  not  gene- 
rated in  the  dog  by  feeding  it  with  the  tape-worm  eggs.”^'  Why  in  some 
animals  these  ova  are  fully  developed  into  Taeniae  in  the  intestines,  whilst 
in  others  they  enter  the  blood  and  are  transformed  only  into  Cystic 
worms  in  the  liver,  brain,  or  other  organs,  is  probably  owing  to  peculi- 
arities of  structure  which  have  not  yet  been  investigated. 

The  importance  of  the  head  of  tape-worms,  so  long  recognised  by 
practical  physicians  as  the  only  certain  proof  of  the  complete  expulsion 
of  the  worm,  has  also  received  an  explanation  from  the  researches  of 
* Dublin  Quarterly  Journal  of  Med.  Science,  Feb.  1867. 


542 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


helminthologists  into  the  anatomy  and  development  of  these  animals. 
Notwithstanding  the  doubts  expressed  by  Van  Benedin  as  to  the  lateral 
canals  being  connected  with  the  digestive  system,  and  his  notion  of  their 
being  peculiar  secreting  organs,  Br.  Nelson  in  his  Thesis  has  distinctly 
traced  them  into  the  suckers  of  the  Tcenia  crassicollis.  From  each  of 
the  four  suckers  canals  descend,  which  afterwards  unite,  two  and  two,  to 
form  the  lateral  canals.  He  also  carefully  describes  the  manner  of  feed- 
ing and  propulsion  of  the  contents  of  these  canals  from  the  cephalic  to 
the  caudal  segment.  Hence  the  head  is  important  as  the  means  by 
which  the  animal  is  nourished. 

But  the  head  is  further  important,  as  pointed  out  by  Van  Benedin, 
as  tlie  part  from  which  all  the  joints  are  thrown  off  b}'  gemmiferous  re- 
production— those  formed  first  being  pushed  downwards,  and  afterwards 
undergoing  further  development.  Hence  why  the  joints  are  narrow  near 
the  head,  and  become  larger  and  longer  near  the  tail.  These  caudal 
joints  after  a time  separate,  and  then,  according  to  Van  Benedin,  may 
still  go  on  developing,  and  become,  he  thinks,  a species  of  fluke  or  distoma. 
In  fact,  he  considers  a tape-worm  as  a compound  fluke- worm,  the  whole 
consisting  of  three  stages  or  periods  : — 1,  The  cystic  head  {Scolex)  ; 2, 
The  compound  tape-worm  (Strohild) ; 3,  The  separate  joint  {Proglottis). 
This  latter  view,  however,  is  opposed  by  the  observations  of  Steenstrup 
as  to  the  development  of  the  fluke,  as  well  as  by  what  we  know  of  the 
arraugement  of  the  nervous  and  digestive  systems  of  this  entozoon. 

The  intestinal  worms  hitherto  discovered  in  man  are — the  Ascaris 
lumhricoides  ; Tcsnia  solium;  Bothriocephalus  latus ; Tricoceplialus  dispar ; 
and  Ascaris  vermicularis.  None  of  these  are  very  common  in  Edin- 
burgh, a circumstance  which  I attribute  to  the  diet  of  the  people,  as  well 
as  to  the  excellent  quality  of  the  water  distributed  over  the  town.  In 
unhealthy  children,  indeed,  Ascarides  are  occasionally  observed,  but  such 
children  seldom  enter  the  Infirmary.  Lumbricoid  worms  in  man  are 
very  rarely  observed  here,  whereas  in  certain  districts  on  the  Continent, 
and  especially  in  the  Blienish  provinces,  the  great  majority  of  bodies  I 
have  seen  examined  contained  them  in  abundance.  Tape-Avorm  also  is 
very  rare,  though  sometimes  met  with,  of  which  the  following  cases  are 
examples : — 

Case  LXXXVIII.^ — Tape-worm  treated  hg  the  Ethereal  Extract  of  the 
Male  Shield  Fern. 

History. — James  Seth,  let.  35,  a weaver — admitted  April  Yth,  1852.  When  a 
boy  he  used  to  pass  the  himbi-icoid  worms ; during  the  past  six  months  he  has  also 
observed  ascarides.  It  is  now  three  years  since  he  first  noticed  fragments  of  the 
tape-worm  in  his  stools.  These  fragments  were  then  about  a foot  in  length,  and 
were  noticed  at  intervals  of  months.  About  twelve  mouths  ago  the  fragments  oc- 
curred almost  every  day  for  six  weeks,  varying  from  single  joints  to  a piece  six  feet 
in  length.  No  long  piece  has  been  passed  for  three  months.  No  information  can  be 
obtained  as  to  the  kind  of  food  on  which  he  has  lived  ; but  his  appetite  has  remained 
natural.  Before  admission  he  was  treated  with  turpentine  by  the  mouth,  and  also  by 
injection. 

Progress  of  the  Case. — April  ^th. — To  have  25  grains  of  the  ethereal  extract  of 
the  male  shield  fern;  and  in  a few  hours,  a powder  containing  three  grains  of  calomel, 

^ Reported  by  Mr.  William  Broadbent,  Clinical  Clerk. 


INTESTINAL  WOEMS. 


543 


and  one  drachm  of  compound  jalap  powder.  A pril  9^7i.— Several  fragments  of  Taenia, 
in  single  or  double  joints,  or  iu  longer  pieces,  were  passed,  being  7U  inches  in  all. 
They  varied  in  breadth  from  one-eignth  to  one-fourth  of  an  inch.  April  '■Aid. — The 
dose  was  repeated  on  the  10th,  but  only  two  or  three  single  joints  were  I'ound.  jNo 
further  trace  of  the  worm  has  been  obtained  by  administration  of  castor-oil,  and  the 
patient  was  discharged  cured. 

Was  re-admitted  July  IsL — States  that  two  months  after  he  left  the  hospital  he 
again  detected  joints  of  the  entozoon  in  his  stools.  He  was  at  once  ordered  twenty- 
four  grains  of  the  ethereal  extract  of  the  male  shield  fern,  and  a subsequent  dose  of 
castor-oil.  Numerous  fragments,  in  all  8 feet  in  length,  were  discharged  in  the  next 
stool.  July  9)th. — The  remedy  was  repeated  on  the  Uh  without  further  elfect.  Castor- 
oil  has  also  been  administered,  but  no  fragments  appear.  Patient  now  states  that  he 
has  been  in  the  habit  of  drinking  marsh  water  of  impure  quality,  and  of  eating  salt 
pork  meat.  July  13^A.  Dismissed  cured. 

Case  LXXXIX.'^ — Tape-worm  expelled  lij  the  Ethereal  Extract  of  the 

Male  Shield  Fern. 

History. — Catherine  Watt,  get.  25,  married,  with  children — admitted  November 
20th,  1854.  She  had  always  enjoyed  good  health,  until  three  years  ago,  when  joints 
of  tape-worm  passed  from  her  involuntarily  when  out  working,  and  they  have  con- 
tinued to  pass  from  her  involuntarily,  and  sometimes  in  large  quantities  by  stool  ever 
since.  On  one  occasion  she  passed  blood  at  stool  with  portions  of  tape-worm.  Has 
taken  various  kinds  of  medicine,  but,  with  the  exception  of  turpentine,  does  not  know 
what  they  were.  They  have  all  been  ineffectual. 

Symptoms  ox  Admissiox. — On  admission,  she  complained  of  tenderness  in  the  left 
iliac  region,  and  of  tenesmus  when  at  stool ; but,  with  the  further  exception  of  the 
frequent  passage  of  joints  of  tape-worm,  the  functions  of  the  body  were  performed 
with  regularit3\  She  was  ordered  3ij  of  the  ethereal  extract  of  the  male  shield  fern, 
to  be  followed  in  the  morning  by  § j of  castor-oil.  This  caused  the  evacuation  of 
seven  joints  of  the  worm,  each  of  which  was  longer  than  they  were  broad.  Another 
Dj  dose  of  the  extract  was  ordered  at  night,  also  to  be  followed  by  | j of  castor-oil 
in  the  morning. 

Progricss  op  the  Case. — November  22(7. — Only  three  joints  of  the  worm  passed. 
To  have  this  evening  3 ss  of  the  extract.  Nov.  23(7. — This  morning  after  taking  the 
oz.  dose  of  castor-oil,  she  passed  many  separate  joints,  and  several  long  portions  of 
tienia.  The  whole  together,  when  measured,  was  calculated  to  be  about  fifteen  yards 
long.  One  portion  was  evidently  formed  of  the  joints  of  the  worm  near  the  head,  as 
they  were  broader  than  they  were  long,  and  not  above  the  tenth  of  an  inch  in  length. 
Some  joints  were  square,  and  others  longer  than  they  were  broad,  measuring  from 
half  an  inch  to  three  quarters  of  an  inch  in  length.  No  head  could  be  discovered, 
though  carefully  searched  after.  She  remained  in  the  house  till  the  6th  of  December; 
but  although  she  took  3 ss  of  the  extract  three  times,  and  one  dose  of  Dij,  no  more 
joints  of  the  worm  came  away.  This  woman  was  freed  from  the  worm  for  many 
months,  but  it  subsequently  returned. 

Case  XC.f — Tape-worm  expelled  hj  the  same  remedy. 

History. — William  Perry,  get.  6.  son  of  a soldier — admitted  November  19th, 
1855.  Has  been  troubled  with  the  tape-worm  since  he  was  two  yc/irs  old.  Has 
passed  several  joints  often  without  medicine ; doses  of  rhubarb  and  jalap  have 
brought  away  more ; the  child  has  also  taken  turpentine.  A year  and  a half  ago  he 
obtained  a prescription  at  this  Infirmary  for  a medicine  which  expelled  a very  large 
portion  of  the  tape-worm.  In  six  months  it  was  necessary  to  repeat  the  same 
medicine,  again  with  success.  But  the  symptoms  have  again  returned ; the  child  is 
always  hungry  and  wants  drink  ; complains  of  pain  in  his  belly,  and  passes  joints  of 
the  entozoon  per  rectum.  His  food  latterly  has  been  plain,  consisting  of  milk,  bread, 
tea,  potatoes,  and  some  meat.  The  meat  is  boiled  for  broth,  and  is  shared  with 
him  by  father  and  mother,  neither  of  them  being  affected.  He  is  fond  of  sugar, 
butter,  and  salt. 

* Reported  by  Mr.  Almeric  W.  Seymour,  Clinical  Clerk, 
f Reported  by  Mr.  John  Glen,  Clinical  Clerk. 


544 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


Progress  of  the  Case. — November  21s^. — Ordered  30  grains  of  ethereal  extract 

of  the  mate  shieid  fern^  with  a subsequent  dose  of  castor-oil,  Nov.  23(i. As  tlie 

remedy  was  inellectual,  it  was  increased  yesterday  evening  to  one  drachm.  This 
morning,  an  unbroken  mass  consisting  of  six  yards  and  six  inches  of  the  tape-worm 
joints  was  evacuated  ; the  smallest  joints  were  one-l'ourth  to  one-sixth  of  an  inch  in 
breadth  and  length ; the  head  was  not  found.  Dec.  25th. — After  other  two  adminis- 
trations of  the  extract,  and  more  frequent  administrations  of  castor-oil,  no  further 
f ragments  of  the  taenia  have  been  procured  ; was  discharged. 

Commentary. — Of  all  the  vermifuge  remedies  proposed  for  the  ex- 
pulsion of  tape-worm,  I have  found  the  ethereal  extract  of  the  male 
shield  fern  the  most  effectual — a preparation  proposed  by  Peschier  of 
Geneva,  and  since  strongly  recommended  by  Dr.  Christison.  That  it 
readily  dislodges  large  masses  of  the  parasite,  has  been  witnessed  by  all 
who  have  tried  it,  although  it  has  not  succeeded  in  every  instance  in 
perma,nently  destroying  or  removing  the  animal.  This,  however,  appears 
to  me  in  great  part,  if  not  wholly,  accounted  for  by  the  circumstance 
that  patients,  on  being  dismissed,  return  to  the  kind  of  food  from  which 
they  originally  received  the  ova  of  these  worms.  This  is  very  likely  to 
be  the  case  in  certain  English  counties,  where  bacon  and  other  pre- 
parations of  pork  are  common  articles  of  diet  among  the  people.  Dr. 
Paterson,  formerly  of  Tiverton,  has  recorded  some  very  obstinate  cases, 
which  resisted  the  action  of  the  male  shield  fern,  of  the  kousso,  and  of 
turpentine.*  Now,  in  Devon,  pork  is  a very  common  article  of  diet, 
whilst  in  Scotland  certainly  it  is  not  much  employed  as  food.  I carefully 
interrogated  the  woman,  Catherine  Watt,  as  to  whetlier  she  had  eaten 
pork,  and  she  admitted,  that  about  the  time  the  disease  commenced,  her 
husband  being  out  of  work,  her  diet  had  been  very  poor,  and  had  consisted 
in  some  measure  of  salt  pork,  and  occasionally  of  rabbits.  Whether  the 
Cysticercus  cellulosoB,  commonly  found  in  the  flesh  of  pigs,  could  have 
retained  its  vitality  in  the  salt  pork  eaten  by  this  woman  cannot,  of 
course,  be  stated  with  certainty.  But  it  is  worthy  of  remark,  that  the 
flesh  of  pork  is  frequently  sold  cheap  to  the  lower  orders,  after  it  has 
been  laid  in  brine  for  a very  short  period,  or  been  imperfectly  cured,  so  that 
the  tenacious  vitality  of  these  Cysticerci,  or  of  the  ova  of  Teenim,  is  by 
no  means  necessarily  destroyed.  Then,  rabbits  are  known  to  be  very 
commonly  infested  with  Cysticerci ; so  that  her  indulgence  in  either 
kind  of  animal  food  may  have  been  the  means  of  introducing  Tasniae  into 
her  economy. 

The  general  considerations  previously  given  as  to  the  origin  and 
mode  of  development  of  tape-worms  must  render  it  evident  that,  whilst 
by  means  of  vermifuge  remedies  the  practitioner  endeavors  to  expel 
such  as  are  already  formed,  his  chief  reliance,  in  preventing  their  return, 
must  be  placed  on  careful  attention  to  the  food  and  drink  consumed  by 
his  patient. 

XCI.f — Tape-TToryn  expelled  lij  Kamala — Return  of  the  Parasite — Ulti- 
mate Cure  hy  Means  of  the  Male  Shield  Fern. 

IIiSTORY. — Mary  Park,  aet.  9,  a thin,  cachectic-looking  girl,  native  of  Edinburgh, 
where  she  has  for  the  most  part  resided — admitted  11th  January,  1859.  Her  mother 


* Monthly  Journal  of  Medical  Science,  July  1854. 
f Reported  by  Mr.  H.  Graham  Dignum,  Clinical  Clerk. 


PEKITON’ITIS. 


545 


states  that  for  four  years  she  has  never  been  free  from  vorms,  for  which  she  has  taken 
turpentine,  castor-oil,  and  other  remedies,  without  benefit. 

Progress  of  the  Case. — On  the  Pith  of  January  a table-spoonful  of  castor-oil 
brought  away  a few  long  joints  of  a tape-worm.  On  the  afternoon  of  the  IGth  of 
January  two  drachms  of  kamala  in  powder  were  given.  On  the  same  evening  she  had 
three  motions  followed  early  the  next  morning  by  a fourth.  In  the  three  first  stools 
were  several  isolated  joints  of  tape-worm,  but  in  the  fourth  there  was  a mass,  con- 
sisting of  the  body  of  the  worm  several  yards  long.  A careful  search  was  made  for  the 
head,  but  without  success.  The  smallest  joints  were  the  tenth  of  an  inch  broad.  Jan. 
23(^. — One  drachm  of  kamala  in  powder  was  administered,  followed  by  three  copious 
motions,  in  which  no  portions  of  worm  could  be  found.  No  more  of  the  worm  having 
passed,  she  was  dismissed  January  31st. 

This  girl  was  re-admitted  on  the  24th  of  March,  the  mother  saying  that  the  tape- 
worm had  returned.  Another  dose  of  kamala  was  given,  and  violent  purging  pro- 
duced, but  no  worms,  and  she  was  dismissed  on  tlie  9th  of  April.  She  wms  again 
admitted  on  the  25th  of  April,  the  mother  bringing  some  joints  of  the  tape  wormAvith 
her  which  the  girl  had  passed.  On  April  3 ss  of  the  extract  of  the  male  shield 

fern  was  given,  which  was  followed  at  night  by  § ss  of  castor-oil.  On  the  following 
morning  a large  mass  of  Taenia  was  expelled,  about  ten  yards  long ; no  head  could  be 
detected. — May  20th. — Another  dose,  with  castor-oil,  of  the  male  shield  fern  was 
given,  but  no  worm  having  passed,  she  was  dismissed  May  25th.  I was  informed  by 
her  mother  two  years  afterwards  that  there  had  been  no  return  of  the  parasite. 

Commentary. — Kamala  has  been  recommended  to  us  by  medical  men 
in  India  as  a cheap  and  powerful  anthelmintic,  and  has  been  pretty  ex- 
tensively tried  in  this  country.  Dr.  M’Kinnon,  of  the  Horse  Artillery, 
pnblished  a brief  account  of  it  in  the  Indian  Annals  of  31  edical  Science 
for  October  1853  ; and  it  is  referred  to  by  Dr.  Boyle  in  his  3Iateria 
3Iedica  as  an  active  vermifuge.  It  is  a dark  brick-red  colored  powder, 
brushed  off  from  the  capsules  of  the  Rottlera  tinctoria,  a species  of 
euphorbiacise  found  in  the  hilly  portions  of  India.  Under  the  micro- 
scope it  exhibits  a mass  of  blood-red  semi-transparent  granules  more  or 
less  shrivelled,  mingled  with  stellate  hairs,  to  the  irritating  properties  of 
which  some  have  ascribed  the  vermicidal  properties  of  the  drug.  The 
dose  is  from  3 ij  to  3 bj  for  an  adult.  Dr.  T.  Anderson  says  an  alcoholic 
tincture  in  3 ss  doses  is  also  very  effectual  (Indian  Annals ^ October  1855). 
Unlike  the  root  of  the  male  shield  fern,  it  is  in  itself  a violent  purgative. 
I have  now  tried  it  in  several  cases,  of  which  the  above  is  one,  and  found 
that  it  failed  in  all,  so  that  it  became  necessary  to  have  recourse  to  the 
male  shield  fern.  (See  also  Dr.  Fleming  on  the  Oil  of  the  Male  Shield 
Fern,  in  the  Brit.  Med.  Journ.  for  January  16,  1864.) 

PERITONITIS. 

Case  XCII.* — Acute  Peritonitis — Recovery. 

History. — James  Stephenson,  set.  19,  sailmaker — admitted  March  21st,  1860. 
Patient  states  that  he  was  well  up  to  the  14th  March,  when  he  felt  slight  pain  in  the 
lower  part  of  his  abdomen.  This  increased  in  intensity,  and  spread  over  the  whole 
of  his  abdomen,  and  on  Saturday  the  Uth,  feeling  himself  very  ill,  and  having  shiver- 
ings,  with  a feeling  of  coldness  down  his  back,  he  consulted  a medical  man,  who 
ordered  him  six  pills,  one  of  which  was  to  be  taken  every  six  hours.  He  was  purged 
once  on  the  morning  of  the  18th,  but  getting  worse  he  was  ordered  by  the  medical 
practitioner  other  pills,  one  to  be  taken  every  four  hours,  and  three  leeches  to  be 
applied  to  the  abdomen.  Although  he  says  that  he  felt  immediate  relief  on  the  applica- 
tion of  the  leeches,  the  pain  continued  to  increase,  up  to  the  date  of  his  admission. 

* Reported  by  Mr.  Colville  Browne,  Clinical  Clerk. 

35 


646 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


His  appetite  also  completely  went  away ; his  thirst  became  excessive ; he  vomited 
everything  taken;  and  has  not  had  one  stool  since  the  18th. 

Symptoms  on  Admission. — Tongue  moist;  a little  streaked.  Bowels  constipated. 
There  is  great  tenderness  on  jiressure  over  the  whole  of  the  abdomen,  especially  in  the 
hypogastric  region,  and  it  is  somewhat  tumid.  Appetite  very  bad;  vomits  all  kinds 
of  food.  Pulse  108,  small,  weak,  and  communicating  a double  thrill  to  the  finger. 
Cardiac  sounds  normal.  Has  a slight  cough,  which  causes  him  great  agony  in  con 
sequence  of  the  abdominal  pain.  Skin  dry  and  hot.  Has  not  slept,  he  says,  since 
the  commencement  of  his  illness.  Urine  of  an  amber  color.  Natural  in  quantity, 
sp.  gr.  1030.  No  albumen  present.  Chlorides  absent.  Habeat  opii  granum  unum 
quaque  sexta  hora.  Warm  fomentations  to  he  sedulously  applied  to  the  abdomen. 

Progress  op  the  Case. — March  22c?. — Bowels  still  unmoved;  abdomen  not  quite 
so  tender  on  pressure  ; tongue  same  as  at  last  report.  Vomiting  has  continued  since 
admittance,  and  is  now  accompanied  by  occasional  hiccough.  Last  night  his  pulse 
being  very  weak,  he  was  ordered  4 oz.  of  brandy.  To  have  a pint  of  olive  oil,  thrown 
gradually  up  the  lower  bowel  as  an  enema.  Vespere^  the  enema  was  given,  but  the 
oil  came  away  without  any  faeces  ; pulse  feeble.  March  23d. — Bowels  have  been  twice 
freely  opened.  Appearance  much  improved.  Pulse  108  per  minute,  full.  Same  ten 
derness  of  abdomen.  March  2Ath. — Still  slight  soreness  on  pressure  over  the  abdomen, 
but  no  acute  pain  ; right  and  left  sides  of  abdomen  perfectly  tympanitic  ; tongue 
clean  ; pulse  strong.  March  25?A. — An  abundant  deposit  of  lithates  appeared  in  his 
urine  to-day  ; general  appearance  still  improving.  March  2Qth. — Urates  still  continu- 
ing to  be  deposited  in  urine.  Chlorides  still  absent.  Bowels  moved  naturally  yester- 
day. There  is  no  pain  complained  of  on  pressure  being  applied  to  the  abdomen. 
Tongue  moist,  but  covered  with  a slight  white  fur.  Pulse  strong.  Appetite  much 
improved ; has  little  thirst,  and  expresses  himself  as  being  altogether  much  better. 
March  2^th. — To-day  the  chlorides  have  returned  to  urine,  though  scantily.  Lithates 
have  disappeared.  Tongue  still  covered  with  a whitish  fur,  but  moist.  Bowels  opened 
naturally  to-day.  Altogether  progressing  favorably.  From  this  time  he  gradually 
recovered ; the  strength,  though  supported  by  nutrients  and  wine,  returning  slowly. 
Dismissed  quite  well,  April  9th. 

Commentary. — There  could  be  no  doubt  as  to  the  intensity  of  this 
case  of  peritonitis,  which  was  ushered  in  by  strong  rigors,  presented 
great  febrile  excitement  with  agonising  local  pain,  and  was  accompanied 
by  total  disappearance  of  the  chlorides  from  the  urine.  The  cough  and 
vomiting  added  greatly  to  his  sufferings,  and  increased  his  prostration. 
Yet  without  antiphlogistics — for  three  leeches  applied  to  the  abdomen 
before  admission  will  surely  not  be  regarded  as  such — the  case  was  con- 
ducted to  a successful  conclusion.  This  Avas  favored  by  the  previous 
good  health  of  the  patient,  the  absence  of  any  serious  complication,  the 
opium,  and  the  support  he  received  throughout  from  nutrients  and 
restoratives. 

Case  XCIII.^ — Acute  Peritonitis  from  lursting  of  Graafian  Vesicles  into 
the  Peritoneum — Pleurisy — Interlolular  Pneumonia. 

History. — Margaret  M’Guire,  aet.  21,  a milliner,  native  of  Edinburgh — admitted 
September  2'7th,  1855.  Had  enjoyed  good  health  until  the  21st  of  the  month,  when, 
being  sent  out  on  a message,  while  walking  she  suddenly  experienced  a sensation  as 
of  a stone  being  dropped  into  the  pelvis  (so  the  patient  describes  her  feeling),  imme- 
diately followed  by  intense  pain.  She  went  immediately  to  bed,  but  was  prevented 
from  sleeping  by  the  intensity  of  the  pain,  wdiich  increased  in  severity.  At  first  felt 
only  in  the  lower  part  of  the  abdomen,  it  gradually  spread  upwards  toward  the  upper 
part  of  the  cavity,  but  has  again,  within  the  last  day  or  two,  become  concentrated  in 
the  lower  and  right  part  of  the  hypogastric  region. 

Symptoms  on  Admission. — On  admission  her  appetite  is  entirely  lost.  The  tongue 
cannot  be  seen,  owing  to  an  old  anchylosis  of  the  lower  jaw.  Lips  dry  and  cracked, 
with  sores  on  them  in  places.  Vomiting,  ivhich  greatly  aggravates  her  pain,  has  fol- 
lowed every  attempt  to  take  food  since  tlie  beginning  of  the  attack.  Abdomen  some- 

*llepoi'teJ  by  Mr.  Alexander  Simpson,  Clinical  Clerk. 


PERITONITIS. 


547 


w liat  swollen.  The  hypogastric  region  is  dull  on  percussion.  Diarrhoea  has  continued 
ever  since  she  took  a dose  of  castor  oil  four  days  ago.  Pressure  causes  intense  pain 
on  every  part  of  the  abdomen.  The  breathing  is  hard  and  irregular,  entirely  thoracic 
in  character.  Respiration  24  per  minute.  No  cough.  No  dulness  on  percussing  the 
chest,  as  far  as  can  be  determined;  though  examination  is  difficult,  owing  to  the  ex- 
treme pain  which  any  movement  causes  the  patient.  Pulse  124,  full  and  thrilling. 
Menstruation  had  been  suspended  for  two  months  previously,  but  has  come  on  pro- 
fusely witliin  the  last  two  days.  Has  frequent  desire  to  pass  water,  which  is  voided 
in  small  Cj[uantity,  attended  with  great  heat  and  uneasiness.  Face  flushed;  expression 
anxious;  severe  headache.  Applicentur  hirudines  xv  ahdomini.  To  be  followed  by 
hot  fomentatiom.  ^ Pulv.  Op'd  gr.  vi ; Conserv.  Rosar.  q.s.^utfiant pil,  \']\  Cap'iat 
unam  tertid  qudque  hord. 

Progress  of  the  Case. — Oct.  Is^. — The  patient  has  regularly  taken  the  pills  of 
opium;  is  in  a very  weak  state;  breathing  lal)ored ; pulse  154.  Both  purging  and 
vomiting  have  in  a great  measure  ceased.  Conjunctivae  slightly  tinged  yellow.  To 
take  strong  beef-tea.^  and  Sherry  3 iij.  Oct.  Id. — Patient  appears  to  be  sinking;  pulse 
160,  quick  and  fluttering  ; respiration  laborious  and  painful ; skin  cold  and  moist ; 
abdominal  tenderness  great ; swelling  in  abdomen  rather  increased  ; bowels  open  this 
morning;  stool  free  and  faeculent.  Urine  acid;  sp.  gr.  1020;  deep  orange  colored, 
contains  a small  amount  of  albumen,  is  tinged  green  by  nitric  acid.  Crystals  of  triple 
phosphate  seen  under  microscope.  Oct.  '6d. — Patient  continued  to  sink  during  the 
night,  and  died  this  morning. 

Sectio  Cadaveris: — Forty-eight  hours  after  death. 

The  tissues  were  well  nourished : more  than  one  inch  of  fat  in  abdominal  parietes. 

Thorax. — Heart  and  pericardium  healthy.  The  entire  surface  of  each  pleura  was 
covered  by  an  exudation  of  recent  lymph.  This  lymph  was  in  some  places  thin,  in 
others  nearly  a line  in  thickness ; it  was  soft,  and  had  an  unhealthy  appearance,  being 
of  a dirty  yellowish-green  color.  There  was  no  fluid  cfliision  in  either  pleura.  Left 
lung.,  when  cut  into,  presented  nothing  remarkable.  The  lower  third  of  the  right 
lung  presented  a singular  marbled  appearance,  in  consequence  of  each  pulmonary 
lobule  being  surrounded  by  a layer  of  coagulated  exudation,  generally  about  one-eighth 
of  an  inch  in  thickness.  Careful  examination  demonstrated  in  fact  that  the  interlobu- 
lar vessels  had  poured  forth  an  exudation,  which  had  coagulated  outside  the  lobules, 
which  were  oedematous,  but  not  hepatized. 

Abdomen. — The  whole  surface  of  the  peritoneum  was  coated  with  lymph,  but  there 
was  no  collection  of  serum.  The  lymph  in  some  places  was  in  flakes,  in  other  situa- 
tions it  was  of  the  consistence  of  thick  gruel,  closely  resembling  pus.  The  coils  of  the 
intestines  were  glued  together  by  lymph  ; but  the  exudation  was  most  abundant  near 
the  pelvis.  The  whole  of  the  intestinal  canal  was  carefully  removed  and  examined ; 
there  was  no  appearance  of  ulceration  or  of  perforation.  Appendix  verrniformis  nor- 
mal. The  liver  was  of  a brick-red  color,  and  was  decidedly  softer  than  natural.  The 
kidneys  likewise  were  somewhat  softened,  but  otherwise  appeared  healthy.  The  spleen 
was  of  pulpy  consistence,  and  broke  down  under  the  slighte.st  pressure.  The  uterus 
was  healthy.  The  right  ovary  was  about  the  size  of  a walnut;  on  being  cut  into,  its 
stroma  was  found  somewhat  softened  ; it  contained  an  unusual  inimber  of  graafian  vesi- 
cles. Externally  there  was  adherent  to  the  serous  covering  a layer  of  firm  lymph,  so 
adherent  that  it  could  only  be  removed  with  difficulty.  It  apparently  originated  from 
the  rupture  of  one  or  more  graafian  vesicles,  several  of  wliich  were  on  the  surface, 
large,  and  filled  with  sanguineous  serum.  The  left  ovary  was  the  size  of  a small  orange, 
and  contained  a cyst  about  the  size  of  a walnut,  filled  with  blood.  Such  of  its  substance 
as  remained  was  of  exactly  the  same  consistence  as  that  on  the  right  side.  The  peri- 
toneum covermg  it,  however,  was  healthy.  The  veins  in  the  broad  ligaments  were 
examined,  but  presented  nothing  unusual. 

Commentary. — In  tie  case  of  this  young  girl,  the  menstruation, 
after  being  suspended  for  two  periods,  comes  back  profusely;  and,  when 
walking,  she  experiences  a sudden  pain  deep  in  the  pelvis.  This  is  fol- 
lowed by  excessive  agony  and  all  the  symptoms  of  acute  peritonitis. 
She  is  admitted  into  hospital  on  the  sixth  day.  Leeches  and  fomenta- 
tions are  applied  locally,  but  without  any  avail.  A grain  of  opium  is 


548 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


given  every  third  hour,  hut  without  checking  the  disease.  She  dies  on 
the  eleventh  day.  On  dissection,  both  ovaries  are  found  enlarged  and 
cystic;  the  right  one  is  firmly  encrusted  with  recant  lymph,  and  several 
cysts  immediately  below  the  layer  of  exudation  are  enlarged,  prominent, 
and  filled  with  sanguineous  serum.  The  inference  obviously  is,  that  one 
or  more  of  these  graafian  vesicles  had  burst  into  the  peritoneum,  instead 
of  into  the  fallopian  tubes,  and  so  excited  the  peritonitis.  The  cause 
of  the  disease  spreading  to  the  right  pleura  and  interlobular  spaces  could 
not  be  discovered.  I have  since  seen  three  other  cases  of  acute  perito- 
nitis in  young  women,  coming  on  exactly  in  the  same  manner,  and  owing 
apparently  to  the  same  cause,  all  of  which  have  recovered.  In  none  of 
these  were  leeches  applied. 

In  such  a case,  where  the  peritonitis  was  clear  and  evident  from  the 
first,  the  treatment  by  quietude,  warm  fomentations,  and  opium  inter- 
nally, was  indicated  and  put  in  practice.  The  leeches  may  be  dispensed 
with.  Purging  rarely  occurs,  though  it  did  in  this  instance;  generally 
speaking,  there  is  great  constipation  in  peritonitis.  Under  such  circum- 
stances, active  purgatives  should  not  be  administered  for  two  or  three 
days  after  the  onset  of  the  inflammation,  and  then  only  the  mildest 
remedies  of  that  class;  or  enemata  may  be  given.  Percussion,  by  indi- 
cating whether  the  caecum  or  rectum  are  the  parts  distended  with  faeces, 
will  occasionally  enable  us  to  decide  whether  an  aperient  or  an  injection 
will  be  most  appropriate.  Other  cases  occur  where,  from  acute  symp- 
toms being  absent  and  local  tenderness  obscure,  active  purgation  is  often 
practised,  to  the  detriment  of  the  patient.  This  is  very  apt  to  occur 
when  acute  peritonitis  is  combined  with  jaundice  and  liver  disease.  The 
treatment  of  such  cases  is  most  difficult,  as  the  means  requisite  for  over- 
coming obstruction  in  the  gall-ducts  are  those  which  we  should  avoid  in 
peritonitis.  In  cases  arising  from  perforation  of  the  stomach  and  intes- 
tines, the  utmost  caution  is  required  (which  cannot  be  too  often  enforced) 
before  stimuli  and  purgatives  are  given.  (See  Cases  LXII.  and  LXIII.) 

Although,  in  the  vast  majority  of  cases,  peritonitis  arises  from  some 
lesion  of  the  abdominal  organs,  which,  as  in  the  present  case,  affects  the 
serous  membrane  secondarily,  it  sometimes  happens  that  no  lesion  to 
account  for  the  inflammation  can  be  discovered  after  death,  although  the 
symptoms  of  perforation  may  have  existed  during  life.  In  such  cases, 
the  inspection  should  never  be  concluded  without  a careful  examination 
of  the  appendix  vermiformis,  where  I have  seen  minute  perforations  very 
apt  to  escape  notice.  This  part,  besides  being  exposed  to  all  the  ordi- 
nary diseases  of  texture,  is  especially  liable  to  have  impacted  in  it  grains 
of  wheat,  barley,  or  other  kind  of  seed,  cherry-stones,  pins,  and  a variety 
of  foreign  bodies,  which  pass  readily  through  the  other  portions  of  the 
intestines,  but  which,  in  the  appendix,  may  give  rise  to  ulceration,  per- 
foration, and  fatal  peritonitis. 

Although  our  first  efforts  in  cases  of  peritonitis  should  be  directed 
to  relieve  pain,  maintain  quietude,  and  diminish  peristaltic  action  by 
means  of  opium,  we  must  not  lose  sight  of  the  necessity  of  favoring 
such  transformations  in  the  exudation  as  will  cause  absorption  or  chronic 
adhesions.  All  exhaustive  remedies,  therefore,  are  to  be  avoided  ; and^ 
as  soon  as  the  circumstances  of  the  case  admit  of  it,  nourishment,  and; 
if  necessary,  stimuli  in  moderation  should  be  administered. 


PERITOXITIS. 


549 


Case  XCIV.* — Tuhercnlar  Peritonitis  with  great  Deposit  in  Parieta^ 
Layer — Tubercle  and  Ileptatization  of  Lungs — Pleuritis — Adherent 
Pericardium — Commencing  Fatty  Degeneration  of  Heart — Biliary 
Congestion  and  Fatty  Degeneration  of  Liver — Slight  Leucocythemia. 

History. — Elizabeth  Barker,  aet.  IV — admitted  Oct.  6th,  1854;  single;  employed 
in  a factory ; has  been  ill  for  about  eight  months.  In  the  month  of  February  last  she 
was  attacked  with  a “fever,”  which  she  attributes  to  working  in  a cold  and  damp 
room.  This  confined  her  to  her  bed,  and  she  was  under  medical  treatment  for  two 
months,  at  the  end  of  which  time  she  was  much  better.  A fortnight  afterwards  she 
was  attacked  with  pain  in  the  lumbar  region  and  left  side,  and  with  a dry  cough,  and 
she  did  not  pass  so  much  water  as  usual.  Her  abdomen  and  legs  also  became  swollen. 
She  took  medicines,  which  partially  removed  the  swelling.  She  came  to  Edinburgh 
three  weeks  ago,  and  since  then  the  swelling  in  the  abdomen  and  legs  has  been  gradu- 
ally increasing. 

Symptoms  on  Admission. — On  admission,  urine  scanty  and  high  colored  ; sp.  gr. 
1030;  does  not  contain  albumen.  She  has  never  menstruated.  Complains  of  pain 
over  the  lumbar  vertebrae,  increased  by  pressure.  Tongue  moist  and  furred,  appetite 
impaired.  Has  a sour  taste  in  mouth,  and  is  troubled  with  flatulence.  Bowels  costive. 
Cardiac  sounds  normal.  Pulse  128,  small  and  thready.  A friction  sound  is  audible 
over  the  inferior  part  of  both  lungs,  anteriorly,  posteriorly,  and  laterally,  with  dulness 
on  percussion,  and  c^minution  of  vocal  thrill.  In  the  upper  part  of  right  lung,  ante- 
riorly and  posteriorly,  the  respiratory  murmur  is  audible,  with  slight  increase  of  vocal 
resonance.  Over  upper  part  of  left  lung  anteriorly,  the  natural  respiratory  murmur  is 
audible,  but  posteriorly  there  is  a marked  increase  of  vocal  resonance,  with  tubular 
breathing.  Posteriorly  legophony  at  the  angle  of  right  scapula.  Skin  moist,  of  natu- 
ral temperature.  ^ Hydrarg.  Protoiod.  gr.  vj ; Ext.  HyoHcyami  3 ss ; Conserv. 
Rosar.  q.s.  nt  fiant  pit.  xij.  Sumat  unam  bis  die.  ^ 8p.  HJth.  Nitrici  § iss ; Tr. 
Scillce  ; Tr.  Digitalis  iik  3 ij-  M.  Sumat  Z ] ex  aqua  indies. 

Progress  op  the  Case. — October  l\th. — Dyspnoea  continues.  Pain  in  abdomen 
increased.  Has  been  suffering  from  purging  for  the  last  24  hours.  To  take  chalk 
mixture  with  Sol.  Mur.  Morphice.  Oct.  14^A. — Six  leeches  w^ere  ordered  to  the  ster- 
num yesterday.  To-day  friction  sound  has  disappeared.  To  have  3 ij  of  port  wine. 
Nov.  Is^. — The  distended  abdomen  measures  32^  inches.  Fluctuation  distinctly  felt. 
Vertical  hepatic  dulness  2J  inches.  Dull  pain  in  hepatic  and  right  lumbar  region, 
but  no  tenderness,  as  it  can  be  handled  and  pressed  freely  without  causing  inconven- 
ience. Feet  oedematous.  Sweats  considerably.  B Potass.  Acetat.  3 ij ; Sp.  .xEth. 
Nitrici  3 ss ; Mist.  Scilloe  § viss.  M.  Sumat  § ss  ter  indies.  Omittantur  alia.  Nov. 
12<A. — Quantity  of  urine  much  increased.  Abdomen  measures  31  inches.  Nov.  22c/. — 
Abdomen  measures  30^  inches.  Nov.  2,Mh. — Fluid  in  abdomen  much  diminished. 
Swelling  and  tension  of  its  walls  greatly  decreased.  Circular  measurement  29  inches. 
On  palpation  a distinct  hardness  may  be  felt  in  the  right  hypochondriac  region,  ex- 
tending into  the  epigastrium.  Tongue  dry  and  brown.  Has  been  suffering  from 
diarrhoea  for  some  days  past.  The  stools  have  of  late  been  clay-colored,  and  slight 
jaundiced  tint  of  skin  has  made  its  appearance.  Urine  contains  bile,  and  is  slightly 
coagulable  by  heat  and  nitric  acid.  Blood  presents  a slight  increase  in  number  of 
white  corpuscles.  To  have  a starch  enema  with  Tinct.  Opii.  Nov.  26^A. — Much 
worse.  Skin  cold.  Face  sunken  and  pale.  She  lies  on  left  side  ; any  other  position 
causes  gre^t  dyspnoea.  Respiration  36  to  40  per  minute.  Coarse  crepitation  may  be 
heard  over  the  whole  right  side.  Pulse  120,  very  weak.  Diarrhoea  continues,  but 
stools  this  morning  were  fgeculent.  Urine  dark  brick-red;  sp.gr.  1012,  with  some 
traces  of  bile.  Not  a trace  of  chlorides  present.  To  have  the  enema  repeated  immedi- 
ately., and  3 oz.  of  brandy.  Nov.  Tlth. — She  gradually  sank,  and  died  to-day  at  10  p.m. 

Sectio  Cadaveris. — Twenty -seven  hours  after  death. 

External  Appearances. — Body  emaciated.  Abdomen  somewhat  distended. 

Thorax, — The  pericardium  was  universally  adherent.  The  adhesions  were  firm, 
and  were  broken  down  with  difficulty.  The  valves  of  the  heart  were  healthy,  but 
the  muscular  substance  was  of  brownish-red  color,  and  rather  softer  than  natural. 
The  size  of  the  heart  w^as  normal.  There  were  firm  old  adhesions  over  the  upner 
lobe  of  the  right  lung.  Over  the  lower  lobe  there  was  a thin  layer  of  recent  lymph. 


Reported  by  Mr.  Almeric  W.  Seymour,  Clinical  Clerk. 


550 


DISEASES  OF -THE  DIGESTIVE  SYSTEM. 


Between  the  dia])hragm  and  the  base  of  the  lung  was  a pouch  containing  six 

ounces  of  turbid  fluid,  in  which  floated  some  flakes  of  lymph.  The  whole  lung  felt 
firm  and  dense.  When  cut  into,  it  presented  a somewhat  granular  surface  of  a red 
color,  was  scarcely  crepitant,  broke  down  readily,  and  some  portions  of  it  sank  in 
water.  Scattered  through  it  were  a number  of  yellow  masses,  from  the  size  of  millet 
seed  to  that  of  a small  pea.  They  were  of  cheesy  consistence,  and  were  pretty  readil;y 
broken  down.  They  were  scattered  equally  through  the  pulmonary  substauce,  and 
w'ere  not  more  abundant  at  the  apex  than  elsewhere.  None  were  softened.  The  left 
lung  was  universally  adherent,  but  there  was  no  recent  lymph.  The  lung  felt  firm, 
and  v/hen  cut  into  presented  altogether  the  same  appearance  as  the  right  lung.  The 
same  yellowish  masses  were  scattered  through  it.  The  bronchial  glands  were  enlai’ged, 
and  when  cut  into  wei-e  found  to  contain  yellow,  cheesy,  tubercular  matter. 

Abdomen. — The  cavity  of  the  abdomen  contained  about  a gallon  of  yellowish,  toler- 
ably clear  fluid.  The  parietal  peritoneum  was  very  much  thickened  by  a deposit, 
varying  from  about  one  line  to  half  an  inch  in  thickness.  It  was  of  a yellowish  color, 
but,  on  looking  closely  into  it,  numerous  opaque  points,  of  the  size  of  pins’  heads  or 
so,  were  seen  separated  from  one  another  by  a clear  substance.  On  cutting  into  the 
deposit,  this  appearance  was  still  more  distinct.  Numerous  blood-vessels  were  seen 
on  its  surface  and  in  its  substance ; and  on  the  former  were  numerous  particles  of  ex- 
tra vasated  blood  of  a bright  red  color.  The  deposit  was  of  firm  consistence.  The 
coils  of  the  intestines  were  firmly  adherent  by  tolerably  firm  lymph.  Their  coats  were 
softened,  so  that,  in  endeavoring  to  separate  the  adhesions,  they  tore  readily.  On 
looking  closely  at  the  surface  of  the  intestines,  numerous  small,  semi-transparent, 
yellowish-white  deposits  were  seen  on  the  serous  surface,  and  these  presented  all  the 
usual  characters  of  tubercle.  The  mucous  coat  of  the  intestines  was  healthy.  The 
capsule  of  the  liver  was  thickened,  and  the  upper  and  anterior  part  of  it  was  adherent 
to  the  diaphragm.  The  liver  was  externally  of  a yellow  orange  color.  On  cutting 
into  it  numerous  opaque  yellowish-white  masses,  varying  from  the  size  of  a pin’s  point 
to  that  of  a millet  sec'd,  were  seen  surrounded  by  deep  orange-colored  matter.  The 
surface  of  the  section  was  quite  smooth ; the  tissue  of  the  liver  was  rather  softer  than 
natui'al ; and  there  did  not  appear  to  l)e  any  increase  in  the  amount  of  fibrous  tissue. 
The  liver  was  small,  and  weighed  2 lb.  7 oz. ; sp.  gr.  1061.  The  gall-bladder  was 
small,  its  coats  were  thickened,  and  it  was  bound  down  to  the  liver  by  fibrous  tissue. 
It  contained  about  two  drachms  of  orange-colored  bile.  The  spleen  was  natural. 
Mesenteric  and  lumbar  glands  enlarged,  of  white  appearance,  of  a smooth  surface  on 
section,  yielding  a copious  opaque  juice  on  pressure.  The  kidneys  presented  nothing 
unusual. 

Microscopic  Examination. — The  muscular  fibres  of  the  heart  had  lost,  to  a cer- 
tain degree,  their  striated  appearance,  which  was  replaced  in  some  by  granular  fatty 
mattter.  The  masses  of  deposit  in  the  lungs  presented  all  the  usual  characters  of 
tubercle.  On  examining  the  thickened  peritoneum,  large  groups  of  tubercle  corpus- 
cles and  granular  matter  were  seen  to  be  surrounded  and  isolated  by  fibrous  tissue. 
The  pale,  opaque-looking  points  in  the  liver,  consisted  of  accumulations  of  fat,  partly 
free,  partly  in  hepatic  cells.  The  surrounding  parts  were  loaded  with  yellow  biliary 
matter.  There  was  no  increased  quantity  of  fibrous  tissue.  The  tubes  and  cells  of  the 
kidneys  appeared  quite  natural. 

Commeniary — This  is  a characteristic  case  of  so-called  tubercular 
peritonitis,  associated  with  pulmonary  tubercle  and  various  other  lesions. 
In  a practical  point  of  view,  it  is  to  be  remarked  that  the  s^^mptoms 
were  wholly  different  from  those  in  the  previous  case.  There  was  no 
abdominal  tenderness,  no  inflammatory  fever — and,  notwithstanding  the 
large  amount  of  lymph  exuded,  some  of  it  recent,  ail  the  symptoms 
were  those  of  ascites  dependent  on  atrophy  of  the  liver.  In  some  cases 
of  this  disorder,  the  peculiar  doughy  feeling  communicated  to  the  hand, 
and  the  roughened  friction  perceptible  on  moving  the  two  peritoneal 
surfaces  over  the  other,  give  an  indication  of  the  nature  of  the  disease— 
the  latter  symptom  was  absent  in  the  present  ease  in  consequence  of  the 
accumulation  of  fluid.  Occasionally  the  amount  of  tubercular  exudation 
is  very  great ; I have  seen  it  matting  together  all  the  intestines  and  abdo- 
minal viscera  in  a layer  varying  from  a half  to  an  entire  inch  in  thickness, 


FEEITONITIS. 


551 


In  sucli  cases  also  it  frequently  happens  that  whilst  the  abdomen  ia 
loadei  with  tubercle,  the  lungs  are  comparatively  free  from  it. 

The  mesenteric  and  lumbar  glands  in  these  cases  are  very  apt  to  be- 
come hypertrophied,  and  the  blood  to  contain  an  unusual  number  of 
colorless  corpuscles.  In  a man,  James  M‘Arthur,  who  died  in  Paton’s 
Ward  during  the  summer  of  1857,  these  glands  were  enlarged.  There 
was  also  an  enormous  collection  of  tubercular  exudation  in  the  abdomen, 
which  on  examination  was  found  to  form  a layer  from  one-half  to  an 
inch  in  thickness,  glueing  the  intestines  and  abdominal  viscera  together. 
On  examining  a drop  of  his  blood  under  the  microscope  in  the  usual 
way,  during  life,  from  twenty-five  to  forty  colorless  corpuscles  could 
always  be  counted  in  the  field  of  the  instrument.  (See  Leucocythemia.) 

Case  XCV.* — Cancer  of  various  Abdominal  Organs  and  of  the  Lungs, 
'producing  Sym'ptcms  of  Peritonitis. 

History. — Christina  Galbraith,  set.  52,  a fish-cleaner,  at  Nev/castle,  single — admit- 
ted November  29,  1854.  The  patient  states  that,  until  nine  months  ago,  she  enjoyed 
good  health,  since  which  time  her  strength  has  been  diminishing.  She  has  been  de 
cidedly  ill  for  the  last  three  months.  Her  first  symptoms  were  pain  in  the  epigastrium, 
a feeling  of  cold,  great  thirst,  anorexia,  sickness,  and  severe  night-sweats.  The  pain 
in  the  epigastrium  has  gradually  increased  up  to  the  present  time.  About  ten  weeks 
before  admission,  she  noticed  that  her  abdomen  began  to  swell,  and  the  swelling  has 
since  gradually  increased.  Her  feet  have,  for  the  last  five  years,  evinced  a tendencj’ 
to  oedema  towards  evening,  in  consequence,  as  she  thinks,  of  her  work  requiring  her 
to  be  much  in  the  erect  position,  and  lately  they  have  become  more  swollen.  Four 
weeks  ago  she  had  an  attack  of  jaundice,  accompanied  by  severe  pain  in  the  lumbar 
and  right  hypochondriac  regions.  The  color  of  the  stools  is  not  known,  but  she  thinks 
her  bowels  were  regular  at  the  time,  although  she  is  habitually  subject  to  constipation. 
A week  after  its  appearance,  her  bowels  became  very  loose  ; the  stools  were  faeculent 
and  abundant.  On  one  occasion  she  passed  a considerable  quantity  of  blood,  accompa- 
nied by  what  she  describes  as  “ great  lumps  of  strings,”  but  of  the  color  of  which  she 
has  no  idea.  At  this  time  she  had  no  vomiting,  but  felt  great  pain  over  the  whole  of 
the  abdomen,  which  became  very  swollen  and  tense.  She  improved  under  medical 
treatment ; the  bowel  complaint  disappeared,  and  the  pain  in  the  abdomen  abated.  But 
she  does  not  know  how  long  the  attack  lasted.  During  its  continuance  she  also  suffered 
from  vomiting ; the  matters  ejected  were  sometimes  of  a green,  at  others  of  a coffee- 
ground  color.  The  bowel  complaint  and  the  pain  returned  with  g.reat  severity  on  her 
voyage  from  Newcastle  to  Edinburgh.  She  also  vomited  considerably,  and  was  brought 
to  the  Infirmary  in  a state  of  great  exhaustion  on  the  evening  of  the  29th  of  November. 

Symptoms  on  Admission. — On  admission,  she  complained  of  great  pain  over  the 
epigastrium  and  right  hypochondrium,  and  generally  all  over  the  abdomen  ; face  very 
anxious ; pulse  small  and  quick.  Ordered  Wine  and  Brandy,  Tanyiin  and  Opium  Pills, 
and  four  Leeches  to  right  hypochondrium.  Next  day  was  carefully  examined.  Face  and 
conjunctivse  have  a yellowish  tinge ; countenance  anxious,  but  speech  is  clear  and  com- 
prehension quick.  She  complains  both  of  a continuous  and  a shooting  pain,  worse  over 
the  epigastrium  and  over  the  left  side  of  the  abdomen,  in  the  course  of  the  descending 
colon.  Tfie  pain  felt  last  night  in  the  right  hypochondrium  has  been  diminished  by  the 
leeches,  which  bled  well.  She  lies  with  greatest  ease  on  the  right  side,  and  feels  great 
pain  when  she  assumes  the  supine  position.  The  abdomen  is  exceedingly  tender  on 
pressure  ; it  is  swollen,  tense,  and  tympanitic,  permitting  nothing  deep-seated  to  be  felt. 
Pungent  heat,  and  dryness  of  skin  over  its  surface.  Tongue  white,  with  prominent 
papillae,  pale,  siuooth,  and  glossy  at  tip  and  edges.  Complains  of  constant  bad  taste  in 
mouth ; has  a burning  pain  at  epigastrium,  and  most  intense  thirst,  but  cannot  take 
cold  water,  as  it  causes  immediate  vomiting,  though  she  does  not  otherwise  feel  sick. 
Appetite  entirely  gone ; bowels  have  not  been  moved  since  her  admission.  Urine 
diminished  in  quantity,  high-colored,  with  a deposit  of  lithates  ; the  chlorides  are 
present ; sp.  gr.  1014  ; she  has  a sense  of  heat  in  passing  it.  Catamenia  last  appeared 


* Reported  by  Mr.  0.  Beaujeard,  Clinical  Clerk. 


552 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


about  a month  ago.  Px^he  108,  small  and  weak.  Apex  of  heart  beats  between 
fifth  and  sixth  ribs;  transverse  dulness  normal.  Sounds  normal.  mostly 

thoraeic;  respirations  82  per  minute;  cannot  take  a full  breath  without  pain;  has  a 
short  hacking  cough.  Chest  expands  equally,  but  imperfectly.  Percussion  good,  both 
anteriorly  and  posteriorly;  respiratory  murmurs  natural.  Has  headache,  tinnitus 
aurium,  and  muscas  volitantes.  Feels  sick  and  giddy  on  sitting  up.  There  is  oedema 
of  the  feet,  ankles,  and  legs.  To  have  xjoixie  4 oz.,  and  in  the  evening  a Tw'pexitixie  and 
Assafoetida  enema. 

Progress  of  the  Case. — December  Is^. — The  enema  was  followed  by  two  faecu- 
lent  and  hard  stools.  Pain  in  the  abdomen  considerable — most  felt  below  the  margin 
of  the  right  false  ribs.  Complete  anorexia.  Great  thirst;  pulse  104,  small  and  hard. 
Dec.  2d. — State  much  the  same  ; bowels  not  again  opened.  Pain  in  the  abdomen  being 
increased,  she  was  oi-dered  six  more  leeches  to  the  x'ight  hypochondrium^  axid  the  follow- 
ing diuretic  mixture — 'Sf.Potassoe  Acetatis  3 ij ; 8p.  jEth.  Nitx'ici  §ss;  Mist.  Scillfe, 
3 vss.  M.  '^B&tohe  taken  three  times  a day.  Dec.  5th. — Breathing  natural;  abdo- 
men not  so  tense  and  hot ; pain  greatly  diminished  ; appetite  not  improved ; stools 
dark  but  healthy;  pulse  96,  small  and  weak.  Dense  deposits  of  lithates  in  urine. 
Dec.  IQth. — Pulse  92,  very  small  and  weak.  No  thirst;  appetite  not  improved,  abdo- 
men less  tense — fluctuation  may  be  distinctly  felt.  Pain  less — most  severe  on  left  side. 
Dec.  I8th. — Passes  very  little  urine;  it  is  high-colored,  and  deposits  lithates  abun- 
dantly. Abdomen  less  tense — measures  33  inches  in  circumference.  It  is  tympanitic, 
and  fluctuation  may  be  felt.  Feet  oedematous;  bowels  regular;  no  appetite,  great 
thirst ; slight  catching  of  the  breath.  H Pn'h.  Digitalis  gr.  iij  ; Pulv.  Scillce  gr.  vj  ; 
Ext.  Taraxaci  q.  s.,  ut  fiant  pil.  vj.  Sumat  unam  bis  indies.  Omittantur  alia. 
Dec.  \^th. — Urine  much  increased  in  quantity ; is  very  high-colored  ; deposits  lithates. 
Dec.  20^/i. — Great  pain  complained  of  in  lumbar  region.  Yellowish  tinge  of  complex- 
ion increasing.  To  apply  to  the  abdomen  the  Spongio-Piline  soaked  in  Inf.  Digitalis 
of  four  times  the  usual  strength.  Dec.  21.s^. — The  Spongio-Piline  has  relieved  the  pain 
in  the  abdomen.  Breathes  easier.  Thinks  her  urine  diminished  in  quantity.  It  is  of 
a deep  copper  color.  Has  vomited  her  breakfast  for  the  last  two  days,  but  is  not  sick 
otherwise.  Bowels  regular,  appetite  not  improved ; pulse  108,  weak.  Dec.  2?>d. — • 
Vomiting  more  frequent:  is  much  troubled  with  flatulence;  tongue  pale,  smooth,  and 
glossy  ; bowels  regular.  Dec  25th. — Tr.  lodinei  to  be  painted  over  the  abdomen. 
Dec.  2^th. — The  iodine  caused  her  great  pain,  which  was,  however,  relieved  by  warm 
fomentations.  The  swelling  of  tlie  abdomen  and  tympanitis,  the  cough,  and  the  ex- 
pectoration, have  increased  ; breathing  slightly  laborious.  ^ Sp.  uEth.  Sulph.  3 iij  ; 
Sol.  Mur.  Morph  3 j ; Mist.  Scillce  ^ iiss.  To  be  taken-in  half  ounce  doses  when  the 
cough  is  troublesome.  Dec.  80th. — Abdomen  measures  34  inches  in  circumference. 
Bowels  regular  ; percussion  normal  over  chest ; mucous  and  sibilant  rales  heard  on 
auscultation.  Coughs  much  ; expectoration  abundant,  purulent,  and  tenacious ; pulse 
small  and  weak ; legs  and  feet  very  oedematous ; ui  ine  as  before.  Jan.  2c?. — Jaun- 
diced tint  of  skin  is  growing  deeper ; distension  of  abdomen  from  tympanitis  increased ; 
pulse  rapid  and  thready;  vomits  all  her  food  immediately  after  taking  it,  together  with 
a quantity  of  black  matter  ; thirst  .great ; stools  pale-colored  but  consistent.  I'o  omit 
the  Squill  and  Digitalis  Pill.,  and  to  take  Potass.  Bitart.  Dj  ter  indies.  Jan.  Ath. — 
Jaundice  increases;  urine  very  small  in  quantity,  and  contains  bile.  Swelling  of  ab- 
domen augmented  ; great  protrusion  of  lower  ribs,  but  breathing  is  not  much  affected. 
Vomiting  continues.  There  isoedema  of  feet,  legs,  and  hands ; she  is  getting  decidedly 
weaker.  Pulse  96,  steady  and  weak.  Jan.  5th. — Died  this  morning  at  2 a.m. 

Sectio  Cadaveris. — Fifty-eight  hours  after  death. 

The  body  emaciated ; the  surface  of  a moderately  yellow  tinge ; abdomen  much 
distended  and  fluctuating. 

Thorax. — The  pericardiuxn  and  heart  were  healthy ; there  were  a few  slight  old 
adhesions  on  the  left  side  of  the  chest ; the  left  lung,  when  removed,  had  an  irregular 
feeling  from  the  presence  of  a number  of  mas.^es,  some  immediately  under  the  pleura, 
others  embedded  in  the  pulmonary  tissue ; the  masses  visible  externally  had  a cir- 
cumference equal  to  about  that  of  a fourpenny  piece ; their  margins  were  slightly 
prominent,  while  they  were  depressed  or  flattened  in  the  centre;  they  appeared  of  a 
greyish-white  color,  and  felt  firm  and  hard  ; on  cutting  into  the  lung,  pretty  nume- 
i-ous  masses  similar  in  size  could  be  seen  scattered  through  it ; they  were  generally 
of  a white  or  greyish-white  color,  while  some  were  yellowish,  as  if  stained  by  biliary 
matter ; most  of  these  masses  felt  tolerably  firm,  but  yielded  on  pressure  a small 


PERlTOXmS. 


553 


quantity  of  a glairy  juice ; others,  however  (which  were  more  opaque-looking  than 
the  rest),  crumbled  down  easily  under  the  fingers.  The  right  lung  was  very  densely 
adherent  throughout  externally ; it  presented  masses  similar  to  those  found  in  the 
left  lung,  and  others  could  be  felt  in  its  substance ; it  was  not  cut  into,  but  was  sent 
entire  to  the  university  museum ; the  pulmonary  tissue  intervening  between  the 
masses  was  quite  healthy.  A few  of  the  bronchial  glands  at  the  root  of  each  lung 
were  a little  enlarged,  and  when  bisected  were  found  to  contain  a substance  like 
that  met  with  in  the  tumors  of  the  lungs.  The  bronchi  were  unaffected.  One 
gland  in  the  anterior  mediastinum  immediately  under  the  upper  part  of  the  sternum 
was  of  the  size  of  a walnut,  and  on  being  divided,  was  found  converted  into  a mass 
of  almost  cheesy  consistence,  of  a yellow  color,  mottled  by  the  presence  of  a good  deal 
of  black  pigmentary  matter. 

Abdomen. — The  cavity  of  the  abdomen  contained  about  a gallon  and  a half  of  a 
clear  yellowish  fluid.  Peritoneal  membrane  everywhere  healthy.  The  liver ^ which 
was  much  enlarged,  presented  a very  irregular  appearance,  in  consequence  of  the 
projection  from  its  surface  of  numerous  masses  of  a whitish-yellow  color,  varying 
from  the  size  of  a pea  to  that  of  the  fist ; some  were  rounded,  others  of  a very  irre- 
gular form.  Only  a very  few  of  these  masses  presented  any  central  depression. 
When  cut  into,  the  substance  of  the  liver  w.as  found,  to  a great  extent,  occupied  by 
a similar  matter ; at  some  places  it  occurred  in  small  isolated  masses,  but  in  general 
it  was  found  infiltrated  in  large  patches.  It  was  of  a yellowish  color;  some  parts 
of  it,  however,  were  opaque,  while  intervening  portions  were  clear  and  semi-trans- 
parent ; other  parts,  again,  were  intermediate  between  these  conditions ; the  matter 
was  generally  tolerably  firm,  but  ,the  more  opaque  parts  had  a tendency  to  crumble 
down.  The  hepatic  tissue  itself  was  of  a yellowish  color,  and  moderately  firm. 
The  weight  of  the  entire  liver  was  7 lbs. ; behind  the  liver  a mass  of  enlarged 
glands  surrounded  and  compressed  the  vena  cava,  the  gall-bladder,  and  common  duct ; 
the  vena  cava  was  somewhat  diminished  in  size : the  gall-bladder  was  much  con- 
tracted, being  little  larger  than  an  almond,  and  contained  scarcely  any  bile ; on 
passing  a probe  from  the  gall-bladder  along  the  cystic  duct,  the  latter  was  found 
quite  occluded,  a little  before  its  point  of  junction  with  the  common  duct ; a probe 
was  passed  from  the  duodenum  along  the  common  duct,  but  both  it  and  the 
hepatic  duct  were  compressed  and  contracted ; the  enlarged  glands,  when  cut  into, 
were  found  converted  into  firm  yellowish  masses,  quite  similar  to  those  met  with 
elsewhere.  The  pancreas  was  healthy ; the  stomach  felt  indurated  towards  its  pyloric 
end,  and  on  being  cut  into,  a large  ulcer  was  found  near  the  pyloric  orifice ; it  was 
of  an  oval  form,  about  3^  by  2i-  inches,  its  longest  diameter  being  from  above 
downwards ; its  right  margin  was  about  an  inch  from  the  pylorus.  The  ulcer  had 
a hard  thickened  base,  and  a very  irregular  surface  from  the  presence  of  numerous 
tungating  excrescences  of  a greyish-white  color.  The  margins  of  the  ulcer  were 
elevated  above  the  surrounding  mucous  membrane,  but  were  irregular  looking  as  if 
they  had  been  gnawed  by  some  animal.  There  was  no  perforation.  The  stomach 
and  the  duodenum  otherwise  healthy.  Some  of  the  gastric  lymphatic  glands, 
particularly  some  of  those  connected  with  the  lesser  curvature,  were  enlarged  and 
cancerous.  The  spleen  was  natural.  The  kidneys,  when  cut  into,  were  of  a yellowish 
color : their  surface  was  a little  irregular,  apparently  resulting  from  old  cysts ; a few 
cysts  were  seen  in  the  surface,  and  also  in  the  cortical  portion ; several  of  the  lumbar 
glands,  lower  down  than  the  mass  found  behind  the  liver,  were  enlarged  and  similarly 
affected.  The  uterus  and  ovaries  were  healthy. 

Microscopic  Examination. — On  examining  a little  of  the  juice  squeezed  out  of 
any  of  the  masses  above  described,  tolerably  large  nucleated  cells  were  found. 
Many  of  them  presented  the  usual  appearance  of  cancer-cells ; others,  however,  were 
small,  and  many  nuclei  were  seen  free.  In  the  opaque  portions,  the  cells  were  less 
distinct,  and  there  was  a large  quantity  of  fatty  matter.  The  cells  of  the  liver  con- 
tained a good  deal  of  biliary  matter,  but  they  were  otherwise  quite  healthy.  The 
kidneys,  when  examined  microscopically,  also  appeared  healthy. 

Commentary. — This  subject  of  cancer  of  the  lungs,  liver,  stomach, 
and  other  organs,  when  she  entered  the  clinical  ward,  presented  all  the 
symptoms  of  acute  peritonitis,  including  great  tenderness,  with  disten- 
sion of  the  abdomen,  fever,  and  increase  of  urates  in  the  urine.  There 
was,  however,  no  evidence,  on  palpation,  of  the  nodular  swellings  found 
after  death  j these  were  masked  by  the  accumulation  of  fluid  and  tym- 


554 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


panitis.  Neither  did  physical  signs  indicate  the  cancerous  deposition  in 
the  lung,  it  being  so  diffused  as  not  to  occasion  any  marked  abnormal 
respiratory  symptoms;  such  as  did  exist  were  explicable  by  the  abdo- 
minal disease. 

The  facts  presented  in  the  three  last  cases  indicate  the  uncertainty 
of  our  diagnosis  in  abdominal  diseases.  In  the  first,  it  is  true,  the  symp- 
toms corresponded  with  the  acute  peritonitis  of  authors ; but  in  the 
second  there  were  no  such  symptoms,  though  there  was  abundance  of 
exudation ; while  the  third  case  presented  all  of  them  in  a marked  and 
characteristic  degree,  in  connection  with  cancer  of  the  abdominal  organs, 
and  elfusion  of  serum.  I never  saw  a case  which  better  satisfied  me  of 
the  insufficiency  of  mere  symptoms,  for  the  purpose  of  arriving  at  an 
exact  knowledge  of  a patient’s  real  disease.  The  history  of  this  case, 
it  is  true,  indicated  the  existence  of  some  chronic  disease,  but  all  the 
positive  symptoms,  after  her  admission,  including  extreme  tenderness  of 
the  abdomen,  its  distension,  tympanitis,  constipation,  high  fever,  vomit- 
ing, etc.,  pointed  out  that  the  chronic  disease  of  the  stomach  and  other 
organs  had  terminated  in  acute  peritonitis.  Yet,  on  examination,  peri- 
tonitis there  was  none,  but  only  serous  effusion,  or  ascites,  evidently 
resulting  from  the  organic  disease  of  the  liver  obstructing  the  abdominal 
circulation.  When  contrasted  with  the  last  case,  in  which  the  peri- 
toneal membrane  was  covered  with  lymph,  the  present  one,  where  it  was 
healthy,  exhibits  a remarkable  discordance  with  systematic  descriptions 
of  disease.  The  true  exudation  had  not  one  of  the  so-called  symptoms 
of  that  lesion,  whereas,  in  the  last  case,  there  was  every  symptom,  with 
a perfectly  sound  peritoneum,  I have  recorded  therefore  this  case  at 
groat  length,  because  the  acute  symptoms  will  speak  for  themselves,  and 
because,  when  compared  with  some  remarkable  cases  afterwards  to  be 
given  of  pleuritis  without  the  usual  symptoms,  it  serves,  in  my  opinion, 
to  convince  us  that  many  of  our  existing  notions  as  to  the  pathology  of 
acute  diseases  require  to  be  modified.  For  other  examples  of  peritonitis, 
see  Gases  LXVll.  and  LXXXVII. 

Case  XCVl.^' — Cancerous  Peritonitis — Ascites  and  Hydrothorax — 
Paracentesis  Abdominis — Arrested  Phthisis  Pulmonalis. 

Historv. — Margaret  Pardon,  aet.  63,  a widow,  has  had  two  children — admitted 
December  15th,  1856.  Three  years  ago  she  had  profuse  hsematemesis,  accom- 
panied by  loss  of  blood  per  anum,  which  caused  faintness.  In  a few  days,  however, 
she  quite  recovered,  and  remained  perfectly  well  until  three  months  ago,  when 
she  first  observed  that  the  lower  part  of  the  abdomen  was  swollen,  but  not  painful. 
About  a fortnight  afterwards  she  experienced  severe  pain  in  the  left  lumbar  region, 
together  with  a sensation  as  of  cold  water  trickling  down  her  left  thigh  as  far  as 
the  knee.  Two  months  after  the  first  symptoms  had  shewn  themselves,  the  abdo- 
men had  become  gradually  much  distended,  and  she  experienced  a “ dead  pain  ” in 
the  epigastric  region,  which,  she  says,  was  constant,  but  not  aggravated  by  pres- 
sure, and  caused  great  shortness  of  breath.  Simultaneously  with  this  epigastric  pain 
a scantiness  and  turbidity  of  the  urine  appeared,  and  a day  or  two  subsequently  both 
feet  and  legs  became  very  much  swollen,  the  right  one  especially  so.  During  the  last 
fortnight  she  has  taken  several  doses  of  rhubarb  and  magnesia,  the  purgative  action  of 
which  has  been  followed  by  considerable  alleviation  of  her  symptoms,  and  diminu- 
tion in  the  size  of  the  abdomen,  and  of  the  dropsical  swelling  of  the  inferior  extremities. 

Symptoms  on  Admission. — The  abdomen  ts  so  distended  as  to  measure  at  the 
epigastrium  20^,  and  at  the  umbilicus  35  inches  round.  It  fluctuates  on  palpation, 
but  there  is  no  pain  on  pressure.  In  every  position  the  lower  portion  of  the  abdo- 
men is  dull,  and  the  upper  tympanitic  on  percussion.  No  tumor  can  be  detected, 


* Keported  by  Mr.  Alexr.  M‘Leod  Pemberton,  Clinical  Clerk. 


PERITONITIS. 


555 


nor  can  the  amount  of  the  hepatic  dulness  be  accurately  determined.  The  tongue 
is  covered  with  a white  fur  on  the  right  side,  and  is  perfectly  clean  on  the  left.  She 
has  a good  appetite,  but  cannot  eat  much  on  account  of  the  uneasiness  it  occasions 
in  the  epigastrium — a symptom  from  which  she  is  now  seldom  free.  The  bowels  are 
open  naturally  every  other  day.  No  flatulence.  There  is  considerable  dyspnoea , 
a slight  cough,  but  no  sputum.  Percussion  is  resonant  over  the  whole  chest.  At 
the  ape.v  of  the  left  lung  expiration  is  prolonged  and  hard,  and  the  vocal  resonance 
increased.  Pulse  85,  of  good  strength.  Heart’s  size  and  sounds  normal.  The  face 
is  much  emaciated  and  pale.  Both  feet  and  legs  somewhat  oedematous,  the  right  one 
most  so.  Does  not  sleep  well  on  account  of  the  dyspnoea.  Urine  sp.  gr.  1012  ; con- 
tains phosphates  in  solution,  but  no  albumen. 

Progress  op  the  Case. — January  5th. — Since  coming  into  the  house  she  has 
had  an  occasional  dose  of  castor  oil,  and  her  symptoms  have  on  the  whole  been  much 
alleviated.  There  is,  however,  great  orthopnoea  at  night,  and  she  says  it  is  easier 
to  lie  on  the  left  side.  A careful  examination  to-day  has  determined  that  there  is 
great  dulness  on  percussion  over  the  lower  half  of  right  lung,  and  that  the  respira- 
tory murmurs  there  are  audible.  The  abdomen  now  measures  at  the  epigastriu'n 
3l|,  and  at  the  umbilicus  37  inches.  Pulse  92,  feeble.  Passes  urine,  loaded  with 
phosphates,  freely.  To  have  extra  nutrients.^  and  four  oimces  of  wine  daily.  Jan- 
uary 12th. — In  consequence  of  the  great  dyspnoea,  which  is  daily  increasing,  para- 
centesis of  the  abdomen  was  performed,  and  190  ounces  of  a pale,  greenish-yellow 
fluid  were  drawn  off.  This  fluid  was  o-f  the  sp.  gr.  1012,  and  formed  a solid,  gela- 
tinous mass  on  the  addition  of  heat.  On  standing  it  became  slightly  turbid,  but 
exhibited  nothing  but  a few  scattered  blood  corpuscles  under  the  microscope.  The 
operation  was  followed  by  a tendency  to  syncope,  which  was  removed  by  the  free 
use  of  port  wine  and  brandy.  Jan.  13^/i. — Feels  greatly  relieved  by  the  operation. 
Several  nodulated  swellings  can  now  be  felt  under  the  flaccid  abdominal  integuments, 
especially  on  the  left  side.  Ja7i.  lUh. — Though  greatly  relieved,  complains  of  great 
weakness.  Jan.  \5th. — Though  liberally  supplied  with  stimulants,  died  this  morning 
at  half-past  two,  apparently  from  exhaustion. 

Sectio  Cadaveris. — Thirty-five  hours  after  death. 

External  Appearances. — Great  emaciation.  Abdomen  flaccid,  she  having  been 
tapped  a short  time  before  her  death,  and  190  ounces  of  serum  removed. 

Thorax. — The  external  surface  of  the  pericardium  contained  a number  of  can- 
cerous nodules,  varying  in  size  from  a pepper-corn  to  that  of  a small  bean,  of  a 
white  and  pinkish-white  color.  The  internal  layer  of  the  pericardium  and  the 
heart  were  healthy.  The  right  pleura  contained  about  four  pints  of  serum.  The 
lung  was  compressed  and  pushed  up  against  the  spine.  Its  upper  Iburth  was 
spongy,  but  most  of  the  three  inferior  fourths  were  carnified,  and  contained  little 
air.  Scattered  over  the  pulmonary  pleura  were  numerous  cancerous  masses,  of  a 
rounded  or  oval  form,  varying  from  the  size  of  a pin’s  head  to  that  of  a split  pea. 
They  were  of  a clear  white  color,  rose  abruptly  from  the  pleura,  and  were  gene- 
rally half  a line  or  a line  deep.  Some  of  them  had  a slight  central  depression,  and 
in  many,  blood-vessels  could  be  seen.  The  costal  pleura  had  similar  nodules,  and 
flat  patches  covering  it,  some  of  the  latter  being  the  diameter  of  a shilling.  The  apex 
of  right  lung  was  strongly  puckered,  and  contained  several  concretions  surrounded 
by  dense  pigment ; the  rest  of  its  tissue  was  healthy.  The  left  lung  was  more  volu- 
minous than  the  right.  The  pleurae  at  the  apex  were  adherent  and  thickened.  On 
section  this  was  found  to  correspond  to  an  old  tubercular  cavity  of  the  size  of  a 
small  filbert,  also  surrounded  by  dense  tissue  loaded  with  pigment.  The  substance 
of  the  lung  was  otherwise  healthy,  and  the  pleurm  generally  presented  only  a few  small 
cancerous  masses  scattered  over  them,  similar  to  those  on  the  opposite  side.  The 
bronchial  and  mediastinal  glands  were  healthy. 

Abdomen. — There  were  two  or  three  pints  of  clear  fluid  in  the  abdominal  cavity. 
The  whole  of  the  peritoneum  (parietad  and  visceral)  was  studded  over  with  cancerous 
masses.  Tiie  great  omentum  was  shrivelled,  drawn  up,  and  converted  into  a thick 
mass  of  opaque,  moderately  firm,  cancerous  matter,  the  substance  of  which  contained 
numerous  yellow  opaque  points.  The  transverse  colon  was  dragged  up  towards  the 
stomach,  and  much  compressed  by  this  mass.  All  the  adjoining  veins  were  greatly 
congested.  The  peritoneum  covering  the  lower  surface  of  the  diaphragm  was  lined 
by  a thick  layer  of  cancerous  matter,  which  appeared  to  have  been  deposited  in 
nodules,  which  were  so  thickly  placed  as  to  have  run  into  one  another,  forming  a 
layer  about  two  lines  thick.  Over  the  o‘her  parts  of  the  peritoneum,  nodules  and  small 


556 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


patches  of  cancerous  matter  were  scattered  about.  The  whole  of  the  mesentery  waa 
studded  with  little  masses  from  the  size  of  a grain  of  sand  to  that  of  a pepper-corn. 
Similar  masses  were  found  in  the  serous  coat  of  the  small  intestines.  The  meso-colon 
and  meso-rectum  were  thickened  and  covered  with  cancerous  masses.  The  uterus, 
urinary  bladder,  and  ovaries  were  matted  together  by  cancerous  exudation.  None 
of  the  abdominal  viscera  or  glands  were  involved  in  the  cancerous  disease,  which  was 
exclusively  confiupd  to  the  serous  membrane. 

Microscopic  Examination. — The  different  nodules  of  cancer  presented  all  stages 
of  development  and  disintegration  of  the  cancer  cell ; in  some  places  numerous  naked 
nuclei ; in  others  large  compound  cells ; in  others,  debris  and  fatty  degeneration, 
forming  yellow  masses  of  the  reticulum. 

Commentary . — The  in.sidions  approach  and  development  of  so  large 
an  amount  of  cancerous  exudation  on  the  peritoneum  is  worthy  of  ob- 
servation. It  is  very  possible  that  the  disease  existed  three  years 
previous  to  her  admission  into  the  house,  when  the  hemorrhage  occurred 
from  the  mucous  membrane  of  the  stomach  and  bowels.  But  she  rapidly 
recovered,  and  remained  well  until  dropsical  symptoms  supervened,  in 
conse'|uenee  or  the  pressure  of  the  indurated  cancerous  masses  on  the 
abdominal  veins  inducing  effusion.  At  no  time  was  there  any  general 
fever,  pain,  or  tenderness  on  pressure.  In  this  respect  the  case  strongly 
contrasts  with  the  last.  Here,  with  extensive  disease  of  the  peritoneum, 
there  were  no  symptoms  of  peritonitis;  there,  with  the  peritoneum  per- 
fectly healthy,  violent  symptoms  of  peritonitis  were  manifested.  Indeed, 
the  only  symptoms  occasioned,  were  those  resulting  from  pressure  on  the 
lungs  by  the  accumulation  of  serum  in  the  peritoneal  and  right  pleural 
cavities.  The  orthopnoea  thus  occasioned  was  so  distressing  as  to  induce 
me  to  have  the  abdomen  tapped ; and  it  is  worthy  of  remark  that, 
although  thereby  the  greatest  relief  was  experienced,  she  rapidly  sunk. 
Indeed,  it  seldom  happens  when,  in  ascites  resulting  from  organic  disease, 
this  operation  is  had  recourse  to,  that  death  is  long  delayed — a remark- 
able proof  of  the  fallacy  of  that  system  which  is  based  on  the  treatment 
of  symptoms.  (See  p.  517.) 

In  a case  very  similar  to  the  above,  occurring  in  a young  man,  aet. 
20,  admitted  under  my  care  during  the  winter  1858,  there  was  the  same 
universal  cancerous  peritonitis,  and  the  same  distension  of  the  abdomen 
from  fluid,  without  local  tenderness.  Instead  of  “nutmeg  liver” — that 
is,  incipient  cirrhosis — however,  the  organ  presented  the  disease  in  a 
more  advanced  condition.  Difficulty  of  breathing,  noth  withstanding,  was 
never  so  urgent,  the  pleurae  being  healthy,  and  three  weeks  before  death, 
the  abdominal  tension  spontaneously  disappeared,  so  as  to  enable  me  to 
feel  the  nodulated  omentum  through  the  abdominal  walls,  and  thus 
determine  the  nature  of  the  case.  He  was  a groom,  and  the  first  symp- 
tom of  the  disease  appeared  in  the  form  of  varicose  veins  in  the  lower 
extremities.  These  on  admission  were  enormously  swollen  and  tortuous, 
especially  in  the  popliteal  and  inguinal  regions,  where  they  formed 
tumors  the  size  of  pigeons’  eggs.  After  death  the  swellings  were  found 
to  consist  of  distended  veins  filled  with  firmly  clotted  blood  of  a red 
brick  color.  The  cause  of  the  varicosities  in  the  extremities  was  the 
pressure  occasioned  by  the  tight  and  thickened  omentum  over  the  ex- 
ternal iliac  veins,  just  before  they  passed  under  Poupart’s  ligament.  It 
results  that  the  cancer  must  have  existed  in  the  abdomen  when  he  was 
actively  pursuing  his  employment,  for  the  varicosities  appeared  a year 
before  his  admission.  In  both  cases  the  ascites  may  have  been  mainly 
owing  to  the  hepatic  disease.  (See  also  Case  LXXXVI.) 


SECTION  VI. 


DISEASES  OP  THE  CIIICDLATORY  SYSTEM. 

Before  proceeding  to  narrate  and  comment  on  lesions  of  the  heart 
and  large  vessels,  allow  me  to  remind  you  of  some  of  the  rules  which 
the  laborious  researches  of  many  able  men  have  established  for  }'our  guid- 
ance in  the  diagnosis  of  cardiac  diseases.  They  are  as  follows  : 

1.  In  health,  the  cardiac  dulness,  on  percussion,  measures,  imme- 
diately below  the  nipple,  two  inches  across,  and  the  extent  of  dulness 
beyond  this  measurement  commonly  indicates  either  the  increased  size 
of  the  organ  or  undue  distension  of  the  pericardium. 

2.  In  health,  the  apex  of  the  heart  may  be  felt  and  seen  to  strike 
the  chest  between  the  fifth  and  sixth  ribs,  immediately  below  and  a lit- 
tle to  the  inside  of  the  left  nipple.  Any  variations  that  may  exist  in  the 
position  of  the  apex  are  indications  of  disease  either  of  the  heart  itself 
or  of  the  parts  around  it. 

3.  A friction  murmur,  synchronous  with  the  heart’s  movements, 
indicates  pericardial  or  exo-pericardial  exudation. 

4.  A bellows  murmur  with  the  first  sound,  heard  loudest  over  the 
apex,  indicates  mitral  insufficiency. 

5.  A bellows  murmur  with  the  second  sound,  heard  loudest  at  the 
base,  indicates  aortic  insufficiency. 

6.  A murmur  with  the  second  sound,  loudest  at  the  apex,  is  very 
rare,  but  when  present  it  indicates — 1st,  Aortic  disease,  the  murmur 
being  propagated  downwards  to  the  apex;  or,  2d,  Roughened  auricular 
surface  of  the  mitral  valves;  or,  3d,  Mitral  obstruction,  which  is  almost 
always  associated  with  insufficiency,  when  the  murmur  is  double,  or  oc- 
cupies the  period  of  both  cardiac  sounds. 

7.  A murmur  with  the  first  sound,  loudest  at  the  base,  and  propa- 
gated in  the  direction  of  the  large  arteries,  is  more  common.  It  may 
depend — 1st,  On  an  altered  condition  of  the  blood,  as  in  anaemia;  or, 
2d,  On  dilatation  or  diseases  of  the  aorta  itself ; or,  3dly,  On  stricture 
of  the  aortic  orifice,  or  disease  of  the  aortic  valves — in  which  case  there 
is  almost  always  insufficiency  also,  and  then  the  murmur  is  double  or 
occupies  the  period  of  both  sounds.  I have  also  seen  cases  which  satisfy 
me  tliat  it  may  occasionally  depend  on  roughness  of  the  ventricular  sur- 
face of  the  mitral  valves,  and  on  coagulated  exudation  attached  to  the 
internal  surface  of  the  heart. 

8.  Hypertrophy  of  the  heart  may  exist  independently  of  valvular 
disease,  but  this  is  very  rare.  In  the  vast  majority  of  cases  it  is  the 
left  ventricle  which  is  affected,  and  in  connection  with  mitral  or  aortic 


558 


DISEASES  OF  THE  CIRCULATOEY  SASTEM. 


disease.  In  the  former  case  the  hypertrophy  is  uniform  with  rounding 
of  the  apex;  in  the  latter,  there  is  dilated  hypertrophy,  with  elongation 
of  the  apex. 

Attention  to  these  rules  alone  will,  in  the  great  majority  of  cases,  eii- 
ahle  you  to  arrive  with  precision  at  the  nature  of  the  lesion  present.  In 
cases  in  which  there  may  be  any  doubt,  you  will  derive  further  assis- 
tance from  an  observation  of  the  concomitant  symptoms  such  as-^lst. 
The  nature  of  the  pulse  at  the  wrist;  2d,  The  nature  of  the  pulmonary 
or  cerebral  derangements.  Thus,  as  a general  rule,  but  one  on  which 
you  must  not  place  too  much  confidence,  the  pulse  is  soft  or  irregular  in 
mitral  disease,  but  hard,  jerking,  or  regular  in  aortic  disease.  Again,  it 
has  been  observed  that  cerebral  symptoms  are  more  common  and  urgent 
in  aortic  disease,  and  pulmonary  symptoms  more  common  and  urgent  in 
mitral  disease. 

I have  purposely  said  nothing  now  of  diseases  of  the  right  side  of 
the  heart,  and  of  a few  other  rare  disordered  conditions  of  the  organ, 
because  I am  convinced  that  an  appreciation  of  the  rules  above  given  is 
the  best  method  of  enabling  you  to  comprehend  and  easily  detect  any 
exceptional  case  which  may  arise.  In  truth,  however,  I have  remarked 
in  our  examinations  at  the  bedside  that  your  difiiculty  is,  not  how  to 
arrive  at  correct  conclusions  from  such  and  such  data,  but  how  to  arrive 
at  til'’  data  themselves.  You  have  to  determine — 1st,  by  percussion, 
whether  the  heart  be  of  its  normal  size  or  not;  2d,  Whether  an  abnor- 
mal murmur  does  or  does  not  exist;  3d,  If  it  be  pre.sent,  whether  it 
accompanies  the  first  or  second  sound  of  the  heart ; and  4thly,  At  what 
place  and  in  what  direction  the  murmur  is  heard  loudest.  These  points 
ascertained,  the  conclusion  flows  from  the  rules  previously  given,  and 
must  ever  essentially  depend  upon  the  existing  knowledge  of  physiology 
and  pathology.  But  no  instruction  on  my  part,  no  reading  or  reflection 
on  yours,  will  enable  you  to  ascertain  these  facts  for  yourselves.  In 
short,  nothing  but  percussing  the  cardiac  region  with  your  own  hands, 
and  carefully  listening  to  the  sounds  with  your  own  ears,  can  be  of  the 
slightest  service,  and  the  sooner  you  feel  convinced  of  this  truth  the 
sooner  are  you  likely  to  overcome  these  preliminary  difficulties.  This  is 
the  reason  why  a series  of  cases  assembled  in  the  ward  of  an  hospital  is 
so  valuable.  By  careful  examination  of  them,  you  can  at  once  convince 
yourselves  of  the  accuracy  of  the  facts  affirmed  by  others  to  exist,  re- 
flect on  the  probable  correctness  of  the  diagnosis  formed  at  the  bedside, 
watch  the  various  complications  and  the  elfects  of  treatment,  and  finally, 
obser'/e  how,  in  the  fatal  cases,  by  following  the  rules  given,  the  ac- 
curacy of  the  diagnosis  has  or  has  not  been  confirmed  by  post-mortem 
examination. 

After  you  have  made  yourselves  familiar  with  the  ordinary  forms  of 
heart  disease,  you  will  find  that  occasionally  ver}’'  puzzling  instances 
occur  where  the  above  rules  do  not  apply.  These  exceptional  cases 
should  always  be  carefully  studied.  Indeed,  this  is  what  is  now  being 
done  by  the  cultivators  of  ph}^sical  diagnosis  throughout  Europe,  with 
a view  if  possible  of  determining  the  characters  which  distinguish 
disease  of  the  right  from  disease  of  the  left  side  of  the  heart ; those 
indicative  of  lesion  of  the  pulmonary  artery,  of  chronic  forms  of  peri- 
carditis, of  open  foramen  ovale,  of  clots  in  the  ventricles  or  auricles, 


PERICARDITIS. 


559 


etc.  etc.  Well  observed  cases  of  these  rarer  diseases,  however,  are 
still  too  few  to  enable  us  to  generalise  confidently  regarding  them.  I 
have  frequently  examined  exceptional  combinations  of  signs  with  the 
utmost  care,  and  then  been  denied  a post-mortem  examination,  or  again 
have  stumbled  on  rare  forms  of  lesions  after  death,  in  cases  where 
during  life  sufficiently  careful  and  repeated  examination  of  the  physical 
signs  had  not  been  made  to  secure  accuracy.  I would  strongly  advise 
you  to  attach  little  importance  to  the  record  of  such  exceptional  cases, 
and  never  to  record  such  yourselves,  unless  equal  care  have  been  shown 
in  the  examination  of  physical  signs  and  functional  symptoms  during 
life,  on  the  one  hand,  and  in  anatomical  investigation  after  death  on 
the  other. 

PERICARDITIS. 

Case  XCVII.* — Acute  Pericarditis — Recovery. 

History. — Jane  Stambroke,  set.  25,  servant — admitted  January  7th,  1857.  Six 
months  ago  she  entered  another  ward  in  the  Infirmary,  on  account  of  rheumatic  pains 
in  tlie  ankle-joints.  These  pains  were  unaccompanied  by  general  fever,  and  there  is 
no  evidence  that  the  heart  was  then  affected.  During  the  last  six  weeks,  however, 
she  has  expex’ienced  considerable  dyspnoea,  palpitation,  and  uneasiness  over  the  central 
part  of  the  sternum,  increased  by  active  exertion,  or  on  ascending  stairs.  Five  days 
ago,  after  exposure  to  sudden  changes  of  temperature,  she  experienced  towards  evening 
a distinct  rigor  and  increased  pain  in  the  prtecordia,  which  compelled  her  to  desist 
from  working,  and  retire  to  bed  at  an  earlier  hour  than  usual.  The  next  day  she  felt 
somewhat  easier,  but  on  the  following  one  the  symptoms  increased  in  intensity,  and 
have  continued  up  to  the  present  time..  Yesterday  evening  six  leeches  were  applied, 
and  caused  relief,  which  however  was  not  permanent. 

Symptoms  ox  Admission. — Cardiac  impulse  is  faintly  felt  between  the  fourth  and 
fifth  ribs.  Dulness  on  percussion,  at  the  level  of  nipple,  extends  transversely  four 
inches  from  the  right  edge  of  the  sternum,  which  is  its  internal  boundary.  On  aus- 
cultation a loud  double  friction  murmur  is  audible,  over  and  limited  to  the  cardiac 
organ,  loudest  over  the  sternum  and  base.  The  systolic  and  diastolic  sounds  are  in- 
audible in  consequence  of  the  loud  friction  murmurs.  Pulse  108,  regular  and  of 
moderate  strength.  She  cannot  lie  on  either  side,  and  prefers  the  sitting  to  the 
recumbent  posture.  Says  she  has  a slight  cough,  but  no  expectoration.  Percussion 
elicits  comparative  dulness  over  the  two  lower  thirds  of  left  back,  and  there  is  audible 
over  the  same  space  increased  vocal  resonance  and  aegophony,  without  rales.  Inspi- 
ratory murmur  on  right  side  is  somewhat  harsh,  but  otherwise  normal ; is  sleepless 
in  consequence  of  cardiac  uneasiness  and  dyspnoea,  which  is  considerable.  Has  not 
menstruated  for  the  last  two  months,  but  the  other  functions  are  well  performed. 
Warm  fomentations  to  be  constantly  apjMed  to  the  prcecordial  region. 

Progress  of  the  Case. — January  2th. — The  pains  and  dyspnoea  have  been 
greatly  relieved  by  the  fomentations.  No  friction  murmur  audible.  The  urine 
densely  loaded  with  urates.  Pulse  80,  soft.  Nutrients  with  wine  § ij.  January 
10th. — No  pain  or  dyspnoea.  Friction  sound  slight,  and  only  audible  over  right  side 
of  cardiac  organ  towards  the  base.  Transverse  dulness  there  is  diminished  by  a 
quarter  of  an  inch.  Physical  signs  of  left  lung  the  same.  No  crepitation.  Chlorides 
in  the  urine  abundant.  January  11th. — No  friction  audible  over  heart,  but  cardiac 
sounds  are  distant.  From  this  time  she  rapidly  became  well.  On  the  13th,  marked 
dulness,  increased  vocal  resonance,  and  aegophony  much  diminished  over  left  back. 
On  the  18th,  the  transverse  cardiac  dulness  measured  two  and  a half  inches,  and 
there  remained  only  increased  sense  of  resistance  on  percussion  over  left  back,  with 
slight  aegophony.  On  the  23d,  complained  of  loss  of  appetite  and  slight  dyspeptic 
symptoms,  which  disappeared  the  following  day.  On  the  27th  she  walked  out,  and 
did  not  experience  so  much  palpitation  or  dyspnoea  as  before  the  present  attack.  Was 
dismissed  January  31st, 


* Reported  by  Mr.  McLeod  Pemberton,  Clinical  Clerk. 


560 


DISEASES  OF  THE  CIRCULATORY  SA^STEM. 


Commentary. — This  was  a pure  case  of  pericarditis  in  a rheumatic 
girl,  in  which  all  the  symptoms  and  physical  signs  were  very  carefully 
examined.  The  disease  went  through  its  natural  stages  with  great 
rapidity.  On  the  fifth  day,  when  she  was  admitted,  there  was  great 
distension  of  the  pericardium  from  exudation,  with  friction  sounds. 
Then  for  a day  these  were  absent,  probably  from  the  two  surfaces  being 
separated  by  serum.  On  the  seventh  day,  distension  of  the  pericardium 
began  to  diminish,  and  there  was  slight  return  of  the  friction.  From 
this  time  there  was  rapid  decline  in  the  area  of  dulness,  which  on  the 
fifteenth  day  was  nearly  normal.  The  local  pain  she  experienced  was 
before  admission  treated  by  the  application  of  six  leeches,  but  was  still 
present  on  her  admission.  Warm  fomentations  to  the  part  removed  it 
at  once,  and  constituted  the  only  medical  treatment  she  was  subjected  to 
in  the  house.  Nutrients  of  course  were  given,  and  a little  wine.  The 
pulmonary  physical  signs  were  probably  dependent  on  pressure  of  the 
lung  backwards  by  the  distended  pericardial  sac. 

Case  XC  VIII.^ — Pericarditis  and  Endocarditis — Hydropericardium: 

History. — Barney  Kilpatrick,  let.  25,  a miner — admitted  July  8th,  1850.  Nine 
weeks  ago  he  was  suddenly  seized  with  dyspnoea  and  a feeling  of  weight  or  dull  pain 
in  the  cardiac  region.  A fortnight  since  this  became  much  more  acute,  and  has 
continued  no  to  the  time  of  admission.  For  five  years  he  has  been  much  exposed  to 
wet  and  chn.nges  of  temperature,  but  never  had  rheumatism. 

Symptoms  on  Admission. — Cardiac  dulness  measures  three  and  a quarter  inches 
transversely,  and  is  limited  above  by  the  margin  of  the  third  rib.  Apex  beats 
between  the  fifth  and  six  ribs,  two  inches  below,  and  considerably  to  the  right  of 
the  nipple.  All  over  the  dull  region  a double  friction  sound  is  heard,  resembling  a 
roughened  bellows  murmur,  but  superficial.  Beyond  the  region  of  the  dulness  these 
murmurs  suddenly  cease.  Action  of  the  heart  regular.  Pulse  96,  regular,  small, 
and  feeble,  stronger  on  the  right  than  on  the  left  side.  The  slightest  movement 
induces  pain,  extending  from  the  cardiac  region  down  the  left  arm  to  the  fingers ; 
great  dyspnoea;  no  cough  or  other  pulmonary  symptoms;  no  fever;  no  cerebral 
symptoms  or  tendency  to  syncope. 

Treatment  and  Progress  of  the  Case. — Twelve  leeches  were  ordered  to  be 
applied  to  the  cardiac  region,  and  a calomel  and  opium  pill  to  be  taken  every  six 
hours.  On  the  11th,  the  friction  murmurs  were  much  louder  at  the  base  than  at 
the  apex.  The  pulse  108;  feeble  at  left  wrist;  at  the  right  wrist  it  had  a double 
impulse — a pretty  strong  beat  being  followed  by  a weaker  one.  3 vj  of  blood  to  be 
drawn  from,  the  cardiac  region  by  cupping.,  and  a pill  to  be  taken  every  four  hours. 
On  the  13th,  the  breath  had  a mercurial  foetor.  Pulse  stronger;  less  dyspnoea; 
friction  munnurs  more  faint;  pain  in  arm  diminished.  On  the  14th,  pulse  full; 
slight  fever;  six  leeches  to  be  applied  to  the  cardiac  region,  morphia  draught  at 
night.  On  the  15th,  friction  murmurs  only  heard  at  the  base;  anorexia;  can  take 
no  food;  omit  calomel  and  opium  pills.  \Uh. — Friction  murmurs  have  disappeared, 
but  there  is  a soft  bellows  murmur  with  the  second  sound,  heard  at  the  base.  18^A. — 
Had  an  attack  of  severe  dyspnoea  and  syncope;  pulse  100,  regular,  but  feeble;  § iv  of 
wine;  cardiac  dulness  increased.  19^A. — Orthopnoea ; pulse  weak  and  fluttering;  a 
quivering  pulsation  felt  in  the  cardiac  region ; faintness ; oedema  of  feet  and  legs. 
Stimulants  to  be  freely  administered.  Died  early  in  the  morning  of  the  20th. 

Examination  of  the  body  was  not  allowed. 

Oommeniary. — This  was  a well  characterised  case  of  pericarditis. 
At  first  the  endocardial  murmur  was  masked  by  the  friction  sounds, 
but  as  these  disappeared,  its  existence  became  apparent.  It  was 
observed  that  as  the  mercury  affected  the  system,  the  friction  murmur 
diminished ; but  there  is  every  reason  to  believe  that  this  was  not  so 
* Reported  by  Mr.  David  Christison,  Clinical  Clerk. 


PERICARDITIS. 


561 


much  owing  to  absorption  of  the  exudation,  as  to  increase  in  the 
amount  of  serous  effusion.  To  the  combined  effects  of  pressure  on  the 
heart  from  liquid  without,  and  incapability  of  performing  its  function 
from  incompetency  of  the  aortic  valves,  the  fatal  result  must  be  attri- 
buted. 

Since  this  case  occurred,  upwards  of  fourteen  years  ago,  I have  satis- 
fied myself  that  the  treatment  pursued  was  not  judicious,  and  that  the 
local  abstraction  of  blood,  with  administration  of  mercury  under  such 
circumstancCwS,  is  not  only  useless  but  injurious.  It  is  true  no  fair  com- 
parison can  be  drawn  between  this  and  the  preceding  case,  inasmuch 
as  here  we  had  undoubted  valvular  lesion  complicating  the  pericarditis. 
But  this  ought  to  be  an  additional  reason  against  depletion.  I have 
given  it,  however,  as  a fair  example  of  cases  that  used  formerly  to  be 
pretty  common,  but  which  now,  owing  to  our  improved  pathological 
views  applied  to  practice,  are  somewhat  rare.  The  following  case  was 
treated  differently. 

Case  XCIX.^ — Acute  PericardHis  followed  hy  Acute  double  Pneumonia 
— Recovery — Aortic  Incompetence — Subsequent  Articular  Rheu- 
matism— Sudden  death — Adherent  Pericardium — Fatty  enlaryed 
Heart — Thickening  of  Ao,ydic  Valves. 

History. — Jessie  Douglas,  set.  22,  employed  in  a paper  warehouse — admitted 
November  19th,  1855.  Has  never  been  very  healthy;  has  had  several  attacks  of 
rheumatic  fever,  the  last  being  about  seven  years  ago.  On  the  9th  current,  after 
exposure  to  cold  and  damp,  she  was  seized  with  rigors  and  pain  in  the  back.  These 
disappearing,  were  succeeded  by  pain  and  slight  swelling  of  the  knees,  lasting  only 
for  a few  days.  During  all  this  time,  though  ill,  she  had  no  headache,  vomiting, 
nor  pain  in  the  chest,  but  the  shortness  of  breath  and  palpitation  to  which  she  is 
subject  became  aggravated.  She  was  under  medical  treatment,  and  got  purgative 
medicines,  but  was  neither  bled  nor  leeched. 

Symptoms  on  Admission. — Apex  beats  distinctly  between  the  fourth  and  fifth 
ribs,  immediately  under  and  a little  to  the  inside  of  the  nipple ; heart’s  impulse  is 
heaving,  and  sensibly  moves  the  whole  mamma ; it  can  be  felt  but  very  indis- 
tinctly in  the  normal  position ; there  is  no  thrill.  Transverse  dulness  at  the  level 
of  the  nipple  4f  inches.  Heart  sounJs  are  exceedingly  indistinct,  and  muffled  at 
the  apex,  but  no  murmur  is  heard  there.  At  the  base  the  first  sound  is  almost 
inaudible,  but  with  the  sound  there  is  heard  a soft  blowing  murmur.  Pulse  80,  full, 
regular,  incompressible.  Breathing  is  rather  labored ; respirations  are  34  per 
minute,  but  regular ; there  is  slight  cough  and  no  sputum.  Percussion  is  everywhere 
good  ; vocal  resonance  is  greater  under  the  left  than  under  the  right  clavicle ; no  rale 
is  audible,  but  respiration  is  exaggerated  under  the  right  clavicle,  and  inspiration  is 
blowing  under  the  left.  She  speaks  languidly,  does  not  sleep,  and  on  sitting  up 
feels  faint.  She  is  thirsty,  and  has  no  appetite ; the  bowels  open ; catamenia  are 
regular.  Urine  is  neutral,  sp.  gr.  1018,  not  albuminous  ; deposits  copious  urates 
and  phosphates  ; contains  no  chlorides.  Patient  lies  on  her  back  ; cheeks  rather 
flushed  ; the  skin  warm  and  perspiring  ; no  pain  nor  swelling  of  any  joints.  Ordered 
half  art  oanoe  every  fourth  hour  of  the  following: — Liquor.  Ammon.  Acetat.  et 
Aquee  aa  3 ij. 

Proorkss  op  the  Case. — November  20^4. — At  the  apex,  the  cardiac  sounds 
continue  exceedingly  indistinct  and  muffled.  At  the  base,  immediately  above  the 
nipple,  there  is  heard  with  each  cardiac  sound  an  exceedingly  soft  blowing  noise, 
equal  in  intensity  and  duration ; it  extends  over  a considerable  space,  being  heard 
but  very  feebly  under  the  right  nipple.  Immediately  under  the  centre  of  both 
clavicles,  there  is  a prolonged  blowing  noise,  occupying  the  period  of  both  sounds. 
Pulse  72,  full  and  somewhat  jerking;  palpitations  are  occasionally  urgent;  respi- 
rations 36,  labored.  Ordered  twelve  leechen  to  he  applied  over  the  prmcordxa.^  and 
mbsequently  warm  fomentations.  2L<?<. — The  leech  bites  bled  well.  There  is  great 

* Reported  by  Messrs.  Geo.  Robertson  and  R.  P.  Ritchie,  Clinical  Clerks, 

36 


562 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


heaving  and  expansive  motion  of  the  whole  prsecordia ; at  the  apex,  murmurs  are 
indistinct — at  the  base  a double  blowing  murmur,  most  clear  over  the  head  of  the 
sternum.  There  is  no  friction  audible — no  pain,  and  the  palpitations  are  not 
increased.  Pulse  80,  slightly  jerking,  but  weak.  She  cannot  sit  up  from  tendency  to 
faint  ; is  depressed  and  exhausted  in  her  aspect.  Urine  scanty  ; still  contains  no 
chlorides.  Ordered  three  ounces  of  wine  with  beef -tea ; to  be  kept  perfecth/  quiet. 
22f/. — The  skin  is  covered  with  moisture ; respirations  46  ; pulse  84  ; still  jerking  and 
weak.  The  apex  beats  exactly  under  the  fifth  rib,  a little  to  the  inside  of  the  nipple. 
At  the  base  there  is  now  a loud  creaking  which  is  double,  and  very  loud  at  tlie  margin 
of  the  sternum.  Transverse  dulness  3^  inches.  Ordered  to  discontinue  the  saline  mix- 
ture. In  the  evening  loud  friction  wms  audible  at  the  apex  as  well  as  at  the  base,  and 
the  apex  beat  had  fallen  about  two  lines  below  and  to  the  inner  side.  23(/. — Pulse  72, 
of  same  character;  respirations  35.  At  the  base  of  the  cardiac  organ,  instead  of  the 
double  friction  heard  yesterday,  there  is  now  a single  continuous  creaking.  The  same 
sound  is  audible  at  the  apex.  24^A. — Pulse  80,  still  slightly  jerking,  but  soft ; respi- 
rations 36  ; apex  as  yesterday.  There  is  a continuous  churning  friction  at  base ; at  the 
apex  it  is  heard,  but  less  loud  and  continuous.  1^  8pir.  JEther.  Nitrici  3 iij  ; Tinct. 
Colchici  3j;  Aquee  3 vss ; M.  One  ounce  thrice  a-day.  Also  I^  Pidv.  Opii  ^v.  iij; 
Extract.  Catechu  gr.  xv. ; Confect.  Rosar.  q.  s.  ut  fiat  massa  in  pilulas  sex  dividenda  ; 
one  to  be  taken  every  sixth  hour.  25fA. — The  same  friction  murmur ; pulse  80  ; respi- 
rations 36 ; urine  is  hyperlithic  ; and  still  contains  no  chlorides.  26if/i. — Pulse  82, 
slightly  jerking,  more  compressible;  respirations  32  ; skin  dry  and  hot;  tongue  moist; 
has  no  appetite;  urine  the  same  in  character;  the  friction  is  less  churning  and  con 
tinuous,  and  occurs  more  with  the  first  sound.  2^th. — At  the  visit  to-day,  dulness  is 
detected  in  the  left  scapular  region  near  the  inferior  angle,  over  a space  the  size  of  the 
hand,  with  crepitation,  and  pealing  vocal  resonance.  Friction  in  cardiac  region  is  now 
diminishing  in  intensity  and  duration.  Ordered  three  additional  ounces  of  wine.  (From 
this  day  commenced  an  intercurrent  attack  of  pneumonia,  affecting  the  left  lung,  ter- 
minating in  seven  days.)  Besides  dulness,  crepitation,  and  increased  vocal  resonance, 
there  were  on  the  fourth  and  fifth  days  a friction  murmur  at  the  base  of  the  left  lung. 
The  chlorides  began  to  reappear  in  the  urine  on  the  fourth  day.  A blister  was  applied 
(3  by  4)  to  the  right  side  anteriorly  on  the  29^A,  and  of  the  same  size  to  the  left  lateral 
region  on  Dec.  2c/.  Dec.  2c/. — On  percussion  the  transverse  cardiac  dulness  is  3^  inches ; 
the  apex  beats  feebly  between  the  fifth  and  sixth  ribs.  At  the  base,  one  long  rough 
prolonged  sound  is  heard,  and  at  the  level  of  the  nipple  this  is  plainly  connected  with 
a second  of  a friction  character.  Over  the  centre  of  the  sternum,  on  a level  wuth  the 
nipple,  this  hoarse  blowing  (or  friction  ?)  is  loudest,  and  is  still  audible  at  the  right  side 
of  the  sternum  within  1^  inch  of  the  right  nipple.  Pulse  96,  still  jerking  and  soft. 
Dec.  6/7i. — Considerable  dulness  is  detected  to-day  on  the  right  side  from  the  inferior 
angle  of  scapula  to  the  base.  Bespiration  is  aln  ost  inaudible,  and  is  faintly  bronchial. 
Over  area  of  dulness  a little  fine  crepitation  may  also  be  detected  on  inspiration,  and 
vocal  resonance  is  increased.  Pulse  126,  soft,  jerking ; respirations  52  ; great  dyspnoea. 
(From  this  attack  of  pneumonia  on  the  right  side,  the  patient  began  to  recover  on  the 
seventh  day.  Throughout  the  whole  course  of  it,  the  chlorides  in  the  urine  were  abun- 
dant ; there  was  little  cough  or  sputum.)  Dec.  \1th. — The  cardiac  friction  murmur  has 
totally  disappeared  from  the  apex.  At  the  base  a blowing  murmur  is  now  heard  with 
the  second  sound,  the  first  being  free  from  murmur.  26///. — This  morning,  about  9.30, 
the  patient  having  assumed  the  recumbent  position  for  a few  minutes,  violent  palpita- 
tions came  on,  and  forced  her  to  sit  up ; she  felt  as  if  about  to  faint,  and  was  so  agitated 
as  to  be  almost  unconscious.  At  11  a.m.,  the  palpitation  had  somewhat  subsided,  but 
the  cardiac  action  was  still  very  violent,  shaking  the  whole  person,  and  causing  severe 
pain  in  the  chest.  Pulse  almost  continuous,  beating  about  180  times  in  a minute, 
jerking,  and  incompressible ; no  difficulty  of  breathing  ; no  affection  of  the  head ; face 
pale  and  anxious ; patient  restless,  and  occasionally  moaning.  The  urine  passed  soon 
after  this  paroxysm  is  scanty,  of  brick  color,  turbid,  clears  up  on  application  of  heat, 
but  on  further  heating  and  being  fully  acidified,  a slight  coagulum  is  obtained.  From 
this  paroxysm  she  recovered  towards  the  evening,  under  the  use  of  Ammoniated 
Tincture  of  Valerian  and  Sol.  Mur.  Morphice.  31.s/. — Patient  now  sits  up  for  about 
two  hovu  s every  day,  and  begins  to  be  very  hungry.  January  l.s/. — Cardiac  signs  are 
the  same  as  at  last  report ; at  the  apex  nothing  but  a dull  impulse  is  heard ; at  the 
base  there  is  still  the  bloAving  with  the  second  sound.  From  this  date  she  gradually 
increased  in  strength,  moving  about  in  the  ward  and  occasionally  taking  walks  in  the 


PERICARDITIS. 


563 


town.  The  pulse  90  to  100  per  minute;  was  easily  raised  to  100  or  120  by  excite^ 
vnent.  Palpitations  also  were  readily  caused  by  any  surprise,  lasting  for  about  fifteen 
minutes  and  accompanied  by  a marked  soreness  along  the  sternum.  On  the  15th  of 
February  it  is  reported  no  change  in  the  cardiac  sounds  had  occurred.  The  transverse 
dulness  2f  inches;  the  pulse  96,  full  and  regular,  retains  its  jerking  character.  Is 
discliarged  much  relieved  on  the  17th  February. 

She  was  re-admitted  (under  care  of  Dr.  Christison)  on  the  29th  of  February,  labor- 
ing under  an  attack  of  articular  rheumatism  ; she  gradually  became  convalescent,  but 
continued  weak,  easily  agitated,  with  painful  palpitations  and  threatening  of  syncope. 
The  blowing  murmur  with  the  second  sound  at  the  base  continued,  but  the  most  careful 
examination,  by  inspection,  percussion,  or  auscultation,  failed  to  elicit  any  other  physi- 
cal sign,  the  dulness  being  still  3d  inches  across.  In  this  condition  she  continued  in 
the  ward,  moving  about,  and  in  tolerable  health,  when  on  the  evening  of  May  I4th  she 
suddenly  started  up  with  a cry,  and  immediately  fell  back,  pale,  gasping,  and  almost 
pulseless,  and  expired  within  three  minutes,  notwithstanding  the  sedulous  administra- 
tion of  restoratives  and  stimulants, 

Sectio  Cadaveris. — Thirty-nine  hours  after  death. 

Thorax. — The  pericardium  was  found  universally  adherent.  The  heart  was  uniformly 
enlarged,  weighing  twenty-eight  ounces.  On  passing  a stream  of  water  down  the  aorta, 
it  escaped  very  freely  into  the  ventricle.  On  examination  the  aortic  semilunar  valves 
were  found  thickened  and  shortened.  There  were  no  vegetations  on  the  valves.  The 
auriculo-ventricular  orifices,  especially  .on  the  right  side,  were  a little  dilated.  The  left 
ventricle  was  very  much  dilated,  and  its  walls  were  fully  of  the  normal  thickness.-  The 
right  ventricle  was  of  normal  dimensions.  The  lungs  were  congested  posteriorly  and 
inferiorly,  but  were  otherwise  everywhere  natural.  The  muscular  substance  of  the  heart 
was  everywhere  of  a pale  fawn  color,  soft  and  easily  breaking  down  under  the  finger. 

Abdomen. — The  abdominal  organs  were  natural. 

Microscopic  Examination. — The  pericardial  adliesions  were  composed  of  well- 
formed  areolar  texture,  in  firm  bands  aggregated  closely  together.  The  substance  of 
the  heart  presented  all  stages  of  the  muscular  fatty  transformation ; the  fasciculi  in 
most  places  being  brittle  and  the  transverse  strim  obscure,  ivhile  here  and  there  fatty 
granules  were  numerous,  displacing  more  or  less  of  the  sarcous  substance. 

Commentary. — This  case  was  carefully  observed  for  nearly  a period 
of  six  months.  On  admission  it  was  evident  that  a pericarditis  existed 
with  such  distension  of  the  pericardium,  that  the  two  diseased  surfaces 
did  not  rub  upon  one  another,  so  as  to  occasion  friction  murmurs.  The 
pulse  was  full  and  jerking,  but  the  exact  character  of  the  valvular  lesion 
could  not  then  be  determined.  There  was  also  dyspnoea,  and  with  a 
view  of  diminishing  this  and  other  symptoms,  twelve  leeches  were  applied, 
with  the  effect,  however,  of  rendering  her  weak  and  faint.  Wine,  nutri- 
ents, and  quietude  were  immediately  ordered,  and  subsequently  consti- 
tuted the  treatment.  The  following  day  the  pericardial  distension  began 
to  diminish,  and  a returning  friction  murmur  to  appear.  As  the  peri- 
carditic  signs  decreased,  the  evidence  of  aortic  incompetency  became 
more  evident,  and  latterly  a prolonged  blowing  with  the  second  sound  at 
the  base  was  the  permanent  sign  of  aortic  valvular  lesion.  She  also 
suffered  from  two  distinct  attacks  of  pneumonia,  one  on  the  left,  and  then 
subsequently  on  the  right  side,  during  the  whole  of  which  time  wine 
with  nutrients  were  assiduously  administered,  with  the  effect  of  conduct- 
ing her  favorably  through  these  formidable  complications.  All  who 
witnessed  the  case  were  satisfied  that  this  woman,  during  these  two 
pneumonic  attacks,  in  both  of  which  were  present  all  the  characteristic 
symptoms  and  physical  signs  of  the  disease,  owed  her  Lfe  to  good  nour- 
ishment and  stimulants,  and  that  the  slightest  approach  towards  an 
antiphlogistic  treatment  would  have  been  fatal.  It  was  further  observ- 
able, that  at  this  time  the  pulse  was  full  and  jerking — many  would  have 


564 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


called  it  hard — so  that  she  presented  what  has  frequently  been  described 
as  the  symptoms  of  an  exquisite  case  of  pneumonia ; in  short  that  very 
group  of  symptoms  in  which  writers  have  advised  us  to  bleed  largely.  I 
have  myself  no  doubt,  that  such  cases  with  aortic  disease  and  dyspnoea 
were,  previous  to  the  days  of  physical  diagnosis,  regarded  as  typical 
examples  of  pneumonia,  were  bled  largely,  and  served  to  swell  the  great 
mortality  which,  as  we  shall  subsequently  show,  characterised  a former 
practice.  Under  an  opposite  treatment,  however,  she  gradually  recovered, 
and  became  so  well  (though  still  laboring  under  the  aortic  incompetency 
with  tendency  to  palpitation),  that  she  insisted  on  going  out.  She  was 
so  imprudent,  however,  as  again  to  catch  articular  rheumatism,  and  re- 
entered the  Infirmary,  the  cardiac  physical  signs,  and  symptoms,  how- 
ever, remained  unchanged.  She  again  recovered,  but  died  suddenly  from 
a fatal  syncope.  On  examination  of  the  body,  the  correctness  of  all  the 
facts  observed  was  confirmed,  and  the  nature  of  the  case  rendered  per- 
fectly clear.  The  two  layers  of  the  pericardium  were  everywhere  ad- 
herent ; the  aortic  valves  were  thickened  and  incompetent,  explaining 
the  persistence  of  the  valvular  murmur  and  jerking  pulse;  the  left 
ventricle  was  hypertrophied,  as  shown  by  percussion ; and  the  muscular 
substance  of  the  heart  was  very  fatty,  accounting  for  the  sudden  death. 


Case  C.^ — Acute  Pericarditis  supervening  on  Phthisis. 

History. — Edward  Campbell,  set.  30,  a porter — admitted  September  5th,  1856. 
For  twelve  years  has  been  of  very  intemperate  habits,  unsettled  in  his  occupation,  and 
often  insufficiently  nourished.  About  one  month  ago,  he  first  noticed  a short  dry 
cough,  attended  with  little  expectoration  till  a few  days  ago,  when  it  became  rather 
copious  and  yellow.  Four  days  ago,  the  sputum  for  the  first  time  was  tinged  with 
blood ; about  the  same  time  the  stools  became  frequent  and  loose,  and  severe  night 
sweats  appeared.  He  has  been  subject  for  some  time  to  shiverings,  but  cannot  re- 
member any  special  rigors  ushering  in  the  present  attack. 

Symptoms  on  Admission. — There  is  a marked  dulness  on  percussion  at  the  apex  of 
left  lung,  and  laterally  in  the  auxiliary  region.  There  is  also  crack-pot  resonance  over 
the  left  front,  from  the  first  to  the  fourth  intercostal  space.  On  auscultation,  there  are 
coarse  moist  rales,  during  inspiration  and  expiration,  over  the  whole  left  lung,  anteriorly, 
laterally,  and  posteriorly,  with  increase  of  vocal  resonance,  amounting  to  bronchophony 
.superiorly.  Over  the  lower  third  of  the  left  lateral  region,  there  is  friction  with  inspi- 
ration. The  right  lung  gives  the  normal  results  on  auscultation  and  percussion.  The 
sputum  is  copious,  frothy,  and  streaked  with  blood  ; considerable  dyspnoea ; the  cardiac 
organ  is  healthy  ; the  pulse  is  112,  rather  incompressible ; the  appetite  bad  ; the  bowels 
are  regular ; the  skin  hot ; the  face  of  a purplish  hue ; the  patient  is  emaciated,  weak, 
and  lies  on  his  back  ; does  not  sleep  well ; there  is  great  tremulousness  of  the  limbs  ; 
the  urine  is  not  coagulable,  and  it  contains  abundant  chlorides ; sp.  gr.  1020. 

Progress  of  the  Case. — September  Uh-2.\sL — Has  been  treated  with  small  doses 
of  antimony,  and  a blister  two  inches  square  over  left  mammary  region.  The  strength 
has  been  supported  by  nutritious  diet  and  wine,  or  occasionally  gin.  On  the  11th,  the 
sputum  was  carefully  examined,  and  yellow  elastic  tissue  was  discovered  under  the 
microscope.  The  physical  signs  on  the  left  side  are  very  slightly  altered ; the  rales  are 
less  numerous ; there  is  more  bronchial  breathing.  At  the  right  apex  there  is  now 
dulness,  harsh  respiration,  and  occasional  crepitation  at  close  of  the  inspiratory  murmur. 
The  fever,  though  still  great,  has  considerably  abated.  Pulse  generally  120,  soft. 
From  Sep.  21st  to  30th,  the  pulmonary  phenomena  were  little  altered,  although  they 
were  subject  to  remissions,  but  the  diarrhoea,  which  the  patient  had  before  only  slightly 
experienced,  became  very  troublesome.  Oct.  ls<. — To-day  a distinct  double  friction 
murmur  is  audible  all  over  the  cardiac  region,  soft  at  the  base,  more  coarse  and  loud 

* Reported  by  Dr.  Thorburn,  Resident  Physician,  and  II.  N M’Laurin,  Clinical  Clerk. 


PERICARDITIS. 


565 


towards  the  apex.  The  cardiac  dulness  on  percussion  is  extended — externally  it  cannot 
be  limited,  but  internally  it  reaches  to  the  centre  of  sternum.  No  fremitus ; pulse  128, 
feeble,  intermittent,  and  compressible;  respirations  36  per  minute ; voice  hoarse  ; cough 
))aiiiful ; sputum  purulent;  patient  weak,  but  feels  no  pain  anywhere,  and  expresses 
liimself  as  being  so  well,  that  he  is  even  anxious  to  go  out  and  see  a friend.  Has  no 
appetite  ; the  diarrhoea  continues.  Oct.  Id  to  9/A. — The  pericardial  friction  continues 
distinct.  TJiere  is  also  pleural  friction  murmur  on  the  left  lateral  region  more  distinct 
and  extensive  than  on  admission  ; the  right  side  is  dull  at  the  apex,  with  moist  rales 
during  inspiration ; to-day  there  are  friction  sounds  during  expiration  at  the  right  base. 
Oct.  9th  to  \^ith. — The  auscultatory  phenomena  are  unaltered.  The  moist  rales  in  lung 
are  more  coarse  and  bubbling  : dyspnoea  is  intense  ; respiration  60  per  minute  ; the  face 
is  liviJ;  the  pulse  more  and  more  weak,  becoming  imperceptible.  Oct.  l^th. — Die-d 
this  morning. 

Sectio  Cadaveris.  Fifty-one  hours  after  death. 

The  body  was  emaciated. 

Thorax. — The  left  lung  was  infiltirated  throughout  with  grey  tubercle  ; at  the  apex 
there  was  great  condensation  around  three  or  four  cavities  containing  pus,  the  largest 
being  the  size  of  a hen’s  egg.  Numerous  smaller  cavities  existed  throughout  the  upper 
lobe,  which,  with  the  cut  bronchi,  poured  out  abundant  pus  on  the  texture  being  squeezed. 
Tlie  right  lung  was  also  infiltrated  with  grey  tubercle  throughout  the  upper  lobe  ; at 
the  apex  there  were  two  cavities  the  size  of  hazel  nuts.  Its  inferior  lobe  was  thinly 
scattered  with  the  same  tubercle,  and  was  greatly  engorged  with  blood  and  serum. 
Universal  adhesions  on  both  sides.  Both  layers  of  the  pericardium  were  covered  with 
villous  lymph,  generally  about  one-eighth  of  an  inch  in  thickness.  Between  them  were 
about  two  ounces  of  serum.  The  valves  and  substance  of  heart  were  healthy. 

Ardomen. — The  abdominal  organs  were  healthy. 

Microscopic  Examination. — The  structure  of  the  villous  lymph  in  this  case  was 
very  carefully  examined,  and  Fig.  156,  p.  1V5,  is  a representation  of  the  structure. 
The  villi  varied  greatly  in  length  and  size,  and  could  be  perceived  by  the  naked  eye. 
Individually  they  were  of  pulpy  consistence,  consisted  of  a delicate  membrane,  covered 
in  many  places  by  layers  of  pavement  epithelium  (Fig.  156,  b).  Their  substance  con- 
sisted of  an  aggregation  of  fibre  cells  in  all  stages  of  development,  several  of  them 
were  floating  loose  in  the  field  of  the  microscope  (Fig.  156,  c).  On  the  addition  of  the 
acetic  acid  the  whole  became  very  transparent,  showing  the  mere  outline  of  the  villi, 
with  fusiform  nuclei  imbedded  in  them.  Here  and  there  they  contained  transparent 
spaces  or  vacuoles,  having  in  some  transverse  markings  or  folds  externally  (Fig.  156, 
a a).  The  heart  was  subsequently  carefully  injected  by  Professor  Goodsir,  and  portions 
of  it  may  now  be  seen  in  the  University  Museum,  with  the  layer  of  lymph  nearest  the 
muscle  containing  a rich  plexus  of  vessels  filled  with  colored  size. 

Commentary. — On  the  admission  of  this  man  (September  5),  he  was 
laboring  under  intense  fever.  He  had  cough  and  expectoration  tinged 
with  blood;  dyspnoe-i ; livid  face;  hot  pungent  shin;  pulse  112,  firm; 
dulness,  with  cracked-pot  sound  on  percussion  over  left  chest  anteriorly  ; 
and  coarse  moist  rales  during  inspiration  and  expiration.  These  were 
the  symptoms  of  acute  pneumonia  in  its  suppurative  stage.  On  the 
other  hand,  the  disease  was  described  to  have  come  on  a month  before 
with  dry  cough  ; there  was  no  distinct  rigor  ushering  in  the  attack ; and 
the  chlorides  in  the  urine  were  abundant.  Hence  it  might  be  a ease  of 
acute  tuberculosis.  His  general  aspect  taught  us  nothing,  as,  without 
being  robust,  he  was  by  no  means  emaciated.  He  was  treated  with 
gentle  salines,  in  order  to  moderate  the  excessive  fever ; whilst  wine, 
gin,  and  nutrients  were  liberally  administered  to  support  his  strength. 
This  treatment  succeeded  in  somewhat  diminishing  the  fever.  On  the 
Gth  day  after  his  admission,  I carefully  examined  the  sputum  with  the 
microscope,  and  found  it  to  contain  abundant  fragments  of  lung  tissue, 
mingled  with  numerous  pus  and  a few  blood  corpuscles.  This  fact  first 
demonstrated  the  phthisical  character  of  the  disease.  Subsequently  the 


566 


DISEASES  OF  THE  CIECULATOKY  SYSTEM. 


pneumonic  symptoms  disappeared ; dulness  with  moist  rales  became 
limited  to  the  apices  of  both  lungs,  and  the  thoracic  physical  signs  were 
only  examined  from  time  to  time.  At  the  visit  of  the  1st  of  October,  a 
double  friction  murmur  was  discovered  to  exist  all  over  the  cardiac  region, 
so  distinct  as  at  once  to  satisfy  me  that  pericarditis  was  already  fully 
established.  It  was  unaccompanied  by  pain,  palpitation,  or  any  local 
functional  symptom  whatever,  so  that,  without  the  physical  sign  of  fric- 
tion, attention  would  never  have  been  directed  to  it.  Indeed  about  this 
period,  there  had  been  a remission  in  the  febrile  symptoms,  there  was  less 
cough,  and  he  felt  so  much  better  that  great  difficulty  was  experienced 
in  making  him  keep  his  bed,  and  even  retaining  him  in  the  house. 
The  phthisical  symptoms,  however,  continued,  the  diarrhoea  became 
colliquative,  exhaustion  came  on,  and  he  sunk,  without  having  exhibited 
one  symptom  of  heart  complaint  in  addition  to  the  physical  signs.  On 
examining  the  body,  besides  the  pulmonary  lesion,  the  heart  presented  a 
shaggy  layer  of  lymph  covering  the  whole  of  both  pericardial  surfaces. 
These  were  already  vascular,  while  their  surfaces  were  covered  with 
epithelium,  and  they  must  have  been  actively  engaged  in  absorbing  the 
serum  which  separated  them,  which  was  small  in  amount.  Here,  then, 
we  have  a remarkable  example  of  a true  acute  inflammation  of  a serous 
surface  coming  on  under  our  eyes,  which  was  detected  by  physical  signs 
alone,  and  w^as  unaccompanied  b}^  any  functional  symptoms  whatever. 
The  only  treatment  indicated  in  this  case  was  to  support  the  general 
strength.  As  there  were  no  local  symptcms,  topical  remedies  were  evi- 
dently unnecessary. 

In  this  case,  also,  we  remark  an  exception  to  the  general  laws  sup- 
p sed  to  govern  exudations,  viz,,  that  in  a phthisical  person,  while  tu- 
bercle was  thrown  into  the  lungs,  an  inflammatory  exudation  was  thi  own 
out  in  the  pericardium  (See  Case  LIV.  p.  472).  Here,  however,  it  was 
observable  that  when  the  pericarditis  appeared,  his  general  health  had 
temporarily  improved,  and  he  was  taking  generous  diet,  a circumstance 
which  may  serve  to  account  for  the  altered  constitution  of  the  exuded 
matter.  It  must  be  obvious  however,  from  this,  as  well  as  from  many 
other  observations  previously  made,  that  a true  inflammation  has  no 
necessary  connection  with  robust  constitutions,  and  that  it  may  come  on 
at  the  close  of  the  most  exhausting  maladies. 

Case  CI."^ — Ascites — Anasarca — Adherent  Pericardium  with  Fatty  Atro- 
phied Heart — Congested  Liver. 

History. — John  Young,  iBt.  19,  a farm  servant — admitted  April  16th,  1855.  Nine 
months  ago  he  felt  pains  in  the  right  hypochondrium,  and  shortly  afterwards  his  abdo- 
men began  to  swell.  Under  medical  treatment  the  swelling  subsided,  returning  when 
medicines  were  discontinued,  and  again  subsiding  under  medical  treatment.  It  has 
increased  a third  time,  and  has  induced  him  to  apply  for  admission. 

Symptoms  on  Admission. — He  is  a stout  person,  with  a protuberant  abdomen,  no 
oedema  of  integument,  and  very  slight  yellow  tint  of  the  sclerotic.  He  says  there  has 
been  swelling  of  the  legs.  Tongue  moist,  and  a little  coated  ; appetite  good  ; no  dys- 
phagia nor  vomiting.  The  area  of  hepatic  dulness  cannot  be  determined,  owing  to  the 
dulness  of  percussion  over  the  abdomen.  On  percussion,  the  distension  of  the  abdomen 
is  seen  to  be  owing  to  an  accumulation  of  fluid  which  gravitates  to  the  dependent  por- 
tions. Bowels  are  regular.  Cardiac  sounds  normal.  Area  of  cardiac  dulness  is  not 

* Reported  by  Mr.  Robert  Byers,  Clinical  Clerk. 


PERICARDITIS. 


567 


stated.  Pulse  80,  of  good  strength.  On  auscultation,  sibilant  rales  are  heard  all  over 
his  chest.  He  expectorates  a good  deal  of  tough  frothy  mucus.  Complains  of  dyspnoea 
and  cough,  especially  after  meals.  Urine  scanty  (only  12  ounces  during  the  last  24 
hours),  of  natural  color,  with  exceedingly  slight  trace  of  albumen.  Is  ordered  a squill 
and  digitalis  pill  thrice  a day. 

Progress  of  the  Case. — April  \^th. — Urine  not  increasing.  Is  ordered  to  apply 
over  his  abdomen,  spongio-piline  soaked  in  an  infusion  of  digitalis,  four  times  stronger 
than  usual.  %Uh. — Coughs  less,  and  expectoration  is  more  easy,  but  urine  is  not  in- 
creased. A papular  eruption  has  appeared  over  abdomen  from  the  action  of  the  spongio- 
piline.  29//i. — Has  had  frequent  watery  evacuations  without  griping,  and  with  only 
slight  nausea  under  the  action  of  elaterium,  in  the  dose  of  one-sixth  and  one-fourth  of 
a grain.  May  2d. — The  spongio-piline  was  ordered  to  be  removed,  as  it  appears  to 
cause  irritation  of  the  integument.  3(/. — The  cardiac  sounds  are  healthy  at  apex  and 
base.  The  abdomen  is  less  tense.  The  upper  border  of  the  area  of  hepatic  dulness 
is  not  higher  than  usual.  The  lower  cannot  be  determined.  The  urine  is  not  coagula- 
ble.  Uh. — Has  felt  more  comfortable ; the  ascites  appear  slowly  increasing.  Is  ordered 
half  a drachm  of  compound  jalap  powder.  11th. — Has  felt  I’elieved  as  usual  after  pur- 
gation ; the  urine  is  slightly  increased.  The  feet,  legs,  thighs,  and  scrotum,  are  now 
oedematous.  Haheat  Potass.  Bitart.  3j  ter  indies.  iWi. — The  general  anasarca  is 
increasing.  Dyspnoea  is  greater.  Urine  quite  free  from  albumen.  Pulse  63,  irregular 
and  weak.  Bowels  costive.  18^A. — Bowels  have  been  kept  freely  open  by  the  admin- 
istration of  purgatives,  chiefly  of  Extract.  Elater.,  in  doses  of  one-sixth  and  one-fourth 
of  a grain.  Anasarca  is  not  quite  so  great,  and  micturition  is  more  easy,  notwithstanding 
the  oedematous  condition  of  penis  and  scrotum.  To  continue  the  doses  of  Bitart.  Po- 
tassce.  21s^. — Not  so  well  to-day  ; feels  uneasy  in  horizontal  position ; is  to  get  a special 
pillow  for  the  support  of  his  shoulders  and  head.  Pulse  88,  weak  and  intermittent. 
24ih. — Pulse  84,  weak  and  irregular  ; urine  24  ounces  in  24  hours  ; sp.  gr.  1028  ; con- 
tains no  albumen.  The  abdomen  is  becoming  evidently  by  degrees  more  and  more  dis- 
tended. 2i)th. — Feels  much  the  same  as  yesterday  ; cannot  lie  down  in  horizontal  posi- 
tion. Urine  27  ounces,  not  in  the  least  coagulable.  28th. — Urine  continues  to  range 
from  20  to  28  ounces  per  diem  ; sp.  gr.  1021 ; no  traces  of  albumen.  Feet  and  limbs 
enormously  swollen.  31.s^.— Urine  diminished  in  amount;  cough  is  i)retty  severe. 
Orthopnoea  continues ; pulse  94,  weak  and  intermittent.  Patient  is  becoming  exhausted, 
does  not  even  take  the  food  for  which  he  has  an  appetite,  from  the  distressing  sensation 
of  the  tenseness  of  his  abdomen.  B Spir.  Mdther.  Sulph. : Ammonice  sesquicarb.  aa 
§ ss  ; Aquce,  3 vj  ; one  ounce  every  th'.rcl  hour.  June  od. — Died  to-day. 

Sectio  Cadaveris. — Fifty-six  hours  after  death. 

Body  anasarcous.  Face  swollen  and  oedematous ; some  hemorrhage  from  the  nose. 
Limbs  oedematous  ; abdomen  protuberant  and  fluctuating  ; great  cadaveric  liver. 

Thorax. — The  right  pleura  contained  nearly  two  pints  of  clear  serum ; the  left  one 
pint.  The  lower  lobe  of  the  right  lung  was  compressed  and  non-crepitant,  and  the 
margin  of  the  other  lobes  emphysematous ; otherwise  both  lungs  natural.  The  pericar- 
dium was  found  to  be  firmly  adherent  over  the  whole  surface.  It  was  much  thickened, 
varying  from  two  lines  to  two  and  a half,  and  it  was  of  fibrous  or  almost  cartilaginous 
consistence.  The  heart  itself  was  about  the  normal  size,  but  its  walls,  particularly 
those  of  the  left  ventricle,  were  rather  thinner  than  natural,  being  less  than  two  lines 
at  the  apex.  The  valves  and  endocardium  were  healthy ; the  muscular  tissue  was  of 
a pale  fawn  color. 

Abdomen. — Contained  three  gallons  of  clear  serum.  Liver  weighed  3 lb.  and  2 oz. 
Its  hepatic  vessels  were  congested,  so  that  the  organ  presents  on  section  a nutmeg  ap- 
pearance. The  spleen  soft,  weighed  6^  oz. ; but  was  healthy.  The  two  kidneys  weighed 
each  10|-  oz.  ; and  were  quite  healthy.  The  whole  alimentary  canal  was  carefully  ex- 
amined, but  with  the  exception  of  congestion  of  the  mucous,  membrane  in  the  lower  two- 
thirds  of  the  rectum,  was  found  to  be  quite  healthy.  The  large  arteries  and  veins  of 
the  neck,  chest,  abdomen,  and  pelvis,  were  also  minutely  examined,  and  found  healthy. 

Microscopic  Examination. — The  striae  in  many  of  the  cardiac  muscular  fibres  were 
indistinct,  and  numerous  minute  oil  globules  were  visible  within  the  sarcolemma. 
Tlie  hepatic  cells  contained  somewhat  more  biliary  and  fatty  matter  than  usual.  But 
in  almost  all  of  them  the  nuclei  could  be  seen.  The  renal  structure  was  normal. 

Commentary . — The  history  and  symptoms  of  this  man  induced  me 
to  consider  his  disease  as  essentially  hepatic.  According  to  bis  account 


568 


DISEASES  OF  THE  CIRCULATOEY  SYSTEM. 


it  commenced  with  ascites  nine  months  before  admission,  and  was  fol- 
lowed by  oedema  of  the  legs  and  general  anasarca.  On  taking  charge  of 
the  case  in  May,  however,  I could  not  detect  any  alteration  in  the  size 
of  the  liver,  or  any  uneasiness  in  the  right  hypochondrium.  The  heart 
was  carefully  examined  and  found  to  be  healthy,  and  at  no  time  had  he 
ever  complained  of  that  organ.  The  lungs  presented  evidence  of  slight 
bronchitis,  which  could  never  be  supposed  to  have  occasioned  the  dropsy. 
The  urine  when  scanty  contained  a slight  trace  of  albumen,  which  after- 
wards disappeared.  At  no  time  did  the  case  resemble  one  of  Bright’s 
disease,  and  the  kidneys  after  death  were  quite  healthy.  The  rapidly- 
advancing  dropsy  was  the  source  of  danger  in  this  case.  As  diuretics 
had  no  ehect,  hydragogue  cathartics  were  had  recourse  to,  and  although 
these  produced  temporary  relief,  the  anasarca  went  on  steadily  increasing, 
and  he  died.  On  examining  the  body,  the  liver  was  found  to  be  simply 
congested,  while  its  structure  had  undergone  little  alteration ; the  peri- 
cardium was  universally  adherent,  and  somewhat  thickened ; the  lungs 
collapsed  posteriorly,  with  slight  emphysema  anteriorly.  It  seems  to  me 
that  the  congested  liver  and  the  chief  pulmonary  lesions  were  the  results 
rather  than  the  causes  of  the  anasarca,  and  that  the  true  origin  of  the 
disease  must  be  referred  to  the  cardiac  lesion.  During  life,  it  is  true, 
there  were  no  symptoms  or  physical  signs  to  indicate  that  the  heart  was 
diseased.  But  it  became  apparent  after  death  that  he  must  have  had  an 
extensive  pericarditis,  and  we  have  previously  seen  that  such  may  occur 
without  any  symptoms  at  all.  This,  as  in  the  case  of  Douglas,  led  to 
fatty  degeneration  of  the  organ,  with  atrophy,  however,  instead  of 
enlargement;  and  the  result  was  that,  instead  of  dying  suddenly  as  in 
her  case,  such  slow  languor  of  the  circulation  w’as  occasioned,  as  to  pro- 
duce the  venous  congestion  in  the  liver  and  lungs,  which  in  its  turn 
occasioned  the  anasarca.  In  most  cases  where  enlargement  of  the  heart 
follows  adherent  pericardium,  I have  noticed  the  existence  of  valvular 
disease.  In  the  present  case  the  valves  were  hearlthy,  and,  instead  of 
hypertrophy,  there  was  atrophy. 


Case  CII.* — Rheumatic  Pericarditis. 

History. — Jane  Beaton,  ?et.  13,  a thin,  weak  girl — admitted  November  30th,  1853. 
She  states  that  two  years  ago  she  was  confined  to  bed  for  a month  with  acute  rheuma- 
tism, some  time  after  which,  she  cannot  say  precisely  when,  she  observed  that  her 
heart  was  wont  to  beat  very  quickly.  The  impulse  also  was  distinctly  seen  by  her  on 
undressing  before  going  to  bed.  She  had  never  suffered  before  from  any  cardiac  unea- 
siness, pain,  or  dyspnoea,  and  asserts  that  she  was  able  to  run  about  as  well  as  the  other 
children  at  school,  until  the  commencement  of  the  present  illness.  Three  weeks  ago, 
after  no  unusual  exposure  to  cold,  so  far  as  she  was  aware,  she  felt  weak,  lost  her  ap- 
petite, and  went  to  bed  early.  Next  day  she  could  not  move  in  consequence  of  pain 
in  both  hip  joints,  and  in  two  days  the  knees,  wrists,  elbows,  and  shoulders  were  also 
afiected.  The  knees  were  much  swollen,  but  not  red.  In  eight  days  the  pains  abated, 
and  have  not  since  returned.  Since  then  she  has  been  subject  to  cough,  with  a white 
frothy  expectoration,  but  has  no  pain  in  the  chest,  dyspnoea,  or  palpitation.^ 

Symptoms  on  Admission.-- The  cardiac  impulse  is  seen  and  felt  in  the  third,  fourth, 
and  fifth  intercostal  spaces,  so  low  as  one  and  three-fourths  of  an  inch  below,  and 
to  the  outside  of  the  nipple.  It  is  strong,  but  unaccompanied  with  fremitus.  Per- 

* Reported  by  Dr.  David  Christison,  Resident  Physician,  and  Mr.  James  Walker, 
Clinical  Clerk. 


PERICAEDITIS. 


569 


cnssion  causes  slight  pain.  Cardiac  diilness  was  much  increased,  extending  to  the 
right  side  of  sternum,  but  its  exact  limits  were  not  determined.  All  over  the  cardiac 
region  there  was  a double  friction  murmur,  appearing  close  to  the  ear,  and  of  a fine 
grating  character,  but  very  distinct.  Over  the  manubrium  of  the  sternum  is  a single 
blowing  murmur,  apparently  with  the  first  sound.  The  second  sound  cannot  be 
heard.  Pulse  136,  regular,  of  good  strength  and  somewhat  jerking.  The  chest  ex- 
pands equally  on  both  sides ; percussion  normal.  Respiration  harsh  and  sibilant 
over  right  pulmonary  apex,  over  left  apex  normal.  Posteriorly  respiratory  sounds 
healthy.  She  has  slight  cough,  with  trifling  mucous  expectoration.  Does  not  com- 
plain of  dyspnoea,  but  the  breathing  is  evidently  somewhat  accelerated.  Tongue 
clean.  Appetite  somewhat  impaired  ; sliglit  thirst.  Bowels  regular.  No  headache  ; 
does  not  sleep  well,  but  no  startings  at  night.  Face  flushed  ; no  anxiety  of  counte- 
nance ; skin  hot  and  dry;  often  sweats  at  night;  no  oedema  of  limbs.  Otlier  functions 
normal.  Eight  leeches  to  he  applied  to  the  prcecordial  regio'u,  and  a sixth  of  a grain 
of  Tartrate  of  Antimony  to  he  given  in  solution  every  third  hour. 

Progress  of  the  Case. — Dccemher  U'^. — Pulse  more  soft.  To  discontinue  the 
antimony.  R Calomel  gr.  xxiv  ; Pulv.  Jacohi  gr.  xxiv ; Pulv.  OpH  gr.  iii.  M.  et 
divide  in  chartulas  xij.  One  to  he  taken  every  four  hours,  Dec.  Zd. — Friction  mur- 
murs much  diminished.  Cardiac  dulness  apparently  increased.  Urine  loaded  with 
lithates.  Cough  continues.  R Sp.  Esther.  Nit.  3 iij  ; Dot.  Acet.  3 ij  ; Mist.  Scillce 
§ vss.  M.  A table-spoonful  to  he  taken  every  four  hours.  Dec.  Ath. — Careful 
examination  determined  that  the  cardiac  dulness  measures  five  inches  transversely, 
commencing  half  an  inch  outside  the  left  nipple,  and  extending  across  tlie  sternum  to 
an  inch  and  a half  from  the  right  nipple.  Friction  is  now  only  audible  over  the 
margin  of  dulness  on  the  right  side.  A soft  blowing  murmur  is  audible,  synchronous 
with  the  impulse  over  a space  of  two  inches  in  diameter  below  the  nipple.  At  the 
base  a harsher  blowing  is  heard,  which  alternates  with  the  soft  murmur  at  the  apex. 
It  is  propagated  in  the  direction  of  the  large  vessels,  and  is  very  audible  under  the 
centre  of  the  right  clavicle.  Pulse  120,  soft,  and  slightly  jerking.  No  pain  or 
dyspnoea.  Gums  not  affected  by  the  mercurial  powders,  but  complains  of  tormina  and 
slight  diarrhoea.  Discontinue  the  powders,  atid  apply  a blister  (3  by  4)  over  the  ster- 
num. Dec.  V2th. — Dulness  somewhat  diminished.  Double  friction  is  again  very  loud 
over  the  base  of  the  heart.  Dec.  loth. — Dulness  much  decreased;  friction  has  disap- 
peared. Dec.  l^th. — Dulness  now  only  measures  three  inches  transversely  across. 
Dec.  2%th. — Has  been  doing  well,  and  taking  her  food  regularly.  The  cough  and  ex- 
pectoration have  nearly  disappeared,  and  the  harshness  of  breathing  on  the  right  side 
has  much  diminished.  Last  night  w'as  seized,  without  apparent  cause,  with  violent 
palpication,  a sense  of  suffocation,  and  coldness  of  the  body,  which  continued  for  an 
hour.  Brandy  and  sulphuric  ether  were  given,  and  hot  bottles  app'-ied  to  the  feet. 
To-day  slie  is  tranquil  as  usual.  Impulse  is  undulating  between  fourth  and  sixth 
I'ibs.  The  blowing  at  the  apex  is  more  harsh  and  prolonged.  Above  the  nipple,  on 
a level  with  the  margin  of  sternum,  there  is  a superficial  blowing,  occupying  the 
period  of  both  sounds.  It  is  no  longer  audible  under  the  clavicle.  No  retraction  of 
the  intercostal  space  over  the  undulation  visible  between  the  fourth  and  sixth  ribs. 
January  14/A. — Since  last  report,  the  attacks  of  palpitation  and  dyspnoea  have 
recurred  occasionally  at  night,  apparently  excited  by  any  unusual  circumstance. 
Puerile  respiration  still  continues  on  the  right  side,  but  all  pulmonary  disorder  other- 
wise has  ceased.  There  is  now  heard,  both  at  the  apex  and  at  the  base,  one  loud 
blowing  murmur,  synchronous  with  the  impulse,  occu[)ying  the  period  of  both  sounds. 
That  at  the  base  is  harder  and  more  clanging  in  character  than  that  at  the  apex,  and 
ceases  suddenly  on  carrying  the  stethoscope  to  the  articulations  of  the  third  and 
fourth  right  ribs  with  the  sternum.  Pulse  128,  soft.  She  is  easily  agitated  ; otiier- 
wise  the  same,  but  says  she  is  better.  Wine  ^ ij  daily.  March  ISth.. — Since  last 
report,  has  been  greatly  better,  and  has  had  comparatively  few  attacks  of  dyspnoea 
and  palpitation.  To-day  the  impulse  is  felt  distinctly  between  the  sixth  and  seventh 
ribs,  a little  to  the  outside  of  a line  drawn  vertically  from  the  nipple.  Over  this 
point  a double  blowing  murmur  is  heard,  that  with  the  second  sound  being  longest 
and  somewhat  distant.  This  blowing  increases  in  intensity  and  loudness  as  the 
stethoscope  is  carried  obliquely  upwards  towards  the  sternum,  and  reaches  its  maxi- 
mum over  the  articulation  of  the  third  left  costal  cartilage  with  the  sternum.  At  this 
point  the  murmur  is  prolonged,  occupying  the  period  of  both  sounds.  It  suddenly 
ceases  as  the  stethescope  approaches  the  clavicles  on  both  sides,  and  it  is  inaudible 


570 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


over  the  large  vessels.  Pulse  120,  of  good  strength,  jex-king;  no  venous  pulse.  Afril 
11///. — Has  continued  the  same,  but  insists  on  leaving  the  Infirmary,  and  is  in  conse- 
quence dismissed. 

Commeniary. — This  was  an  exceedingly  interesting  case  of  pericar- 
ditis and  endocarditis,  the  former  of  which  apparently  terminated  in  ad- 
hesions, while  the  latter  underwent  a variety  of  organic  changes,  which 
were  indicated  by  physical  signs,  and  were  carefully  recorded  in  suc- 
cessive examinations.  From  these  it  seems  probable  that  there  was 
gradually  developed  considerable  hypertrophy  of  the  left  ventricle,  the 
apex  of  which  descended  downwards  and  outwards,  whilst  the  pulse  be- 
came more  and  more  jerking.  The  aortic  orifice  was  apparently  con- 
stricted ; and  it  is  curious  to  observe,  that  whilst  the  murmur  at  the 
base  at  first  was  propagated  upwards  in  the  course  of  the  large  vessels, 
it  subsequently  was  propagated  downwards  towards  the  apex,  and  ceased 
abruptly  above  at  the  margin  of  a certain  area.  The  kind  of  organic 
lesion  which  gradually  forming  ultimately  produced  this  result,  it  is  use- 
less speculating  about,  although  it  must  be  evident  that  the  aorta  itself 
above  the  valves  could  not  have  been  implicated.  At  one  time  it  ap- 
peared to  me  probable  that  the  pulmonary  valves  were  affected,  but  a 
careful  consideration  of  all  the  circumstances  obliges  me  to  negative  this 
supposition.  Again,  the  pressure  of  the  pericardial  exudation  might 
have  produced  the  murmur  at  the  base.  The  constant  blowing  murmur 
at  the  apex  indicated  mitral  insufficiency,  a lesion  which  could  not  have 
been  so  intense  as  the  aortic  disease,  as  the  murmur  was  always  more 
soft,  and  could  easily  be  distinguished  from  the  one  at  the  base.  Indeed, 
it  seemed  as  if  this  remained  almost  stationary,  whilst  the  aortic  lesion 
at  length  became  the  predominant  one.  I heard  some  few  weeks  after  her 
dismissal  that  this  girl  was  dead,  but  under  what  circumstances  could 
not  be  ascertained.  No  doubt  after  the  long  observation  and  successive 
careful  examinations  this  case  underwent,  much  might  have  been  learnt 
from  a post  mortem  examination.  The  disappointment  which  medical 
men  too  frecpiently  experience  in  this  particular,  doubtless  constitutes  an 
argument  with  some  in  favor  of  supineness,  and  must  at  all  times  tend  to 
check  that  habit  of  accurate  observation,  which  is  so  essential  for  working 
out  the  difficult  problems  still  unsolved  in  the  diagnosis  of  cardiac  diseases. 

Pericarditis  consists  of  an  exudation  into  the  pericardial  sac : the 
fibrin  of  which  coagulates  and  attaches  itself  to  the  membrane,  while  the 
serum  is  accumulated  in  the  centre.  Changes  now  occur,  in  con- 
sequence of  which  the  solid  portion,  or  layer  of  lymph  as  it  is  called, 
assumes  a villous  structure  and  becomes  vascular,  whereby,  in  the 
majority  of  cases,  the  fluid  is  absoi'bed,  and  the  two  false  membranes 
unite  to  form  an  adherent  pericardium.  These  changes  are  described 
and  figured,  pp.  174,  175.  (Figs.  155,  156.)  This  result,  however, 
may  be  prevented  by  two  circumstances : — 1st,  The  exudation  maybe 
small  in  quantity  and  limited  in  extent,  when  it  is  transformed  into 
fibrous  tissue,  becomes  covered  with  a true  serous  membrane,  and  there 
is  no  adhesion  with  the  opposite  surface.  This  constitutes  the  white 
patches  so  frequently  observed  on  the  lieart  in  examining  bodies  after 
death,  and  they  are  equally  frequent  on  other  serous  membranes.  2d, 
The  amount  of  exudation  may  be  very  great,  the  distension  of  the 
pericardial  sac  extreme,  and  the  transformation  into  vascular  absorbing 


PERICARDITIS. 


571 


villi  thereby  prevented.  Under  such  circumstances,  the  mass  of  fluid 
remains  stationary,  passes  into  pus,  or  even  increases,  in  consequence  of 
dropsical  eifusion  from  pressure  on  the  veins,  and  so  called  chronic 
pericarditis,  or  pericarditis  with  effusion  (hydro-pericardium),  is  estab- 


Auscultation  and  percussion  are  our  guides  to  a knowledge  of  peri- 


Fig.  433.  Fig.  434. 

carditis  in  the  living  subject.  With  their  aid  the  physician,  if  called 
in  at  the  commencement,  can  trace  the  progress  of  the  disease  through 
the  stages  of  commencing  exudation  with  friction,  gradual  pyriform 
enlargement  with  or  without  friction,  absorption  and  disappearance 
of  the  serum  with  returning  friction,  and  flnal  adhesion  of  the  two 
surfaces.  This  was  accurately  done  in  Cases  XCIX.  and  Cl.  An 
Fig.  433.  Flaccid  pericardium  with  small  amount  of  fluid. — (Sibson.) 

Fig.  434.  Distended  pericardium,  of  a pyriform  shape,  as  an  ordinary  pericarditis. 
— (Sibson.) 


572 


DISEASES  OF  THE  CIRCULATOKY  SYSTEM. 


adherent  pericardium,  or  a limited  exudation  confined  to  the  posterior  sur- 
face of  tlie  heart,  is  detectable  by  means  of  physical  signs  with  extreme 
rarity.  It  is  admitted  that  occasionally  a pericardial  may  closely  resem- 
ble a valvular  murmur,  but  then  the  former  is  superficial,  often  intensified 
by  pressure  of  the  stethoscope,  is  not  permanent,  and  is  liable  to  be  affected 
by  posture,  and  by  the  greater  or  less  energy  of  the  cardiac  contractions. 

As  regards  percussion,  it  is  necessary  to  remember  that  when  the 
amount  of  fluid  is  small,  say  from  two  to  four  ounces,  the  peri- 
cardial sac  is  not  distended,  but  remains  flaccid.  The  fluid  gravitates 

towards  the  lower  end,  and  produces 
the  appearance  represented  in  Fig. 
433.  In  case  of  acute  general  peri- 
carditis, such  as  Cases  XCVII.  and 
C.,  the  amount  of  fluid  may  reach 
from  ten  to  twenty  ounces,  when  the 
pericardium  is  distended,  becomes 
pyriform  with  the  base  dowmwai  ds,  as 
represented  Fig.  434.  In  such  cases 
it  may  be  determined  by  percussion, 
to  extend  upwards  to  the  top  of  the 
sternum,  and  downwards  to  below  the 
xiphoid  cartilage.  It  may  pass  to  the 
right  of  the  sternum  on  one  side, 
and  left  of  the  nipple  on  the  other, 
more  or  less  displacing  the  lungs,  es- 
pecially pressing  backwards  on  the 
left  one.  In  chronic  pericarditis  or 
hydro-pericardium,  more  than  three 
pints  of  fluid  have  been  found  in  the 
sac,  in  which  case  the  pyramidal  form 
of  acute  pericarditis  is  lost,  and  it 
becomes  globular,  as  in  Fig.  d35.  In 
such  cases  it  encroaches  so  far  on  the 
left  lung  as  to  push  it  entirely  back- 
wards. The  liver  and  stomach  are 
at  the  same  time  displaced  down- 
wards to  a great  extent,  by  the  de- 
Fig-  435.  scent  of  the  central  tendon  of  the 

diaphragm.  Hence  the  epigastric  prominence,  and  the  jain  on  pres- 
sure in  the  epigastrium,  sometimes  observed  in  cases  of  pericarditis. 
While  the  increasing  effusion  into  the  pericardium  displaces  the  lungs, 
liver,  and  stomach,  it  also  causes,  especially  in  the  young,  prominence 
of  the  lower  sternum  and  adjoining  left  costal  cartilages,  and  widening 
of  the  left  intercostal  spaces.  If  very  extensive,  it  presses  backwards 
and  upwards  on  the  bifurcation  of  the  trachea,  causing  extreme  dyf-pi  oea. 
In  such  cases  relief  is  experienced  by  sitting  up  and  leaning  i'orwaid  in 
bed,  when  the  pressure  on  the  trachea  is  removed  by  tlie  gravitation  of 
the  fluid  dowmwards  and  forwards. — [Sihso?i.)  Pressure  on  the  oeso- 
phagus may  also  occasion  more  or  less  dysphagia. 


Fi".  485.  Excessive  distcBtion  of  pericardium,  as  in  chronic  pericarditis  or  hydro- 
pericardium. — (^Sibson.) 


PERICAEDITIS. 


573 


Functional  symptoms,  however  they  may  induce  us  to  suspect,  can 
never  alone  positively  enable  us  to  affirm  the  existence  of  pericarditis. 
They  are  very  variable  in  different  cases,  and  appear  to  me  to  be  de- 
pendent more  on  the  general  susceptibility  of  the  nervous  system,  than 
on  anything  else.  Moreover,  we  have  seen  that  the  symptoms  of  local 
pain,  dyspnoea,  and  so,on,  are  often  absent.  In  the  case  of  Campbell  (Case 
C.),  while  the  friction  murmur  told  its  tale  with  the  greatest  clearness, 
he  denied  that  anything  was  wrong  with  his  heart  whatever,  and  yet 
after  death  the  two  pericardial  surfaces  were  found  covered  with  soft 
shaggy  lymph  In  Case  CL,  where  after  death  there  was  adherent  peri- 
cardium leading  to  general  anasarca,  the  man  could  not  remember  that 
he  ever  was  affected  in  any  way  with  cardiac  disorder.  (See  also  Case 
XCVIII.)  This  important  fact  has  been  noticed  by  many  physicians — 
thus  “ acute  pericarditis  is  often  so  latent  as  to  be  discoverable  only  by 
physical  signs.” — [Stokes)  “ The  disease  may  be  absolutely  latent  from 
first  to  last.  I have  known  patients  with  several  ounces  of  fluid  and 
exudation  matter  in  the  pericardium,  grow  irritated  when  inquiries 
were  made  about  symptoms  connected  with  the  heart.”— ( TFa/sAs.) 
But  the  cases  of  Douglas  and  Young,  which  have  been  recorded,  must 
satisfy  us  that  pericarditis  is  a most  serious  complaint.  The  adhesions 
which  form  often  more  or  less  embarrass  the  action  of  the  heart,  and, 
above  all,  impede  its  normal  nutrition;  in  the  one  case  they  caused 
general  dropsy,  and  in  the  other  fatty  degeneration  of  the  texture  of  the 
heart. 

Much  has  been  written  as  to  the  complications  of  pericarditis.  Its 
association  with  acute  rheumatism  is  so  common,  that  some  have  classi- 
fied cases  into  rheumatic  and  non-rheumatic  [Onnerod,  3Iarkham).  The 
causes  of  this  association  are  as  yet  unknown.  Dr.  Taylor  further 
sought  to  establish  a relation  between  pericarditis  and  Bright’s  disease. 
Thus,  out  of  38  of  his  cases,  20  occurred  in  the  progress  of  acute  rheu- 
matism, and  ten  were  complicated  with  renal  disease.  It  so  liappens, 
that  in  none  of  my  cases  of  pericarditis  has  there  been  a complication 
with  Bright’s  disease ; and  yet  this  last  lesion  is  so  common  in  Edin- 
burgh, that  it  is  scarcely  conceivable,  if  it  were  really  a cause  of  the 
former,  that  it  should  have  escaped  my  notice.  Dr.  Christison  also  says, 
in  his  work  on  “ Grranular  Degeneration  of  the  Kidneys  ” (p.  94),  that 
“ pericarditis  is  seldom  seen  among  the  sequelae.”  VYe  cannot,  therefore, 
be  too  cautious  in  reasoning  as  to  the  causes  and  treatment  of  pericar- 
ditis from  the  supposed  conditions  of  the  blood  with  which  it  is  thought 
to  be  associated.  Complications  with  pleurisy,  pneumonia,  and  pul- 
monary emphysema,  are  much  to  be  dreaded,  especially  as  regards  the 
ultimate  effects  on  the  heart  itself,  although  they  may  not  prove  imme- 
diately fatal.  (See  also  Cases  CVII.,  CVIII.,  and  CX.) 

The  treatment,  like  that  of  all  other  forms  of  acute  inflammation 
up  to  a recent  period,  was  at  first  antiphlogistic,  but,  for  the  reasons 
previously  given  (p.  313),  this  is  no  longer  the  rule.  Case  XCYII. 
demonstrates  how,  in  a tolerably  healthy  person,  the  disease  passes 
rapidly  through  its  natural  progress.  But  should  there  be  depression 
of  the  vital  powers,  stimulants  and  nutrients  are  demanded,  as  in  Case 
XCIX.  If  there  be  local  pain,  the  application  of  a few  leeches,  or, 


574 


DISExiSES  OF  THE  CIRCULATORY  SYSTEM. 


what  is  often  better,  of  warm  fomentations  or  a hot  poultice,  tends  to 
relieve  it.  Quietude  of  body  and  mind  is  essential  to  the  treatment. 
In  young  persons  especially,  unnecessary  physical  examination  should 
be  carefully  avoided.  If  the  principle  of  practice  formerly  put  forth 
be  correct  (p,  313),  viz.,  that  a true  inflammation  cannot  be  cut  short, 
and  that  the  only  end  of  judicious  medical  practice  is  to  conduct  it  to  a 
favorable  termination,  we  should  expect  its  truth  to  be  manifested  in 
such  a disease  as  pericarditis.  Now  this,  I think,  we  do  see.  Contrast 
the  treatment  of  Hope  with  that  of  Stokes,  and  what  a difference  is 
observable ! The  former  energetic  in  lowering  remedies,  the  latter 
cautious  and  constantly  warning  us  not  to  proceed  too  far.  Though  he 
recommends  blood-letting,  it  can  only  be  practised  with  his  consent,  at  a 
time,  to  in  extent,  and  under  circumstances  when  obviously  it  is  likely 
to  do  no  harm.  On  the  other  hand,  he  points  out  how,  in  some  circum- 
stances, even  a vigorous  action  of  the  heart,  a jerking  pulse,  and  an  in- 
creased action  of  the  carotids,  do  not  necessarily  contra-indicate  wine;  ” * 
and  remarks,  “ that  the  omission  of  that  active  antiphlogistic  treatment, 
still  so  often  employed  in  the  first  stages  of  inflammation,  might  be  of 
no  great  detriment  to  the  patient.”  f For  my  own  part,  I am  satisfied 
that  there  are  no  circumstances  in  which  an  antiphlogistic  practice  can 
diminish  the  progress  of  the  disease,  whilst  in  the  vast  majority  of  cases 
it  does  positive  harm,  by  checking  the  vital  force  so  necessary  for  en- 
abling the  patient  to  struggle  through  his  malady. 

It  has  been  supposed  that  the  action  of  mercury  has  an  especial 
tendency  to  favor  absorption  in  cases  of  pericarditis,  not  only  of  the 
serum,  but  of  the  organized  lymph  itself.  I have  now  given  it  in 
many  cases,  two  of  which  are  recorded  at  length  (Cases  XCVIII. 
and  CIL),  but  could  never  satisfy  myself  that  it  had  the  slightest 
influence  in  forwarding  or  modifying  then  atural  changes  which  occur. 
The  best  evidence  on  this  subject,  however,  is  to  be  derived  from  a 
careful  analysis  of  forty  cases  of  acute  rheumatic  pericarditis,  by  the 
late  Hr.  John  Taylor,  in  which  mercurial  ptyalism  was  produced  with 
the  following  results  : — 1st,  Ptyalism  was  not  followed  by  any  abate- 
ment of  the  pericarditis  in  twelve  cases.  2d,  In  one  case  ptyalism  was 
followed  by  speedy  relief.  3d,  In  two  cases  ptyalism  was  followed  by 
a diminution,  and  then  gradual  cessation  of  pericardial  murmur.  4th, 
In  one  case  pericardial  murmur  had  been  diminishing  for  some  days 
before,  and  it  ceased  soon  after  ptyalism  was  produced.  5th,  In  one 
case  pericarditis  and  pneumonia  both  increased  in  extent  and  intensity 
after  ptyalism.  6th,  In  four  case  pneumonia  supervened  after  the 
establishment  of,  and  therefore  was  not  prevented  by,  ptyalism.  Was 
it  caused  by  it?  7th,  In  three  cases  endocarditis  supervened  after 
ptyalism.  8th,  In  six  cases  ptyalism  was  followed  by  pericarditis. 
9th,  In  one  case  ptyalism  could  not  be  produced,  and  yet  the  pericar- 
ditis went  on  favorably.  10th,  in  two  cases  ptyalism  was  followed 
by  extensive  pleuritis.  llth.  In  ore  case  ptyalism  was  followed  by 
erysipelas  and  inflammation  of  the  larynx.  12th,  In  two  cases  rheu- 

* Stokes  on  Diseases  of  the  Heart,  etc.,  1st  edit.  p.  89. 
f Ihid.^  p.  15. 


VALVULAR  DISEASES  OF  THE  HEART. 


575 


inatism  continued  long  after  ptyalism  was  produced.'^'  Tims  out  of  the 
forty  cases  only  four  can  be  said  to  have  become  better  after  the  mer- 
curial action  on  the  system  was  established,  and  in  these  there  can  be 
little  doubt  that  it  was  purely  a matter  of  coincidence.  Indeed,  I have 
often  observed  in  hospital  cases,  that  when  mercury  has  been  said  to  be 
most  successful,  its  physiological  action  has  been  established  just  about 
the  time  when,  during  the  natural  progress  of  the  disease,  the  friction  or 
blowing  murmur  may  be  expected  to  cease. 

It  seems  to  me  impossible  to  reconcile  these  positive  facts  with  the 
strong  opinions  of  some  eminent  physicians  as  to  the  good  etfects  of 
mercury  in  pericarditis.  “ If  a person,”  says  Graves,  “ is  seized  with 
very  acute  pericarditis,  how  unavailing  will  be  our  best-directed  efforts, 
unless  they  be  succeeded  by  a speedy  mercurialization  of  the  system  ! ” 
The  case  of  Stambroke  (Case  XCVII.)  is  alone  a sufficient  answer  to 
such  a remark,  not  to  mention  the  researches  of  Louis,  who  demonstrated 
that  only  one  out  of  six  cases  was  fatal  when  they  were  left  entirely  to 
nature. 

Acute  pericarditis,  therefore,  should  be  treated  according  to  the 
general  principles  previously  referred  to.  During  the  acute  febrile 
symptoms,  salines  and  quietude.  If  there  be  much  local  pain,  a few 
leeches  and  local  warmth.  If  there  be  excited  action  and  dyspnoea,  ether 
and  morphia,  and  as  early  as  possible  nutrients  and  wine  to  support  the 
vital  changes  which  it  is  necessary  for  the  exudation  to  go  through,  so  as 
to  favor  absorption.  Active  purgatives  should  be  avoided,  and  I am  by 
no  means  sure  that  blisters  are  of  any  avail.  My  experience  induces  me 
to  concur  with  a remark  of  Dr.  Markham,  viz.,  “ that  rheumatic  peri- 
carditis is  an  inflammation  attacking  rather  those  of  weak  than  of  strong 
constitution;  that  it  is  much  more  common  in  the  delicate  and  young 
than  in  vigorous  persons  in  the  prime  or  middle  periods  of  life ; that 
the  degree  of  inflammation — that  is,  the  general  febrile  reaction  and  the 
local  exudation — is  also  greater  in  them  than  in  the  strong  ; and  more- 
over that  the  disease  is  more  fatal.”  f 

VALVULAR  DISEASES  OF  THE  HEART. 

Although  morbid  anatomists  have  described  a variety  of  lesions 
which  may  cause  imperfect  action  of  the  valves  of  the  heart,  I prefer 
grouping  them  together  under  one  head.  However  they  originate, 
whether  from  mechanical  rupture,  from  endocarditis,  deposits  of  fibrin, 
morbid  growths,  or  other  cause,  they  practically  amount  to  the  same 
thing.  The  disease  is  imperfect  valvular  action,  and  the  duty  of  the 
physician  is  to  prevent  as  much  as  possible  the  consequences  which  this 
is  likely  to  occasion.  It  is  also  his  duty — while  taking  every  advantage 
of  the  laborious  efibrts  which  have  been  made  to  place  the  physical 
diagnosis  of  those  valvular  injuries  on  an  exact  basis — to  remember 
that  perfection  is  far  from  having  been  reached.  Careful  observations 
are  still  required  to  clear  up  many  doubtful  points,  and  to  unravel  the 

* Brit,  and  For.  Med.  Review,  vol.  xxiv. 
f Markham  on  Diseases  of  the  Heart,  etc.,  p.  103. 


576 


DISEASES  OP  THE  CIECULATORY  SA^STEM. 


difficulties  wliicli  arise  from  complication  of  injuries  in  the  mechanism 
and  vital  properties  of  so  important  an  organ.  Hence,  notwithstanding 
the  admirable  monographs  which  have  been  published  on  this  subject, 
constant  research  is  necessary,  not  only  to  confirm  what  is  already 
known,  but  to  determine  with  precision  points  that  are  doubtful,  and 
conditions  as  yet  scarcely  recognizable.  “ A time  may  come,”  says 
Stokes,  “ when  the  science  of  diagnosis  will  be  carried  to  such  perfection, 
that  we  shall  unfailingly  determine  not  only  the  condition  of  each  portion 
of  the  heart,  but  discover  the  rise  and  watch  the  progress  of  every  in- 
terstitial change  in  its  structure,  and  every  mutation  of  its  vitality.”^ 
If  so,  it  can  only  be  done  by  the  careful  study  and  analysis  of  individual 
cases. 

Case  CIILf — Rupture  of  Aortic  Valves. 

History. — Andrew  Anderson,  sot.  32 — admitted  May  l7th,  1859 — a soldier,  who 
has  been  through  the  campaign  in  India  with  Havelock,  and  was  present  at  the  latter 
part  of  the  siege  of  Lucknow.  On  the  16th  of  June  1858,  having  been  in  pursuit  of 
the  enemy,  and  ridden  32  miles  on  horseback,  he  experienced  on  dismounting  a giddi- 
ness in  the  head.  He  then  went  into  his  tent,  and  fell  on  the  bed.  The  doctor  of  the 
regiment  immediately  examined  him,  and  told  him  he  was  to  leave  off  active  duty. 
He  himself,  and,  he  says,  the  neighboring  bystanders,  without  putting  their  ears  to  his 
chest,  heard  a loud  murmur  accompanying  the  actions  of  the  heart.  Since  then  he 
has  never  been  on  active  service.  He  has  been  cautioned  never  to  exert  himself.  He 
was  sent  home  from  India,  and  arrived  at  Chatham  on  the  25th  of  March,  and  was  dis- 
missed from  the  army  on  the  27th  of  April  last.  The  noise  which  he  heard  at  first 
has  gradually  become  less,  and  his  health  otherwise  has  not  been  deteriorated,  with 
the  exception  of  vertigo  on  attempting  any  unusual  exertion. 

Symptoms  on  Admission. — The  apex  of  the  heart  beats  under  the  junction  of  left 
seventh  cartilage  with  the  ensifonn  cartilage.  On  percussion,  the  transverse  dulness 
measures  4 inches  and  one-eighth  of  an  inch,  the  internal  limit  being  half  an  inch 
from  the  mesial  line  on  the  right  side.  On  auscultation  over  the  apex,  the  fii’st  sound 
IS  normal,  the  impulse  considerable,  but  with  the  second  sound  there  is  a loud,  wheez- 
ing, rough  murmur.  This  is  audible  all  over  the  anterior  surface  of  the  chest,  but  is 
loudest  over  the  third  costal  cartilage  on  the  left  side,  and  over  a space  about  the  size 
of  a palm  of  a hand,  extending  towards  the  inght.  The  same  sound  is  audible,  but 
very  distant,  all  over  the  back.  Pulse  8S,  regular,  full,  and  jerking.  Other  systems 
noi  mal.  He  only  further  complains  of  dreaming,  and  occasionally  starting  in  the 
night,  waking  suddenly,  and  breathing  hurriedly.  The  murmur  is  very  loud  over  the 
right  carotid  artery.  Did  not  remain  in  the  hospital.  July  1860. — Says  that  for 

the  last  six  weeks  he  has  occasionally  felt  a sharp  burning  pain  opposite  the  insertion 
of  the  third  costal  cartilage  in  the  breast  bone  on  the  left  side.  He  had  also  ex- 
perienced during  the  winter  giddiness,  which  occasionally  returned,  especially  after  a 
full  meal.  Ordered  a warm  poultice  to  the  seat  of  pain  if  it  be  severe.  Physical  signs 
the  same. 

Died  suddenly  in  Glasgow,  August  1862. 

Commentary. — There  can  be  no  doubt  that  the  accident  which  hap- 
pened to  this  man,  and  incapacitated  him  from  duty,  was  a rupture  of 
the  aortic  valves.  The  whizzing  murmur  with  the  second  sound  loudest 
at  the  base  of  the  heart,  the  giddiness,  jerking  pulse,  and  hypertrophy 
of  the  organ,  were  the  proofs  of  this.  We  have  had  two  similar  cases 
in  the  Clinical  wards  since,  one  of  which  was  caused  by  severe  cough- 
ing, and  another  by  the  kick  of  a horse.  In  such  accidents  nothing  can 
be  done  but  cautioning  the  individuals  not  to  exert  themselves  suddenly 
or  continuously,  and  to  avoid  all  causes  which  may  excite  disease  in  the 
lungs. 

* Op.  Cit.,  p.  342. 

f Reported  by  Mr.  John  Nicholson,  Clinical  Clerk. 


VALVULAR  DISEASES  OF  THE  HEART. 


511 


Case  CIV.^ — Incom'petency  of  Aortic  Valves — Dilated  Hypertrophy 
of  left  Ventricle — Dilatation  of  Ascending  Portion  of  Aortic 
Arch — Chronic  Arteritis  with  Aneurismal  Pouches. 

History. — William  M‘Ritchie,  aet.  38,  fireman  on  board  a Newcastle  steamer, 
entered  the  clinical  ward,  complaining  of  palpitation,  dyspnoea,  and  cough,  on  the  4th 
of  January  1850.  At  that  time  it  was  aseertained  that  the  cardiac  dulness  was  of 
unusual  extent,  and  that  a blowing  murmur  existed  with  the  second  sound  at  the  base 
of  the  heart.  He  remained  in  the  house  under  treatment  until  February  2d,  when  all 
the  urgent  symptoms  having  left  him,  he  was  dismissed.  He  was  re-admitted  on  the 
14th  of  March,  the  palpitation,  cough,  and  dyspnoea  having  returned,  together  with 
anasarcous  swelling  of  the  abdomen  and  inferior  extremities. 

Symptoms  on  Admission. — On  percussion,  the  cardiac  dulness  measures  four 
inches  transversely.  The  apex  beats  between  the  sixth  and  seventh  ribs  external  to 
the  nipple.  The  carotid  and  subclavian  arteries  beat  strongly.  A loud  and  prolonged 
bellows  murmur  is  heard  with  the  second  sound,  loudest  at  the  base  of  the  heart,  and 
propagated  in  the  course  of  the  large  arteries.  First  sound  is  normal  in  character. 
Pulse  70,  regular,  hard,  and  jerking.  Respiration  hurried;  cough  and  dyspnoea 
urgent;  inspiration  harsh;  expiration  prolonged  ; face  livid  ; pain  and  dizziness  in  the 
head ; occasionally  loss  of  vision  ; disturbed  sleep ; nausea  and  anorexia ; abdomen 
considerably  swollen  from  ascites ; inferior  extremities  oedematous ; legs  cold. 

Progress  op  the  Case. — During  April  the  symptoms  continued  with  more  or  less 
intermission.  In  May  he  became  liable  to  attacks  of  syncope,  accompanied  with 
angina  and  palpitations.  In  the  beginning  of  June  it  was  observed  that  the  bellows 
murmur  with  the  second  sound  assumed  a rougher  character  over  the  arch  of  the 
aorta.  He  also  complained  of  dysphagia  and  a pulsation  in  his  throat,  which  obliged 
him  to  keep  his  head  in  a particular  position.  On  the  14th  he  was  seized  with  an 
unusually  severe  attack  of  angina  and  syncope,  which  in  ten  minutes  was  fatal.  The 
treatment  consisted  principally  in  the  exhibition  of  a variety  of  expectorants  and  anti- 
spasmodics,  of  which  a draught  containing  ten  minims  of  chloroform,  and  a teaspoon- 
ful of  Tr.  Cardam.  Co.  afforded  him  most  relief.  A few  leeches  were  also  applied  oc- 
casionally to  the  cardiac  region. 

Sectio  Cadaveris. — Forty  hours  after  death. 

Thorax. — The  pericardium  contained  three  ounces  of  serous  fluid.  There  was 
hypertrophy  with  dilatation  of  the  left  ventricle  of  the  heart,  in  consequence  of  which 
the  organ  weighed  1 lb.  4 oz.,  and  its  transverse  diameter  measured  five  inches.  The 
mitral  valve  was  healthy.  The  aortic  valves  were  considerably  thickened  and  curled 
inwards.  Immediately  above  them  the  aorta  was  unusually  dilated,  the  diameter  of 
its  calibre  being  two  and  a quarter  inches.  Water  poured  upon  the  aortic  valves  from 
above  passed  through  the  orifice  without  apparently  receiving  any  impediment.  One 
inch  below  the  origin  of  the  left  subclavian  there  was  an  aneurismal  pouch,  the  size 
of  a walnut,  projecting  half  an  inch  from  the  general  outline  of  the  vessel.  Thearteria 
innominata,  and  the  origin  of  the  right  carotid  artery,  were  also  somewhat  dilated, 
and  there  was  an  aneurismal  dilatation  of  the  aorta  opposite  the  superior  mesenteric 
artery.  The  aorta,  the  coronary,  and  several  of  the  larger  arteries,  were  roughened 
internally  by  atheromatous  deposits.  The  lungs  were  emphysematous  anteriorly,  and 
oedematous  at  their  apices. 

Head. — Brain  pale  ; slight  subarachnoid  effusion;  cerebral  arteries  slightly  athe- 
romatous. 

Abdomen. — Abdominal  organs  healthy. 

Case  CV.f — Incompetency  of  Aortic  Valves — Hypertrophy  of  Left 
Ventricle  and  Auricle — Ohstruction  and  Incompeteiicy  of  Mitral 
Valve — Pneumonia. 

History. — Samuel  Crawford,  set.  42,  employed  at  Chemical  Works — admitted 
June  10th,  1850.  He  has  been  subject  to  palpitation  and  dyspnoea,  after  any  con- 
siderable exertion,  for  four  or  five  years.  Last  February  he  had  to  leave  off  work  on 
account  of  these  symptoms,  which  subsided  in  a fortnight  under  medical  treatment. 

^ Reported  by  Mr.  Hugh  M.  Balfour,  Clinical  Clerk, 
f Reported  by  Mr.  David  Christison,  Clinical  Clerk. 

37 


578 


DISEASES  OF  THE  CmCULATORY  SYSTEM. 


Three  days  ago  they  once  more  returned.  He  has  noticed,  during  the  last  four  or 
five  months,  swelling  of  the  feet,  legs,  and  abdomen.  He  never  had  rheumatism  or 
any  other  serious  complaint. 

Symptoms  on  Admission, — The  cardiac  dulness  measures  three  inches  and  a 
quarter  transversely.  The  apex  beats  between  the  sixth  and  seventh  ribs,  two  inches 
below  and  to  the  left  of  the  nipple.  The  carotid  and  subclavian  arteries  beat  strongly. 
Over  the  apex  a bellows  murmur  Ic,  heard  with  both  sounds  of  the  heart.  Over  the 
base  there  is  a loud  prolonged  blowing  murmur  with  the  second  sound,  whidi  is  [)io- 
pagated  in  the  course  of  the  large  vessels.  The  first  sound  heard  at  the  base  is  un- 
usually short  and  muffled.  The  pulse  is  regular,  strong,  and  jerking.  He  has  cough, 
and  considerable  dyspnoea.  Percussion  over  the  loins  is  resonant,  but  posteriorly  and 
inferiorly  there  are  fine  moist  rales.  He  is  liable  to  giddiness  and  a feeling  of  faint- 
ness on  sudden  exertion.  Can  only  sleep  in  a half  sitting  posture,  resting  somewhat  on 
his  left  side.  Considerable  oedema  of  the  lower  extremities.  Other  functions  normal. 

Progress  of  the  Case. — The  cough  and  dyspnoea  continued.  On  the  13th  of  June 
the  urine  became  scanty  and  high  colored.  On  the  17th  there  was  diarrhoea.  Moist 
and  dry  rales  were  heard  over  a considerable  portion  of  chest,  and  there  was  much 
cough  and  expectoration.  On  the  26th  the  urine  was  again  abundant,  but  there  was 
general  fever,  cough  suppressed,  dyspnoea,  and  expectoration  tinged  with  blood. 
Pulse  108,  full  and  hard.  Crepitant  and  mucous  rales  were  heard  over  the  lower 
portion  of  the  right  side.  On  the  28th  all  oedema  of  the  extremities  had  disappeared, 
but  there  was  decided  pneumonia  on  the  right  side.  Low  delirium  during  the  night. 
Died  on  the  morning  of  the  29th.  On  the  first  day  ^ x of  blood  were  drawn  from  the 
arm  with  immediate  relief,  but  it  was  followed  by  sleeplessness  and  agitation  at  night. 
He  was  then  ordered  3 vj  of  wine  daily,  and  a mixture  containing  expectorants  and 
diuretics,  with  tincture  of  digitalis.  Local  blood-letting,  by  means  of  leeches,  was 
also  practised  from  time  to  time.  The  scantiness  of  the  urine  and  oedema  gave  way 
under  the  use  of  cream  of  tartar  in  3 j doses  three  times  a-day.  When  the  pneumonia 
came  on,  local  blood-letting,  by  cupping  to  | xij,  and  tartrate  of  antimony  internally, 
were  employed,  but  without  success,  although  the  former  relieved  the  dyspnoea. 
Sedio  Cadaveris. — Forty-eight  hours  after  death. 

Thorax. — The  pericardium  contained  four  ounces  of  straw-colored  serum.  The 
heart  weighed  twenty-three  and  a half  ounces.  This  increase  in  size  was  owing  to 
hypertrophy  of  the  walls  of  the  left  ventricle  and  auricle,  and  to  dilatation  of  the  right 
ventricle.  The  aortic  valves  were  fringed  with  numerous  warty  vegetations.  One 
of  the  valves  was  ruptured,  and  the  ruptured  edges  were  studded  over  with  granules 
of  recen!:  exudation.  In  consequence  of  these  lesions,  the  valves  allowed  water  to 
rush  rapidly  through,  when  poured  on  them  from  abo^■e.  The  septal  leaf  of  the 
mitral  valve  was  perforated  in  two  places  by  orifices  of  sufficient  size  to  admit  a ciow 
quill.  These  orifices  were  surrounded  by  vegetations,  piesenting  a funnel-shaped 
prolongation  on  the  internal  surface  of  the  valve,  thiough  which  the  orifice  passes. 
There  were  several  other  vegetations  on  the  opposite  leaf  of  the  valve  and  fringing 
its  margin.  One  of  the  chordae  tendineae  was  broken  across  at  its  valvular  attach- 
ment, the  ruptured  or  floating  end  being  thickly  covered  with  fibrinous  vegetations. 
Aorta  healthy.  The  lower,  middle,  and  a portion  of  upper  lobe  of  right  lung  dense, 
hepatized,  presenting  a reddish-grey  color,  and  yielding  sanguineous  pus  on  squeezing 
the  cut  surfiice. 

Abdomen. — Abdominal  organs  healthy. 

Commentary.— the  cases  now  detailed  exhibit  very  strongly 
how  the  rules  formerly  mentioned,  correctly  applied,  enable  us  to  de- 
termine the  nature  of  the  cardiac  lesion  present — for  you  will  remember 
that,  in  both,  the  lesions  named  at  the  head  of  each  case  were  con- 
fidently stated  to  exist  before  the  body  was  examined.  In  case  CIV. 
“ a bellows  murmur  was  heard  with  the  second  sound,  loudest  at  the 
base  of  the  heart,  and  propagated  in  the  course  of  the  large  arteries.” 
Kule  5 tells  us  that  this  indicates  aortic  insuflSciency,  and  on  examina- 
tion such  was  found  to  exist.  As  the  case  progressed,  however,  he  com- 
plained of  a pulsation  in  his  throat  and  of  dysphagia;  and  it  is  worthy 
cf  remark,  that  not  only  had  an  incipient  aneurism  formed  in  the  arch  of 


VALVULAR  DISEASES  OF  THE  HEART. 


579 


tlie  aorta,  which  explained  these  symptoms,  but  that  a tendency  to  the 
formation  of  aneurisms  existed  in  other  parts  of  the  arterial  system.  In 
case  CV.  the  diagnosis,  though  more  complicated,  and  therefore  more 
difficult,  was  also  determined  on  by  paying  attention  to  the  same  rules. 
“ Over  the  apex  a bellows  murmur  was  heard  with  both  sounds  of  the 
heart.”  Now  rule  G tells  us  that  this  indicates  mitral  obstruction  with 
insufficiency,  and  a description  of  the  lesion  found  affecting  this  valve 
after  death,  must  convince  us  that  whilst  the  vegetations  prevented 
proper  closure  of  the  orifice,  some  of  them  must  also  have  obstructed  the 
flow  of  blood  in  its  passage  from  the  auricle  to  the  ventricle.  But  there 
was  also  a bellows  murmur  with  the  second  sound,  heard  loudest  at  the 
base;  and  this,  as  in  Case  CIV.,  is  a sign  of  aortic  insufficiency.  A 
careful  determination  of  the  cardiac  signs,  therefore,  and  an  exact  appre- 
ciation of  the  facts  in  the  first  instance,  led  us,  in  accordance  with  the 
laws  previously  generalized,  to  a correct  conclusion  as  to  the  nature  of 
this  complicated  case.  No  two  cases  could  better  convince  you  of  the 
diagnostic  value  of  physical  signs.  The  treatment  in  the  last  case  is 
what  I should  now  consider  as  far  too  depletory.  On  looking  back  to  it 
after  fourteen  years’  additional  experience,  it  will  be  observed  that  it 
confinns  all  that  I have  previously  stated  as  to  the  inutility  of  such  prac- 
tice. The  hard  pulse  of  the  pneumonia  which  ushered  in  death,  was 
evidently  caused  by  the  aortic  disease,  in  the  same  manner  that  a similar 
complication  in  the  course  of  pericarditis  was  attended  with  the  same 
symptom.  (See  Case  XCIX.) 

Case  CVI.^ — Incompetency  of  Mitral  Valve. 

History. — Agnes  Murray,  get.  41 — admitted  June  16th,  1860.  About  eighteen 
months  ago  she  first  experienced,  without  any  obvious  cause,  palpitations  and  pains  in 
the  cardiac  region,  which  have  continued  ever  since.  They  became  more  violent  after 
exertion,  and  were  accompanied  by  dyspnoea.  Latterly  there  has  been  an  oedematous 
swelling  of  the  legs,  abdomen,  and  face.  She  has  had  four  attacks  of  hg0mopt5’sis, 
the  first  occurring  eighteen  months  and  the  last  three  months  ago. 

Symptoms  on  Admission. — The  cardiac  dulness  measures  two  and  a quarter  inches 
across.  The  apex  of  the  heart  beats  under  the  sixth  rib,  below  and  a little  outside 
the  nipple.  Over  the  apex  there  is  heard  a harsh  bellows  murmur,  which  diminishes 
in  intensity  towards  the  base  and  large  vessels.  Pulse  80,  weak.  Great  dyspnoea  and 
palpitation  on  exertion,  and  occasional  severe  pain  in  the  cardiac  region.  Resonance 
of  lungs  natural.  Posteriorly,  over  right  lung,  loud  sibilant  murmurs  are  heard,  both 
with  inspiration  and  expiration.  Expectoration  abundant.  No  anasarca  at  present,  or 
cerebral  symptoms. 

Progress  op  the  Case. — This  woman,  under  the  action  of  small  doses  of  digitalis 
and  cream  of  tartar,  and  the  occasional  application  of  a few  leeches  to  the  cardiac 
region,  became  gradually  much  better.  The  palpitations,  dyspnoea,  and  bronchitis  dis- 
appeared. She  was  dismissed  greatly  relieved,  July  16th. 

Case  CVII.f — Incompetency  of  Mitral  Valve — Pulmonary  Hemor- 
rliage — Hydrothorax. 

History. — Robert  Ross,  get.  30,  a lath-splitter — admitted  June  28th,  1850.  For 
some  time  past  he  has  occasionally  experienced  palpitation,  and  observed  now  and 
then  slight  swelling  of  the  legs.  He  first  became  severely  ill  only  seven  weeks  ago, 
when  he  was  seized  with  repeated  vomitings,  which  continued  two  days.  He  sub- 

* Reported  by  Mr.  Edmund  S.  Wason,  Clinical  Clerk, 
f Reported  by  Mr.  David  Christison,  Clinical  Clerk. 


580 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


sequently  caught  cold,  to  which  he  is  very  liable,  and  since  then  has  been  laboring 
under  cough,  dyspnoea,  a feeling  of  tightness  across  the  upper  part  of  the  abdomen,  and 
general  weakness. 

Symptoms  on  Admission. — Cardiac  dulness  cannot  be  distinctly  defined.  The 
apex  beats  feebly  between  the  fifth  and  sixth  ribs,  two  inches  below  the  nipple.  A 
bellows  murmur  is  heard  with  the  first  sound  over  the  apex,  but  much  more  dis- 
tinctly three  inches  to  the  right  of  it,  near  the  sternum.  It  is  almost  inaudible  over 
the  base.  The  second  sound  is  normal.  Pulse  100,  small  and  soft.  Considerable 
dyspnoea  and  cough  ; sputa  viscid  and  tinged  with  blood.  No  dulness  on  percussion 
over  the  lungs.  Sibilant,  mucous,  and  crepitating  rales  are  heard  very  generally 
over  the  inferior  parts  of  chest,  both  anteriorly  and  posteriorly.  No  increase  of 
vocal  resonance.  The  general  surface  is  slightly  jaundiced.  On  careful  percussion 
of  the  liver,  its  inferior  border  presents  a prominence,  anteriorly  the  size  of  an  egg, 
over  the  pylorus. 

Progress  op  the  Case. — Up  to  the  8d  of  July  there  was  occasional  vomiting. 
The  inferior  extremities  became  oedematous,  and  fluid  accumulated  in  the  abdomen. 
On  percussion  the  resonance  over  the  right  lung  is  diminished  as  high  as  the  scapula; 
there  is  a slight  increase  of  the  vocal  resonance.  On  the  8th  of  July  the  surface 
generally  was  anasarcous.  From  the  10th  to  the  15th,  the  dyspnoea  greatly  increased. 
He  expectorated  on  various  occasions  mouthfuls  of  florid  blood.  Latterly,  he  could 
only  lie  on  the  left  side.  The  left  side  of  the  chest  became  completely  dull  on  per- 
cussion, with  absence  of  respiration.  He  was  now  removed  from  the  Infirmary  by  his 
friends.  Leeches  to  the  epigastrium,  with  naphtha  and  anodynes  internally,  checked 
the  vomiting.  The  principal  object  of  the  treatment,  however,  was  by  means  of 
diuretics,  to  increase  the  amount  of  urine,  and  thereby  diminish  the  anasarca.  Pills 
of  lead  and  opium  were  also  administered  to  check  the  haemoptysis. 

Commentary. — The  two  last  cases  contrast  very  strongly  with  the 
two  first.  In  both,  the  bellows  murmur  was  heard  only  with  the  first 
sound,  loud  over  the  apex,  diminishing  towards  the  base  ; and  rule  4 
tells  us  that  this  indicates  mitral  incompetency.  The  concomitant 
symptoms  fully  bear  out  this  diagnosis.  The  pulse  was  weak, — the  pul- 
monary organs  were  those  disturbed,  while  the  cerebral  functions  were 
unaffected.  In  Case  CVI.  there  was  bronchitis  which  diminished  under 
appropriate  treatment.  In  Case  CVII.  bronchitis  also  existed,  but  it 
was  much  more  general,  and  mingled  with  a certain  degree  of  collapse 
of  the  lung  on  the  right  side.  Extravasation  of  blood  into  the  pulmonary 
itissue  of  both  lungs  had  most  probably  also  taken  place,  as  indicated  by 
the  haemoptysis;  and,  latterly,  the  general  dropsy  which  prevailed 
affected  the  thoracic  cavities,  causing  hydrothorax  on  the  left  side.  The 
man  was  evidently  in  a dying  condition  when  his  friends  insisted  on  his 
removal ; and  I was  rather  surprised  to  hear  that  he  lingered  a fortnight 
before  death  took  place.  No  examination  could  be  obtained. 

Case  CVIII.'^ — Mitral  Incompetency — Hypertrophy  of  left  Ventricle 

— Attack  of  Acute  Rheumatism.^  followed  hy  Aortic  Incom^ 

potency. 

History. — John  Conolly,  mt.  49,  a joiner — admitted  June  22d,  1850.  He  has 
for  some  years  past  been  subject  to  pain  in,  and  swelling  of,  the  joints.  Eighteen 
months  ago  he  was  suddenly  seized  with  pain  in  the  cardiac  region,  unaccompanied 
by  dyspnoea,  but  followed  by  severe  cough.  He  has  been  copiously  bled,  and  under- 
gone a lengthened  treatment. 

Symptoms  on  Admission. — The  cardiac  dulness  measures  2f  inches  across.  The 
apex  beats  in  a hollow  between  the  xiphoid  cartilage  and  the  cartilage  of  the  seventh 
left  rib.  Heart’s  impulse  strong.  A bellows  murmur  can  be  heard  with  the  first 
sound,  synchronous  with  the  cardiac  impulse.  It  is  loudest  at  the  apex,  and  dimi- 
nishes in  intensity  towards  the  base.  Pulse  74,  full  and  strong.  No  cough,  but 


* Reported  by  Mr.  Charles  Murchison,  Clinical  Clerk. 


valvular  diseases  of  the  heart. 


581 


considerable  dyspnoea  on  making  the  slightest  exertion.  Percussion  and  auscultation 
indicate  slight  pulmonary  emphysema  anteriorly,  but  no  bronchitis.  _ Slight  tinnitus 
aurium,  and  dimness  of  vision  occasionally.  There  is  a patch  of  psoriasis  Jigurata^  an 
‘inch  and  a half  in  diameter,  on  the  right  cheek  and  side  of  the  nose. 

Progress  of  the  Case. — July  1st,  he  was  attacked  with  severe  articular  rheumatism 
in  the  hip,  knee,  and  wrist  joints,  which  had  entirely  disappeared  under  appropriate 
treatment  on  the  9th.  On  the  14th  he  had  diarrhoea,  accompanied  by  considerable 
dischat'o-e  of  blood  per  anum.  This  continued  in  smaller  quantities  from  time  to  time. 
On  the°22d,  a careful  examination  exhibited  a change  in  the  cardiac  signs.  The  im- 
pulse over  the  apex  was  more  prolonged,  with  a deep  murmur  and  jog.  The  bellows 
murmur  synchronous  with  the  impulse  was  no  longer  audible,  but  one  can  be  heard 
alternating  with  it  at  the  base — that  is,  with  the  second  sound.  Great  pulsation  of  the 
carotid,  subclavian,  and  humeral  arteries  was  seen  and  felt,  and  a loud  puffing  murmur, 
synchronous  with  their  dilatation,  could  be  heard  over  them.  His  general  health,  how- 
ever, was  greatly  improved,  the  local  and  other  symptoms  have  disappeared ; and  he 
left  the  house  at  his  own  desire,  July  24th.  At  first  he  took  digitalis  for  six  days, 
with  a view  of  diminishing  the  cardiac  impulse  and  pain.  It  was  then  suspended  on 
account  of  the  nausea  and  weakness  it  apparently  occasioned.  The  rheumatic  fever  and 
arteritis  were  combated  by  salines,  diaphoretics,  and  venesection  to  the  extent  of  3 xij. 
Afterwards  the  local  pains  rapidly  yielded  to  small  blisters  placed  over  each  affected 
joint.  The  diarrhoea  and  discharge  of  blood  were  checked  by  pills  of  lead  and  opium. 

Commentary. — This  man,  after  frequent  attacks  of  rheumatism,  entered 
the  Infirmary  laboring  under  hypertrophy,  with  incompetency  of  the 
mitral  valve.  At  the  time  there  was  no  bronchitis,  but  he  had  previously 
suffered  from  severe  cough  and  pulmonary  derangement.  Whilst  in  the 
house,  one  of  the  acute  rheumatic  attacks  came  on.  Many  of  the  joints 
were  swollen  and  exceedingly  painful.  This  affection  was  treated  by 
one  small  general  bleeding,  tartar  emetic  internally,  and  blisters  locally. 
The  effect  of  this  attack  was  to  give  rise  to  acute  endocarditis,  which, 
instead  of  affecting  the  auriculo-ventricular  orifice  formerly  diseased, 
fixed  itself  upon  the  aortic  valves.  This  lesion,  however,  must  have 
been  slight — probably  limited  to  a few  small  vegetations  upon  the 
margins  of  the  valve — because  the  murmur  was  soft  in  character,  and 
the  incompetency  not  of  such  amount  as  to  occasion  either  cerebral  or 
other  functional  symptoms.  The  pulsation  in  the  large  vessels,  how- 
ever, was  greatly  augmented,  and  there  is  every  reason  to  fear,  that 
should  the  incompetency  continue  (as  is  most  probable),  the  aorta  and 
cavity  of  the  left  ventricle  will  both  become  dilated. 

Case  CIX.* — Mitral  Incompetency— -Hypertrophy  of  Left  Ventricle — 
Aortic  Incompetency  and  Obstruction — Angina, 

History. — Edward  Monro,  get.  41,  a painter — admitted  June  24,  1850.  Two  years 
ago,  without  any  assignable  cause,  he  was  suddenly  seized  with  angina,  consisting  of 
severe  pain  in  the  middle  of  the  sternum,  often  running  down  the  left  arm,  accompanied 
by  violent  palpitations.  Since  then  the  paroxysms  have  been  increasing  both  in  fre- 
quency and  intensity. 

Symptoms  on  Admission. — The  cardiac  dulness  below  the  nipple  measures  three  and 
a quarter  inches  transversely.  The  apex  of  the  heart  cannot  be  felt  to  beat  at  any  par- 
ticular spot.  Heart’s  action  is  regular.  A distinct  bellows  murmur  can  be  heard  ac- 
companying both  the  first  and  second  cardiac  sounds,  which  are  equally  loud  at  the 
apex  and  at  the  base.  Both  are  heard  loudest  to  the  right  of  sternum,  opposite  the 
second,  third,  and  fourth  costal  cartilages.  A loud  blowing  murmur  is  heard  over  the 
carotid  arteries.  Pulse  74,  regular.  Has  a slight  cough  with  expectoration.  Lungs 
resonant  cn  percussion,  and  on  auscultation  the  inspiratory  murmurs  are  louder  and 
rougher  than  natural,  and  the  expiration  is  slightly  prolonged.  He  has  frequently  ex 


* Reported  by  Mr.  Charles  Murchison,  Clinical  Clerk. 


582 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


pectorated  small  quantities  of  dark-colored  blood.  There  is  great  dyspnoea  on  making 
the  slightest  exertion,  and  he  has  occasional  severe  attacks  of  angina.  There  is  con- 
sideral)le  dyspepsia.  Slight  dimness  of  vision,  and  muscae  volitantes,  but  otherwise  no 
cerebral  symptoms. 

Progress  of  the  Case. — The  attacks  of  angina  returned  four  or  five  times  a day. 
They  occasioned  great  agony,  profuse  perspiration,  and  increased  action  of  the  heart, 
during  which  the  murmurs  were  heard  louder.  There  was  also  occasional  nausea  and 
tendency  to  vomit.  On  the  8th  of  July  he  fainted,  being  unconscious  for  five  minutes. 
At  this  time  the  murmur  with  the  first  sound  assumed  a whining  character,  heard 
loudest  at  the  apex.  There  was  a double  bellows  murmur  heard  distinct  from  this,  at 
the  base.  July  Wth. — There  w^as  cough  and  expectoration.  A fine  moist  rale  could 
be  heard  over  the  lower  half  of  left  chest,  both  anteriorly  and  posteriorly.  No  dulness 
on  percussion,  or  increased  vocal  resonance.  July  lUh. — He  has  now  only  one  attack 
of  angina  in  the  day  which  is  also  much  less  severe.  The  cough  and  expectoration 
are  diminished.  A mucous  rale  still  perceptible  in  left  lung  inferiorly.  A whining 
murmur  with  the  first  sound  is  still  heard  at  the  apex,  and  a double  bellows  murmur  at 
the  base,  propagated  in  the  course  of  the  great  vessels.  He  left  the  house  at  his  own 
desire.  The  attacks  of  angina  were  at  first  treated  with  anodyne  and  antispasmodic 
draughts  containing  Ti[,v.  of  chloroform  for  a dose.  Afterwards  they  were  greatly  re- 
lieved by  taking  carminatives,  such  as  three  drops  of  each  of  the  oils  of  aniseed  and 
cajeput  dropped  on  sugar.  Latterly  they  greatly  diminished  after  § vj  of  blood  w'ere 
drawn  from  the  cardiac  region  by  cupping.  The  bronchitis  was  treated  with  anodynes 
and  expectorants. 

Commentary . — When  this  man  entered  the  Infirmary  it  was  very 
difficult  to  determine  at  what  point  the  two  bellows  murmurs  were  heard 
loudest.  Repeated  and  careful  examination  failed  to  discover  whether 
one  or  both  were  referable  to  the  apex  or  to  the  base  ; and  in  consequence 
we  could  not,  according  to  the  rules  given,  determine  whether  the  disease 
was  aortic,  mitral,  or  both.  This  was  probably  owing  to  the  circum- 
stance of  the  abnormal  murmurs  originating  in  two  places,  and  being  at 
the  same  time  so  similar  in  tone,  that  the  diffusion  of  sound  was  pretty 
equal  over  the  whole  cardiac  region.  But  as  the  case  progressed,  the 
murmurs  underwent  such  modifications  as  left  us  in  no  doubt.  The 
murmur  with  the  first  sound  over  the  apex  assumed  a whining  tone  so 
that  it  was  easily  separated  from  the  double  bellows  murmur  which 
still  remained  loud  at  the  base.  The  former,  according  to  the  rules  given, 
must  have  depended  on  mitral  incompetency ; whilst  the  latter,  for  the 
same  reason,  must  have  been  owing  both  to  incompetency  and  obstruction 
of  the  aortic  orifice.  The  man  labored  under  slight  pulmonary,  as  well 
as  cerebral,  symptoms.  His  chief  complaint,  however,  was  the  angina, 
the  attacks  of  which  were  in  him  very  severe,  causing  the  most  excrucia- 
ting agony  and  bathing  the  whole  surface  with  sweat.  This,  in  its  turn, 
seemed  to  be  connected  with  a state  of  dyspepsia  which  existed.  When- 
ever gas  accumulated  in  the  stomach,  so  as  to  distend  that  organ  and 
press  the  heart  upwards,  the  attacks  were  most  severe.  The  carminatives 
gave  relief  by  causing  discharge  of  this  gas.  After  local  bleeding,  and 
an  improvement  in  his  general  health,  but  more  especially  in  the  dyspeptic 
symptoms,  the  angina  diminished  in  intensity. 

The  two  last  cases  recorded  exhibit  how  important  it  is  carefully  to 
examine  the  cardiac  signs  from  time  to  time  as  the  case  progresses,  and 
to  watch  the  modifications  they  undergo.  Where  doubt  and  difficulty 
prevail,  it  is  only  in  this  way  they  can  be  removed.  Under  such  cir- 
cumstances, never  state  an  opinion  at  all,  but  continue  to  watch  until  the 
signs  become  permanent  and  unequivocal.  This  advice  you  will  find  to 


VALVULAR  DISEASES  OF  THE  HEART. 


583 


be  even  more  useful  in  private  than  in  hospital  practice,  for  reasons 
which  I shall  allude  to  hereafter.  But  not  only  are  frequent  examina- 
tions useful  in  clearing  up  difficult  points  in  diagnosis,  they  also  reveal 
to  the  pathologist  the  changes  which  take  place  in  the  affected  parts. 
Of  this  the  following  case  affords  us  an  instructive  example. 

Case  CX.* — Incompetency  of  the  Aortic  Valves  with  Musical  Murmur — 
Hypertrophy  with  Dilatation  of  Left  Ventricle — Pneumonia — Pulmon- 
ary Hemorrhage. 

History. — William  Caird,  aet.  29,  laborer — admitted  May  30,  1850.  Five  months 
ago  he  first  noticed  that  he  became  unusually  breathless,  and  had  palpitations  after 
exertion.  He  continued  to  work  until  two  months  ago,  when,  being  engaged  in  lifting 
heavy  stones,  he  was  suddenly  seized  with  pain  in  the  cardiac  region,  violent  cough, 
and  haemoptysis.  He  entered  the  Glasgow  Infirmary,  from  which  he  was  discharged, 
much  relieved,  in  a fortnight.  Since  then  he  has  been  subject  to  giddiness,  dyspnoea, 
and  palpitation,  with  occasional  haemoptysis. 

Symptoms  on  Admission. — Cardiac  dulness  extends  three  and  three  quarter  inches 
transversely.  The  apex  beats  between  the  sixth  and  seventh  ribs,  three  inches  below, 
and  a little  to  the  left  of  the  nipple.  A bellows  murmur  is  heard  with  the  second  sound, 
loudest  at  the  base,  and  propagated  in  the  course  of  the  large  vessels.  The  first  sound 
is  normal.  Pulse  92,  strong  and  regular.  He  feels  a shooting  pain  in  the  cardiac 
region,  extending  to  the  epigastrium.  There  is  great  dyspnoea,  and  palpitation  on  ex- 
ertion. Slight  cough,  and  fine  moist  rale  in  both  lungs,  heard  inferiorly  and  posteriorly. 
Occasional  giddiness. 

Progress  oe  the  Case. — The  pain  in  the  cardiac  region  and  epigastrium  was  the 
chief  source  of  complaint  during  the  progress  of  the  case.  The  dyspnoea  and  palpitations 
were  from  time  to  time  distressing.  There  was  occasional  vomiting.  On  the  12th  of 
July,  it  was  observed  that  the  bellows  murmur  assumed  a whining  character,  and  on 
the  15  th  it  was  distinctly  musical,  like  the  chirping  of  a small  bird.  On  the  l'7th,  the 
heart’s  action  was  tumultuous,  and  vomiting  was  very  distressing.  On  the  23d  there 
was  considerable  haemoptysis,  mouthfuls  of  blood  being  evacuated.  On  the  24th,  there 
was  dulness  on  percussion,  over  the  inferior  portion  of  chest,  and  distinct  crepitation 
could  be  heard  with  increased  vocal  resonance  The  cardiac  dulness  was  determined, 
on  careful  percussion,  to  measure  five  inches  transversly.  The  vomiting  and  haemop 
tysis  defied  all  remedies.  The  pulse  was  100,  soft.  He  gradually  became  weaker.  The 
urine  was  scanty,  and  oedema  of  the  legs  appeared.  Latterly  there  was  muttering 
delirium  at  night.  Died  on  the  29th.  At  first  he  experienced  relief  from  the  cardiac 
and  epigastric  pains,  after  small  local  bleedings  by  means  of  leeches  and  cupping. 
Blisters  were  also  applied.  All  kinds  of  remedies  were  tried  to  check  the  vomiting, 
but  with  little  effect.  Antispasmodics  were  employed  to  relieve  the  dyspnoea ; and 
latterly  as  the  pulse  became  weak,  wine  and  stimulants  were  freely  administered. 

Sectio  Cadaveris. — Thirty  hours  after  death. 

Thorax. — Heart  much  enlarged,  weighing  25  ounces,  owing  almost  entirely  to 
hypertrophy  with  dilatation  of  the  left  ventricle.  When  water  was  poured  upon  the 
aortic  valves  from  above,  it  passed  rapidly  through  the  orifice.  The  aortic  valves  were 
thickened  throughout  and  shortened ; their  eurled-in  and  dense  margins  were  one-tenth 
of  an  inch  thick.  Two  of  the  valves  were  united  at  their  neighboring  surfaces,  so  as 
to  form  one,  the  only  vestige  of  a septum  between  them  being  a hardened  nodule  at 
the  base  of  the  enlarged  valve.  On  the  edge  of  the  smaller  valve  was  a warty  excres- 
cence, the  size  of  a coffee  bean,  soft  in  consistence,  composed  of  recent  exudation, 
and  infiltrated  with  blood,  so  as  to  present  a purple  color.  There  was  red  hepatization 
of  the  posterior  and  inferior  portion  of  both  lungs,  and  there  was  considerable  apo- 
plectic extravasation  in  the  substance  and  the  neighborhood  of  the  diseased  portions 
of  the  lung.  The  bronchi  were  filled  with  frothy  mucus. 

Abdomen. — The  liver  presented  the  nutmeg  appearance,  being  in  the  first  stage  of 
cirrhosis.  Other  organs  healthy. 

Commentary. — We  had  very  little  difficulty  in  determining,  from  the 
* Reported  by  Mr.  David  Christison,  Clinical  Clerk. 


584 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


cardiac  signs  in  this  case,  that,  according  to  the  rules  laid  down,  there 
was  incompetency  of  the  aortic  valves,  with  dilated  hypertrophy  of  the 
left  ventricle.  The  bellows  murmur,  which  was  at  first  soft,  gradually 
changed  its  character  as  the  case  progressed,  without  altering  its  position. 
It  became  whining,  and  then  chirping,  constituting  what  is  called  a 
musical  murmur.  It  is  generally  found  in  such  cases  that  a solid  body 
projects  into  the  current  of  the  blood  as  it  flows  through  the  valve,  so  as 
to  be  thrown  into  vibrations ; and  it  was  interesting  to  discover,  on  the 
examination  of  the  body,  that  the  vegetation  described  exactly  fulfilled 
these  conditions.  From  its  softness,  also,  there  is  every  reason  to  sup- 
pose it  was  of  recent  formation,  originating  probably  about  the  time  the 
musical  murmur  was  first  observed.  From  the  great  induration  of  the 
aortic  valves,  there  can  be  very  little  doubt  that  they  had  been  afiected 
for  a long  time,  at  least  many  months ; but  it  becomes  a question, 
whether  the  adhesion  and  formation  of  one  valve  out  of  two  might  cot 
have  been  caused  by  a rupture  of  one  or  both  valves,  two  months  pre- 
viously, at  the  time  he  was  lifting  heavy  stones,  and  was  suddenly  seized 
with  cardiac  pain  and  other  symptoms.  It  is  worthy  of  observation, 
also,  that,  although  he  had  cerebral  symptoms,  the  lungs  were  greatly 
afi’ected,  the  bronchitis  latterly  passing  into  pneumonia  with  pulmonary 
hemorrhage. 

Case  CXI.'^ — Mitral  Incompetenmj — Hypertrophy  of  Left  Ventricle — 
Dilatation  and  Disease  of  Arch  of  Aorta — Aortic  Incompetency, 

History. — Hugh  Devine,  let.  40,  laborer — admitted  July  IV,  1850.  Dates  his 
illness  from  a severe  strain  of  the  back,  eighteen  months  ago,  but  is  not  sure  when  he 
first  noticed  dyspnoea  and  palpitation,  which  have  prevented  him  from  working  for 
the  last  eight  months.  Never  had  rheumatism  or  haemoptysis. 

Symptoms  on  Admission. — Cardiac  dulness  measures  two  and  three  quarter  inches 
transversely.  The  apex  beats  between  the  fifth  and  sixth  ribs,  two  inches  below  and  a 
little  to  the  right  of  the  nipple.  A bellows  murmur  with  the  first  sound  is  heard  at 
the  apex  decreasing  towards  the  base.  A bellows  murmur  of  a rougher  character  is 
also  heard  with  the  first  sound  at  the  base,  which  is  prolonged  in  the  course  of  the  large 
vessels.  The  second  sound  is  normal.  There  is  distinct  pulsation  under  the  clavicles, 
but  none  above  the  sternum.  Pulse  104,  regular,  full,  and  jerking.  No  cough  or 
pulmonary  symptoms,  with  the  exception  of  dyspnoea  on  exertion.  Has  frequent  pain 
in  the  upper  part  of  the  head  and  across  the  temples,  and  occasional  dimness  of  vision. 
The  thyroid  gland  is  somewhat  enlarged. 

Progress  op  the  Case. — Since  his  residence  in  the  Infirmary  the  symptoms  have 
been  greatly  ameliorated.  The  dyspnoea,  palpitation,  and  cephalalgia,  have  nearly 
disappeared.  The  cardiac  signs,  however,  have  undergone  considerable  change.  On 
the  16th  of  August  it  is  reported  that  there  is  still  a bellows  murmur  with  the  first 
sound,  heard  loud  at  the  apex.  An  inch  above,  and  to  the  inside  of  the  nipple,  a loud, 
harsh,  grating  murmur  is  beard  with  the  first  sound,  and  followed  by  a soft  bellows 
murmur  with  the  second.  In  the  course  of  the  aorta  there  is  unusual  impulse,  and 
coinciding  with  it  there  is  a bellows  murmur,  which  is  propagated  along  the  carotids. 
He  was  dismissed,  September  12th. 

Commentary. — This  man  was  examined  with  great  care,  and  cardiac 
signs  ascertained  to  exist  which  are  not  often  associated  together.  For 
instance,  there  was  a distinct  bellows  murmur,  loud  over  the  apex  and 
diminishing  towards  the  base,  which,  according  to  the  rules  given,  we 
ascribed  to  mitral  incompetency.  Over  the  aortic  valves,  however,  and 


* Reported  by  Mr.  David  Christison,  Clinical  Clerk. 


VALVULAR  DISEASES  OF  THE  HEART. 


585 


extending  along  the  arch  of  the  aorta,  there  was  a bellows  murmur  of  a 
rougher  character,  and  also  occurring  with  the  first  sound.  Now,  rule  7 
tells  us  that  this  may  depend  on  three  circumstances, — “ 1st,  On  an 
altered  condition  of  the  blood,  as  in  anaemia : 2d,  On  dilatation  or  dis- 
ease of  the  aorta  itself;  or,  3d,  On  stricture  of  the  aortic  orifice,  in 
which  case  it  is  almost  always  associated  with  insufficiency,  and  then 
the  murmur  is  double.”  It  is  clear  that  the  first  and  third  propositions 
would  not  apply,  and  I therefore  came  to  the  conclusion  that  in  addition 
to  mitral  regurgitation,  the  aorta  was  dilated  and  diseased,  the  former 
indicated  by  the  increased  impulse,  and  the  latter  by  the  roughened 
murmur.  Latterly,  when  dismissed,  the  roughened  murmur  over  the 
aorta  assumed  a rasping  character,  and  a soft  bellows  murmur  was  also 
heard  with  the  second  sound — so  that  the  dilated  and  diseased  aorta  had 
at  that  time  probably  become  associated  with  aortic  incompetency. 

Case  CXII.^ — Great  constriction  of  Mitral  Orifice — Dyspnceay  Palpita- 
tions^ Cough,  and  Ilcenioptifsis — Loud  Free- Systolic  {or  Diastolic- 
Mitral)  Murmur — Death  following  Abortion — Enlargement  of  the  two 
Auricles  and  right  Ventricle — Atrophy  of  left  Ventricidar  walls. 

History. — Ann  Laurie,  aet.  19,  a servant — admitted  May  2d,  1859.  Says  that  she 
has  always  enjoyed  good  health  until  four  years  ago,  when  she  first  observed  herself 
to  become  breathless  on  making  any  unusual  exertion.  Six  months  afterwards  breath- 
lessness became  much  worse,  and  she  experienced  violent  palpitations  of  the  heart 
when  working.  Cough  and  haemoptysis  now  occurred,  for  which  she  entered  the  In- 
firmary, and  went  out  in  a month  nearly  well.  Eighteen  months  ago  these  symptoms 
returned,  and  she  again  entered  the  Infirmary,  was  once  more  relieved,  and  has  re- 
mained pretty  well  until  a week  ago,  when  the  violent  coughing  and  spitting  of  blood 
returned,  and  have  continued  up  to  this  time. 

Symptoms  on  Admission. — There  is  great  dyspnoea,  frequent  cough,  with  copious 
frothy  sputum  mixed  with  mouthfuls  of  pure  blood.  Pulse  96,  weak.  Complains  of 
excessive  palpitations.  Heart’s  action  strong;  impulse  between  the  fifth  and  sixth 
ribs,  an  inch  below  and  in  a line  with  the  nipple.  A loud  prae-systolic  murmur  is 
heard  at  the  apex  on  auscultation.  Dry  and  moist  bronchial  sounds,  with  prolonged 
expiration  heard  over  the  whole  chest.  Face  anxious,  clammy  sweat  on  the  surface. 
Is  a well-nourished  girl.  No  appetite.  Great  thirst.  Diarrhoea,  having  6 or  7 stools 
daily,  with  tormina.  Starts  during  her  sleep,  and  is  subject  to  dreams.  Other  systems 
normal.  To  have  two  table-spoonfuls  of  the  chalk  and  catechu  mixture  three  times  daily. 
Quietness  and  rest  enjoined. 

Progress  of  the  Case. — May  Ath. — Diarrhoea  has  ceased.  Other  symptoms  alle- 
viated. On  carefully  examining  the  heart  it  was  ascertained  that  the  transverse  dul- 
ness  was  2^  inches ; that  there  existed  one  prolonged  hoarse-blowing  murmur,  occu- 
pying the  period  of  both  sounds,  and  terminating  suddenly  with  a jog,  immediately 
before  the  long  pause.  The  sound  also  increased  in  intensity  from  its  commence- 
ment to  its  close  at  the  moment  of  systole.  It  was  heard  loudest  immediately  below 
the  nipple,  and  over  a space  about  an  inch  and  a half  in  diameter  outside  it.  Over 
the  sternum  though  audible  it  was  distant.  At  the  base  of  the  heart  the  second 
sound  was  heard  quite  healthy.  May  &th. — Hgemoptysis  and  dyspnoea  had  ceased. 
Cough,  expectoration,  and  other  symptoms  greatly  ffiminished.  June  18^/i. — Has 
been  in  tolerably  good  health  since  last  report,  and  the  bronchial  signs  have  disap- 
peared, with  the  exception  of  prolonged  harsh  expiration.  Cardiac  sounds  the  same. 
To-day  she  complains  of  rheumatic  pains  in  various  parts  of  the  body ; and  it  would 
seem  that  in  consequence  of  exposing  herself  unnecessarily  in  the  lobbies  of  the  house, 
there  was  a rigor  last  night,  followed  by  febrile  symptoms.  There  are  now  pain  in  the 
chest,  dyspnoea,  cephalalgia,  and  increased  action  of  the  heart.  Venesectio  ad  5 iv^ 
June  IWi. — Bleeding  gave  great  relief  to  pains  in  head,  chest,  and  dyspnoea.  Has 

* Reported  by  Messrs.  Wm.  Willis,  and  J.  Broster,  Clinical  Clerks. 


586 


DISEASES  OF  THE  CIRCULATOKY  SYSTEM. 


rheumatic  pains  in  the  joints  of  lower  limbs,  which,  however,  are  not  swollen.  Warm 
fomentations  to  the  painful  parts.  June  2.%t1i. — The  rheumatic  pains  have  disap- 
peared for  four  days,  but  this  morning  haemoptysis  returned.  July  ^th. — Has  had  no 
haemoptysis  since  the  2d,  August  M. — Since  last  report  her  general  health  has  been 
excellent,  and  she  has  even  been  assisting  the  nurse  in  her  ward  duties.  Is  only  sub- 
ject to  occasional  palpitations.  Was  dismissed  with  careful  directions  as  to  how  she 
was  to  manage  herself. 

Re-admitted.^  February  13^A,  1860. — Has  on  the  whole  enjoyed  excellent  health 
since  she  left  the  house,  and  two  months  ago  was  married.  Three  weeks  since,  in 
consequence  of  the  roof  of  her  house  being  out  of  repair,  she  was,  during  a stormy 
night,  exposed  to  the  rain  and  wind,  which  entered  her  room,  and  she  took  a severe 
cold  which  induced  a return  of  all  her  bad  symptoms.  At  present  there  is  fever,  bron- 
chitis, with  great  dyspnoea  ; no  haemoptysis,  cardiac  palpitation,  the  prae-systolic  mur- 
mur as  loud  as  ever.  Pulse  90,  of  good  strength.  H Sp.  jEtlier.  Chloric.  3 iii ; 
Tr.  Card.  C.  |ss;  Aquamad  § iv.  A table-spoonful  to  he  taken  occasionally.  March 
hth. — I'he  acute  symptoms  have  subsided  for  some  time.  To-day  there  is  slight 
haemoptysis.  She  has  not  menstruated  for  two  months.  April  2\st. — Since  last  re- 
port has  been  on  the  whole  well,  although  from  time  to  time  there  has  been  slight 
haemoptysis.  To-day.  however,  she  suddenly  brought  up  about  § xxij  of  blood.  Or- 
dered to  remain  in  hed.^  and  to  suck  occasionally  a piece  of  ice.  April  Wth. — Haemoptysis 
has  ceased  ; again  feels  well ; cardiac  signs  the  same.  3fay  bth. — Last  night  she  was 
delivered  of  a four  months’  foetus,  and  expired  immediately  afterwards. 

Sectio  Cadaveris — Sixteen  hours  after  death. 

Thorax. — The  right  side  of  the  heart  was  much  enlarged,  in  part  forming  the  apex. 
Both  auricles  as  well  as  the  right  ventricle  were  dilated  and  hypertrophied.  The  left 
ventricle  normal  in  size,  its  walls  thinner  than  usual.  The  mitral  orifice  was  round 
and  constricted,  so  as  to  be  incapable  of  admitting  the  top  of  the  little  finger.  The 
chordae  tendineae  of  the  valves  were  glued  together  and  shortened.  The  aorta  was 
smaller  in  calibre  than  the  pulmonary  artery,  which  was  somewhat  dilated.  The  aortic 
valves  rvere  healthy.  The  heart  weighed  11  oz.  Slight  adhesions  of  the  pleurae  on 
both  sides.  No  recent  pulmonary  hemorrhage  into  the  lungs,  but  the  lower  lobe  of 
the  left  lung  was  firm  and  more  crepitant,  and  on  squeezing  it  after  section,  a purplish 
thick  fluid  escaped,  probably  the  result  of  old  hemorrhagic  extravasation. 

Abdomen. — Abdominal  organs  healthy.  The  uterus  enlarged  and  flaccid,  the  cervix 
presenting  an  ecchymosed  appearance. 

Commentary. — The  prge-systolic  murmur  heard  in  this  girl  was  un- 
usually loud,  and  consisted  of  a rushing  sound,  increasing  in  intensity 
until  it  was  suddenly  arrested  by  a knock  or  jog  synchronous  with  the 
systole.  It  exactly  occupied  the  period  of  both  sounds,  completely  mask- 
ing the  second  sound  at  the  apex,  although  at  the  base  the  latter  was 
heard  clearly,  following  the  impulse  as  usual.  In  this  manner,  at  the 
apex  there  was  audible  only  one  long  sound  and  one  pause,  both  of  equal 
length,  separated  from  one  another  by  the  abrupt  systole.  The  leading 
symptoms  were  palpitations  and  dyspnoea  on  exertion,  together  with  ten- 
dency to  bronchitis  on  exposure  to  cold,  with  haemoptysis.  There  is  every 
reason  to  suppose  that  the  cardiac  lesion  had  originated  in  rheumatism, 
as  she  was  strongly  predisposed  to  this  disease,  and  had  on  one  occasion 
a smart  attack  of  it  when  in  the  ward.  She  was  a remarkably  well-formed 
and  otherwise  healthy  girl,  the  appetite  generally  good,  and  nutrition  well 
performed.  Her  long  residence  in  the  Infirmary  gave  all  who  witnessed 
the  case  ample  opportunities  of  studying  the  physical  signs  and  symptoms 
which  it  presented,  and  it  was  observable  that  quietude,  non-exposure  to 
cold,  and  good  diet,  always  succeeded  in  restoring  her  to  good  health. 
Very  little  medication  was  required.  On  one  occasion  I ordered  a small 
bleeding  to  relieve  the  palpitation  and  great  congestion  of  the  lungs,  which 
it  succeeded  in  doing  at  once,  this  being — as  I pointed  out  in  1857,  when 


VALVULAR  DISEASES  OF  THE  HEART. 


687 


condemning  large  bleedings  in  the  treatment  of  pneumonia — a most 
valuable  result  of  the  practice  which  remained  to  us.  The  diagnosis,  of 
mitral  contraction,  was  evident  from  the  first,  and  how  long  she  might  have 
lived,  but  for  her  pregnancy,  it  is  of  course  difficult  to  determine.  This, 
by  enlarging  the  uterus,  and  thereby  causing  increased  embarrassment  to 
the  lungs,  must  have  produced  grave  results  at  no  distant  time.  Abor- 
tion, however,  occurred  about  the  fourth  month  of  utero-gestation ; and 
although  the  labor  pains  did  not  last  above  an  hour,  such  was  the  ex- 
haustion occasioned  that  fatal  syncope  occurred.  The  post-mortem 
examination  revealed  effects  not  uncommon  as  the  result  of  extreme  con- 
traction of  the  mitral  orifice — viz.,  diminution  in  i-he  size  and  thickness 
of  the  left  ventricle,  with  unaltered  aorta  and  aortic  valves,  while  the 
other  three  cavities,  together  with  the  pulmonary  artery,  were  dilated. 
The  dilated  cavities  are  at  once  accounted  for,  as  a result  of  the  obstruc- 
tion they  had  to  overcome  in  the  lung,  and  constricted  mitral  orifice; 
while  the  left  ventricle  often  remains  of  its  normal  size,  and  occasionally 
becomes  smaller,  or  is  atrophied,  as  occurred  in  the  case  before  us.  It 
was  pointed  out  by  Dr.  Jenner,  that  in  these  cases  the  muscular  tissue 
of  the  heart  must  be  congested,  in  consequence  of  the  pressure  on  the 
veins  producing,  as  he  thought,  peculiar  induration  and  toughness  of 
the  hypertrophied  walls.*  The  rushing  noise  heard  during  life,  previous 
to  the  systole,  could  leave  little  doubt  that  it  was  caused  by  the  passage 
of  tlie  blood  from  the  auricle  through  the  constricted  orifice ; and  it 
would  appear  that  after  this  the  left  ventricle  for  a long  time  must  have 
acted  quite  naturally,  as  it  was  observable  that  the  pulse  throughout  was 
of  good  strength,  never  irregular,  and  seldom  weak,  as  in  cases  of  incom- 
petency.  Latterly,  the  walls  of  the  ventricle  had  become  thinner,  show- 
ing that  the  extreme  contraction  of  the  mitral  orifice  not  only  acted  as  a 
perfect  valve,  during  systole,  but  must  have  so  removed  tension,  or  the 
necessity  for  great  exertion,  as  to  have  allowed  the  muscular  walls  of  the 
ventricle  to  become  atrophied.  Many  other  examples  of  contracted 
mitral  orifice,  with  prge-systolic  murmurs,  have  entered  the  wards;  in- 
deed, the  disease  is  far  from  uncommon,  although  Latham  considered  it 
a kind  of  cardiac  curiosity,  but  in  none  have  I ever  seen  it  proceed  to 
so  great  an  extent  before  death.  According  to  Skoda,  the  second  sound 
of  the  pulmonary  artery  is  apt  to  be  intensified  in  this  disease,  in  conse- 
quence of  the  increased  force  and  tension  thrown  upon  its  sigmoid 
valves.  No  doubt  the  second  sound  in  these  cases  is  often  heard 
unusually  clear,  but  cannot  be  separated  in  point  of  time  from  that  of 
the  aortic  valves. 

Case  CXIIl.f — Constriction  of  Mitral  and  Tricuspid  Orifices — Aortic  In- 
competence— Anasarca — Ihjdrothorax — Collapse  of  Left  Lung-— 
BrigMs  disease  of  Kidneg. 

History.— Elizabeth  King,  get.  26— admitted  July  20th,  1855.  T<vo  years  ago 
she  entered  this  hospital,  laboring  under  an  attack  of  acute  rheumatism ; was  dismissed 
relieved  at  the  end  of  six  weeks,  but  soon  afterwards  she  was  again  laid  off  work  by 
general  anasarca;  and  in  the  November  of  the  same  year  (1853)  she  again  returned  to 
this  Infirmary.  She  was  a patient  in  the  Clinical  Wards ; was  treated  for  double 

* See  Med.-Chir.  Trans,  of  London,  vol.  xliii. 

f Reported  by  Mr.  D.  M‘Gregor,  Clinical  Clerk. 


588 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


pneumonia ; was  recognised  at  that  time  to  labor  under  mitral  insufficiency ; was  much 
relieved  during  her  stay,  and  discharged  in  the  middle  of  February,  1854.  But  she 
has  never  recovered  her  strength.  Three  months  ago  she  became  affected  with  swell- 
ing of  the  legs  and  abdomen,  with  occasional  slight  lumbar  pain,  and  with  severe  pain 
in  the  hypogastric  region  attendant  upon  tiie  abdominal  swelling.  The  pain  and  the 
swelhng  nave  gradually  become  worse.  She  has  been  confined  to  bed  for  the  last  ten 
days. 

Symptoms  on  Admission. — Impulse  weak ; apex  beat  not  definable  • transverse 
dulness  three  and  a half  inches ; at  the  normal  site  of  apex  beat  there  is  a double 
blowing  murmur;  the  same  is  audible  all  the  way  up  to  the  clavicle,  but  it  diminishes 
in  intensity  from  below  upwards.  Pulse  86,  small  and  weak ; palpitation,  vertigo, 
slight  cough ; muco-purulent  expectoration ; dyspnoea  on  exertion,  with  occasionally 
orthopnoea  at  night;  face  slightly  livid,  with  a faint  tinge  of  yellow;  is  naturally 
freckled.  Has  great  thirst  and  little  appetite ; the  bowels  are  costive.  The  urine  is 
scanty,  of  an  orange-yellow  color;  sp.  gr.  1015;  is  not  albuminous.  The  lower  ex- 
tremities and  the  skin  over  the  hypogastric  region  are  oedematous,  tense  and  painful 
on  pressure.  Yesterday  had  severe  pain  in  the  right  iliac  passing  to  the  lumbar  region. 
Does  not  sleep  well  at  night. 

Progress  o?  the  Case. — The  pain  in  the  right  iliac  region  disappeared  under 
treatment  during  the  first  week.  Vomiting  occurred  at  every  meal  during  the  same 
period.  After  the  24th  July,  the  urine  contained  a large  quantity  of  bile,  and  the 
whole  body  became  slightly  jaundiced.  No  increase  in  urine  could  be  effected.  On 
the  9th  August  it  is  reported  very  scanty  and  albuminous.  The  anasarca  steadily 
increased,  with  painful  tension  of  limbs  and  abdomen.  Ultimately  the  whole  trunk, 
upper  extremities,  and  face  became  oedematous.  Respiration  became  more  embarrassed, 
and  over  the  upper  parts  puerile.  On  the  8th  August  there  were  signs  of  hydrothorax 
on  the  left  side.  The  dyspnoea,  cough,  sleeplessness,  and  want  of  nourishment  wore 
out  her  remaining  strength,  and  she  died  September  5th.  At  first,  leeches,  lollowed 
by  warm  fomentations,  were  applied  to  the  hypogastric  and  right  iliac  regions  to  relieve 
the  local  pain.  Sub^e  tuently,  diuretics  and  cathartics  were  employed  to  relieve  the 
anasarca,  combined  with  nutrients  and  latterly  stimulants. 

Sectio  Cadaveris. — Eighteen  hours  after  death. 

Body  extremely  anasarcous. 

Thorax. — Heart  weighed  10^  ounces,  lay  unusually  transverse,  with  apex  pointing 
to  left  side.  Tne  right  auricle  was  dilated,  especially  the  auricula  ; the  foramen  ovale 
within  the  annulus  was  not  patent,  but  the  membrane  was  pushed  back  into  a pouch ; 
its  lining  membrane  was  much  thickened.  The  tricuspid  valves  were  thickened  at 
their  margin,  and  so  constricted  that  the  first  joint  of  the  little  finger  up  to  the  root  of 
the  nail  could  alone  pass.  The  pulmonary  valves  were  quite  healthy.  The  left  auricle 
was  not  dilated ; the  mitral  valves  were  thickened  and  constricted  so  as  only  to  admit 
the  first  joint  of  the  little  finger  up  to  about  the  middle  of  the  nail ; the  tendinous  cords 
were  so  shortered  that  the  valves  appeared  to  be  fixed  directly  to  the  summit  of  the 
columnae  carneae.  The  aortic  valves  were  also  thickened  (more  at  the  margin  than  the 
base)  so  as  to  be  inelastic  and  incompetent.  Both  ventricles  hypertrophied  and  dilated. 
The  left  lung  was  collapsed  ; about  one  pint  and  a half  of  fluid  in  the  pleural  cavity. 
The  right  lung  was  adherent  throughout,  especially  at  the  base,  to  the  diaphragm  ; the 
diaphragm  itself  was  adherent  to  the  costal  pleura  from  the  sixth  rib  downwards.  On 
section,  the  lung  appeared  very  oedematous  in  some  portions,  and  in  others  collapsed. 

Abdomen. — The  liver  was  fatty ; weighed  2 lb.  10|  oz.  The  spleen  seemed  healthy. 
The  kidneys  were  atrophied,  especially  the  right,  which  weighed  2^  ounces ; and  on 
section  presented  a good  specimen  of  the  hard,  contracted,  and  granulated  kidney  of 
Bright.  In  the  left  kidney  only  one  cone  was  disorganized.  The  uterus  and  ovaries 
were  normal,  and  the  intestines  healthy. 

Case  CXIV."^ — Constriction  of  Mitral  and  Tricuspid  Orifices — (Edema — 
ELemorrhage  into  the  Limgs. 

History. — William  Page,  aet.  20,  ploughman — admitted  August  30th,  1852.  States 
that  nine  months  ago,  while  carrying  a heavy  sack  of  grain  on  his  back  up  a flight  of 


* Reported  by  Mr.  William  Calder  and  Mr.  David  Milroy,  Clinical  Clerks. 


VALVULAR  DISEASES  OF  THE  HEART. 


589 


Btairs,  his  foot  slipped,  and  he  fell  with  the  load  upon  him.  Asserts  that  he  was  insen- 
sible for  a fortnight  afterwards,  and  on  recovering  was  affected  with  cough  and  bloody 
expectoration  for  a month.  He  has  also  been  constantly  liable  to  palpitation,  dys- 
pnoea, and  starting  from  sleep,  and  been  unable  to  ascend  stairs  in  consequence  of  the 
violent  palpitations  and  feeling  of  faintness  thereby  produced.  Says  he  was  in  perfect 
health  at  the  moment  of  the  accident,  and  never  had  rheumatism.  He  has  been  sub- 
jected to  various  kinds  of  treatment,  and  been  salivated  with  mercury  without  any 
benefit. 

Symptoms  on  Admission. — Apex  of  the  heart  beats  distinctly  in  the  intercostal  space 
between  the  sixth  and  seventh  ribs.  The  impulse  is  strongest  in  a line  drawn  vertically 
from  the  nipple — is  full  and  rather  diffused.  The  pulsations  at  the  heart  are  more 
numerous  than  those  at  the  wrist.  On  percussion  the  cardiac  dulness  measures  three 
and  a half  inches  across.  On  auscultation  a prolonged  blowing  murmur  is  audible 
with  the  first  sound  at  the  apex,  which  decreases  in  intensity  towards  the  base  of  the 
organ,  and  is  entirely  lost  at  the  commencement  of  the  great  vessels.  Second  sound 
normal.  Pulse  ^72,  full,  not  hard ; and  there  is  an  occasional  small,  sharp  beat  occur- 
ring after  every  five  or  six  of  the  ordinary  pulsations.  Breathing  slightly  accelerated, 
amounting  to  dyspnoea  on  the  slightest  exertion ; occasional  cough,  followed  by  tough 
mucous  expectoration,  interspersed  with  a few  points  of  dirty  rusty  color.  Percussion 
normal  and  auscultation  over  lungs  only  elicits  a few  scattered  sibilant  and  sonorous 
rales,  posteriorly  on  left  side.  The  appetite  has  been  diminished,  with  occasional 
vomiting  for  the  last  three  months.  Is  apt  to  start  hurriedly  from  sleep  after  lying 
down,  and  is  disturbed  by  dreams.  Slight  oedema  of  the  feet  and  ankles.  Urine 
healthy.  Other  functions  normal. 

Progress  op  the  Case. — During  the  months  of  September  and  October  the  symp- 
toms gradually  increased.  The  dyspnoea  became  more  urgent,  and  the  piiroxysms  more 
frequent.  The  cough  with  bloody  expectoration,  the  oedema,  general  weakness,  and 
palpitations  were  all  augmented.  There  has  also  been  occasional  vomiting,  and  the 
skin  has  assumed  a yellow  jaundiced  hue.  He  had  again  been  put  under  a mercurial 
course,  and  a variety  of  remedies  were  employed  to  relieve  cough  and  spasm,  all  of 
which  produced  only  temporary  relief  On  taking  charge  of  the  case  on  the  1st  of 
November,  I found  a loud  blowing  murmur  occupying  the  period  of  both  sounds  at 
the  apex,  the  impulse  of  which  was  felt  between  the  fifth  and  sixth  ribs  two  inches  in 
a straight  line  below  the  nipple.  Over  the  xiphoid  cartilage  the  second  sound  was 
determined  to  be  healthy,  immediately  following  the  blowing  with  the  first.  At  the 
base  also  the  second  sound  was  heard  distinctly  normal,  and  the  blowing  with  the  first 
sound,  though  still  loud,  more  distant.  Sputum  was  gelatinous,  deeply  tinged  with 
fluid  blood.  Anteriorly  the  chest  was  resonant,  but  inferiorly  and  posteriorly  percus- 
sion was  slightly  impaired,  with  occasional  crepitating  rale  and  double  friction.  Pulse 
120,  feeble,  and  irregular;  great  weakness.  Nutrients  with  wine.  November  127/<. — Is 
worse.  Great  lividity  of  face  and  orthopnoea.  Heart’s  action  so  tumultuous  that  no 
individual  sounds  can  be  distinguished.  Extremities  oedematous  and  cold.  Pulse  im- 
perceptible. In  this  condition  he  continued  until  the  15th,  when  he  died. 

Sectio  Cadaveris. — Forty-four  hours  after  death. 

Body  not  emaciated ; surface  considerably  jaundiced. 

Thorax. — Pericardium  contained  several  ounces  of  serum.  Heart  much  enlarged, 
especially  on  right  side.  Eight  auricle  the  size  of  a large  orange.  Left  auricle  also 
considerably  distended.  Both  ventricles  dilated,  the  walls  not  much  hypertrophied. 
Endocardium  of  left  auricle  thickened  and  opaque.  Mitral  valve  constricted,  its  edges 
rigid,  and  partly  calcareous,  so  that  it  could  only  admit  one  finger.  The  tricuspid 
valve  was  also  constricted,  so  as  scarcely  to  admit  two  fingers.  This  was  owing  to 
thickening  and  shortening  of  the  valvular  segments,  which  were  also  abnormally  ad- 
herent to  each  other  at  their  extremities.  At  the  edge  of  one  valve  were  a few  rough 
granulations  of  lymph.  Aortic  and  pulmonary  valves  healthy.  Both  lungs  were 
emphysematous  anteriorly,  but  the  dilatation  of  individual  air-cells  was  not  extreme. 
In  the  posterior  and  inferior  portions  were  irregular  condensed  masses  of  hemorrhagic 
extravasation,  varying  in  size  from  a walnut  to  a hen’s  egg.  Interspersed  through 
the  lungs  generally  were  several  miliary  tubercles.  The  pleurm  were  adherent  in  sev- 
eral places,  and  also  contained  a few  tubercles.  The  trachea  and  bronchi  were  loaded 
with  viscid  muco-purulent  matter. 


590 


DISEASES  OF  THE  CIRCULATOEY  SYSTEM. 


Abdomen. — Liver  congested,  presenting  to  a certain  extent  the  nutmeg  appearance. 
Kidneys  and  other  abdominal  organs  healthy. 

Commentary. — In  both  these  cases  careful  examination  of  the  heart  did 
not  enable  me  to  form  a conjecture  that  the  tricuspid  valve  was  diseased. 
In  the  first  case,  the  continuous  blowing  at  the  apex  completely  masked  the 
second  sound,  even  at  the  base  of  the  organ.  In  the  other  case,  while 
the  blowing  occupied  the  period  of  both  sounds  at  the  apex,  the  second 
sound  was  audible  towards  the  right,  over  the  xiphoid  cartilage.  In 
the  case  of  King,  there  was  also  incompetency  of  the  aortic  valves,  but 
in  both  the  auriculo-ventricular  valves  were  the  chief  seat  of  disease. 
The  symptoms  were  not  unlike,  and  were  characterized  by  excessive 
palpitation;  great  dyspnoea,  with  oedema  of  the  lungs  in  one,  and 
hemorrhage  into  the  lungs  in  the  other  case ; vomiting,  dropsy,  and 
jaundice.  None  of  which  symptoms,  however,  either  individually  or 
collectively,  can  be  said  to  indicate  tricuspid  as  distinguished  from  mitral 
lesion.  The  origin  of  the  two  cases  was  widely  different.  The  one  de- 
pendent apparently  on  rheumatic  endocarditis,  the  other  caused  by  a fall 
and  contusion,  although  how  this  should  have  affected  both  auriculo- 
ventricular  valves  is  by  no  means  clear.  The  utility  of  mercury  was 
fairly  teste-d  in  Page’s  case,  and  as  usual  found  to  be  of  no  benefit  what- 
ever. Theoretically  it  is  impossible  to  understand  how  this  drug  is  to 
diminish  thickening  of  the  valves  or  contractions  of  the  chordae  tendineae, 
and  practical  experience  has  utterly  failed  in  demonstrating  its  ad- 
vantage in  endocarditis  any  more  than  in  pericarditis. 

Case  CXY.'^ — Soft  Adherent  Polypus.,  causing  incompetency  of  the  Mitral 

Orifice — Anasarca. 

History. — William  Taylor,  set.  60,  a compositor — admitted  December  20th,  1852. 
The  patient  enjoyed  good  health  till  a year  ago,  when  be  became  subject  to  attacks  of 
vertigo.  The  first  of  these  came  on  after  a long  race;  they  recurred  frequently, 
especially  after  meals.  Three  months  ago,  cough  and  dyspnoea  came  on,  which  have 
gradually  become  worse.  Two  weeks  ago,  his  legs  began  to  swell,  and  five  days  ago 
the  lower  part  of  both  legs  became  of  a purple  color,  not  disappearing  on  pressure, 
the  rest  of  the  skin  of  the  body  assuming  a yellowish  hue ; these  discolorations  have 
since  increased.  Has  suffered  much  mental  distress  during  the  last  six  months. 

Symptoms  on  Admission. — Cardiac  apex  in  normal  position;  impulse  somewhat 
increased.  With  the  first  sound  there  is  a blowing  murmur  heard  loudest  at  the  apex ; 
second  sound  normal;  transverse  dulness  normal.  Pulse  very  small  and  weak,  120 
per  minute.  Percussion  of  the  lungs  normal ; breathing  hurried,  respirations  being 
40  per  minute ; no  abnormal  sounds  audible  on  auscultation.  Sleeps  badly  and  is  very 
weak.  Tongue  slightly  furred ; appetite  bad  ; bowels  constipated ; stools  dark  colored. 
Urine  in  goodly  quantity,  high  colored,  loaded  with  lithates;  contains  a slight  amount 
of  albumen.  Legs  swollen.  Ordered  to  have  3 iv  of  wine  and  diuretic  mixture. 

Progress  op  the  Case. — Becemher  23d — Crepitation  over  lower  half  of  both  lungs 
posteriorly ; no  dulness  or  increased  vocal  resonance.  Expectoration  streaked  with 
blood.  Weakness  great ; pulse  hardly  perceptible.  Ordered  expectorants  and  J vj  of 
wine.  24/A. — Urine  passed  in  very  small  quantity.  Ordered  diuretics  with  nitric  ether 
and  half  the  wine  to  be  replaced  by  an  equal  quantity  of  gin.  25/7g — W as  delirious 
last  night,  and  suffered  from  dyspnoea.  Died  this  morning  at  half-past  eleven. 

Sectio  Cadaveris. — Forty-eight  hours  after  death. 

Thorax. — The  pericardium  contained  about  an  ounce  of  turbid  yellowish  serum. 
The  heart  was  slightly  enlarged  on  the  right  side.  All  the  cavities  were  full  of  blood, 


* Reported  by  Mr.  R.  Brown,  Clinical  Clerk. 


VALVULAR  DISEASES  OF  THE  HEART. 


591 


partially  coagulated,  the  coagula  being  soft  and  colored  throughout.  In  the  left  auricle 
was  a soft,  gelatinous,  semitransparent  mass,  the  size  of  a pigeon’s  egg,  which  hung 
over  the  mitral  orifice,  and  appeared  to  choke  it  up.  It  was  firmly  attached  to  the 
membrane  of  the  auricle  by  a surface  about  half  an  inch  square,  in  substance  resem- 
' bling  colloid,  and  externally  was  not  unlike  a soft  polypus,  or  a mass  of  uterine  hyda- 
tids ; on  section,  it  was  homogeneous,  and  consisted  of  a fibrous  stroma,  which  could 
easily  be  torn,  enclosing  between  its  meshes  a clear  viscous  fluid.  The  flaps  of  the 
mitral  valve  were  somewhat  thickened,  without  deformity  or  thickening  of  the  chordse 
tendinese,  which,  with  the  columns  carnem,  were  quite  healthy.  The  other  valves  were 
normal.  The  lungs  were  cedematous,  with  small  hemorrhagic  patches  at  various  points. 

Abdomen.  — The  peritoneal  cavity  contained  about  half  a gallon  of  clear  serum. 
There  was  slight  hepatic  congestion  of  the  liver,  but  the  other  abdominal  viscera  were 
unfortunately  not  examined  by  the  pathologist. 

Microscopic  Examination. — The  attached  polypus  in  the  left  auricle  consisted 
of  bands  of  fibrous  tissue,  crossing  one  another  and  forming  oval  and  circular  areol83 
containing  a viscous  serum.  Embedded  in  these  bands  were  nucleated  cells,  round, 
oval,  and  fusiform  in  shape.  Some  of  the  latter  were  lengthened  out  into  fibres. 
They  were  fibre-cells  exhibiting  every  stage  of  transformation,  from  the  rounded  cell 
up  to  that  of  perfect  areolar  tissue. 

Commentary, — ^The  structure  and  firm  attachment  of  the  polypus  in 
this  case,  can  leave  us  in  no  doubt  that  it  must  have  existed  some  time 
before  death,  and  caused  the  symptoms  of  which  this  man  complained. 
From  its  position  it  appeared  calculated  materially  to  interfere  with  the 
passage  of  the  blood  from  the  left  auricle  to  the  left  ventricle,  but  the 
sound,  during  life,  indicated  an  incompetency  rather  than  a narrowing  or 
stricture  of  the  auriculo- ventricular  orifice.  To  it,  however,  the  excessive 
dyspnoea,  which  was  the  chief  character  of  the  case  during  life,  was  most 
probably  owing.  The  mass  itself  closely  resembled,  to  the  eye  as  well 
as  under  the  microscope,  some  kinds  of  simple  colloid  I have  seen; 
whether  it  originated  in  an  exudation,  in  a deposition  of  fibrin  from  the 
blood,  or  in  a combination  of  the  two,  it  is  difficult  to  determine ; the 
last  supposition  is  the  most  probable. 

That  coagula  are  formed  from  the  blood  in  the  cavities  of  the  heart 
during  life,  there  can  be  little  doubt,  although  we  are  ignorant  of  any 
means  of  detecting  them.  They  have’  been  supposed  to  be  the  result  of 
endocarditis.  If  so,  we  must  suppose  that  an  exudation  thrown  out  on 
the  endocardial  lining  membrane  causes  roughness,  which,  as  the  blood 
flows  over  it,  tends  to  produce  fibrinous  deposition  from  that  fluid. 
However  formed,  two  subsequent  changes  may  occur — 1st,  Fibre  cells 
may  be  formed  in  it,  and  the  whole  gradually  developed  into  a fibrous 
structure,  as  in  Case  CXV.  This  is  very  rare.  More  commonly  it  softens 
in  the  centre,  and  is  gradually  reduced  to  a fluid,  which  to  the  naked  eye 
closely  resembles  pus.  Such  collections  have  been  called  “purulent 
cysts.”  I have  frequently  examined  the  contents  of  these  cysts,  and 
have  no  doubt  that,  in  many  cases,  the  so-called  “ purulent  cysts  ” are 
simply  formed  by  a mechanical  disintegration  of  the  clot,  in  the  manner 
first  described  by  Mr.  Gulliver,  and  are  not  purulent  cysts  at  all.  I once 
found  a pyriform  clot  in  the  right  ventricle  of  the  heart,  firmly  attached 
to  the  endocardium  by  its  smaller  extremity.  It  was  the  size  of  a hen’s 
egg,  and  on  cutting  into  it  there  flowed  out  two  ounces  of  a fluid  exactly 
like  good  laudable  pus.  Yet  it  did  not  contain  one  pus  corpuscle,  but 
was  wholly  made  up  of  molecular  matter,  associated  with  the  broken 
down  debris  of  a fibrous  clot,  and  a few  collapsed  colorless  cells  of  the 


592 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


blood.  In  this  way  a microscope  demonstrates,  not  unfrequently,  that 
what  was  regarded  as  pus,  and  considered  a proof  of  inflammation,  is  in 
truth  quite  unconnected  with  the  latter  process,  and  is  owing  to  alto- 
gether different  causes. 

Case  CXYI.'^ — Enlarged  Foramen  Ovale — Phthisis. 

History, — James  M‘Queenie,  set.  27,  a tailor — admitted  June  23d,  1863.  Has 
never  been  a strong  man,  having  been  very  liable  to  suffer  from  colds  and  indigestion. 
Since  boyhood  he  has  been  liable  to  palpitation  and  dyspnoea  on  the  slightest  exertion. 
His  health,  however,  continued  pretty  good  till  eighteen  months  ago,  when  he  was  ad- 
mitted into  this  Infirmary.  He  then  labored  under  inflammatory  fever,  with  cough 
and  pains  in  the  chest ; there  was  evidence  of  condensation  of  the  apex  of  the  right 
lung;  and  obscure  shifting  murmurs  were  heard  with  the  cardiac  sounds,  which  led  to 
the  belief  that  the  patient  was  suffering  from  subacute  pericarditis  in  the  course  of 
tubercular  disease.  He  was  treated  with  aconite,  and  afterwards  with  mercury.  He 
became  much  better,  but  did  not  entirely  regain  his  health ; the  physical  phenomena 
remained  as  before ; cough  and  expectoration  also  continued.  Of  late  these  symptoms 
have  become  more  troublesome,  so  as  to  induce  him  to  re-enter  the  Hospital. 

Symptoms  on  Admission. — Apex  of  the  heart  beats  slightly  to  the  right  of  the 
usual  position ; transverse  dulness  three  inches;  sounds  feeble  and  indistinct;  with 
the  first  and  running  into  the  second,  there  is  a peculiar  whizzing,  neither  a blow- 
ing nor  a friction  murmur ; it  is  heard  most  distinctly  at  the  base,  is  not  constantly 
present,  and  is  not  propagated  along  the  large  vessels.  Heart’s  impulse  feeble,  and 
producing  a wavy  motion  under  three  intercostal  spaces.  Palpitation  on  exertion  or 
mental  excitement.  Pulse  90,  small  and  slightly  intermittent.  Under  the  right  clavi- 
cle, dulness  on  percussion,  with  increased  sense  of  resistance,  and  imperfect  cracked- 
pot  sound ; on  auscultation  there  are  loud  moist  rales  almost  gurgling  in  character ; 
much  prolonged  expiration ; loud  bronchophony.  Towards  the  lower  margin  of  the 
right  lung  there  is  harsh  respiration  with  sibilus.  Below  the  left  clavicle  for  a hands- 
breadth  there  are  fine  moist  rales  with  prolonged  expiration  and  loud  vocal  resonance  ; 
sibilus  also,  as  on  the  right  side.  Posteriorly  the  signs  correspond  to  those  in  front. 
Sputum  abundant  and  muco-purulent ; cough  frequent,  but  not  harsh ; breathing  easy. 
Appetite  scarcely  impaired.  Occasional  diarrhoea,  now  checked  by  astringents.  He- 
patic and  splenic  dulness  normal.  Great  sweating  at  night.  Urine  of  normal  charac- 
ter. Ordered  to  take  cod-liver  oil^  and  to  have  nourishing  diet 

Progress  of  the  Case. — June  ^Zd  to  July  \^th. — Treatment  as  above;  strength 
much  increased.  Yesterday  had  a rigor,  followed  by  stitch  in  the  side ; it  was  relieved 
after  the  application  of  leeches.  July  \Zth-2Zd. — Has  gradually  become  much  worse. 
Suffers  now  from  great  dyspnoea,  frequent  cough,  copious  expectoration,  night  sweats, 
loss  of  appetite,  diarrhoea,  and  great  weakness.  No  great  change  in  the  physical  signs ; 
the  heart  sounds  are  much  masked  by  the  pulmonary  rales.  Has  taken  cod-liver  oil, 
with  occasional  antispasmodics  and  astringents,  and  latterly  § iv  of  wine  and  § ij  of 
brandy  in  the  course  of  the  day.  July  lUh. — Gradually  sunk,  and  died  at  twelve 
noon. 

Sectio  Cadaveris. — Twenty-five  hours  after  death. 

Body  much  emaciated  ; rigor  mortis  moderate. 

Thorax. — No  adhesions  between  the  layers  of  the  pericardium,  or  between  the 
pleura  and  that  membrane.  The  pericardium  contains  about  two  ounces  of  turbid 
yellowish  fluid  with  small  flocculi  of  lymph.  Surface  of  the  heart  presents  a milky 
patch  the  size  of  a shilling  towards  its  base  posteriorly,  and  there  are  some  smaller 
ones  over  left  auricle.  Heart  soft,  flaccid,  and  fatty ; it  weighs  twelve  ounces.  The 
right  ventricle  is  much  dilated  and  the  walls  are  thin ; the  tricuspid  orifice  admits 
four  fingers  with  ease;  mitral  valves  very  slightly  thickened  at  the  margins,  but 
otherwise  healthy;  aortic  valves  healthy.  In  the  septum  auricularum  there  is  a large 
opening  which  can  admit  three  fingers ; evidently  the  foramen  ovale  much  enlarged ; 


* Reported  by  Mr.  W.  M.  Calder,  Clinical  Clerk. 


VALVULAR  DISEASES  OF  THE  HEART. 


593 


it  is  oval  in  shape,  and  the  edges  are  smooth  and  rounded.  Pulmonary  artery  dilated  ; 
calibre  of  the  aorta  diminished,  and  only  half  the  size  of  the  pulmonary  artery.  Right 
lung  adherent  all  over.  Adhesions  firmest  near  the  apex.  The  lung  is  non-crepitant 
throughout,  and  everywhere  infiltrated  with  tubercle,  which  is  most  chronic  at  the 
apex,  where  there  are  several  puckerings  and  dense  cicatrizations.  The  left  lung  also 
infiltrated  with  tubercle,  but  not  to  so  great  an  extent,  and  more  recent. 

Abdomen. — The  liver  was  much  congested,  with  a linear  cicatrix  two  inches  long, 
situated  half  an  inch  anterior  to  its  diaphragmatic  attachment.  The  lower  third  of  the 
ileum,  with  the  caesium  and  ascending  colon,  the  seat  of  numerous  tubercular  ulcera- 
tions. A few  tubercular  deposits  in  the  mesenteric  glands.  Other  organs  normal. 

Commentary. — The  peculiarity  of  the  cardiac  sounds  in  this  case, 
consisted  in  the  existence  of  a kind  of  whizzing  murmur,  synchronous 
with  the  systole,  and  loudest  at  the  base,  combined  with  palpitations, 
feeble  impulse,  and  a weak  intermittent  pulse.  This  combination  of 
signs  and  symptoms  forbade  the  supposition  that  the  lesion  was  aortic, 
while  the  sex,  and  absence  of  murmur  in  the  larger  vessels,  were  opposed 
to  the  notion  of  its  being  anaemic.  After  death  a large  opening  was 
found  between  the  auricles,  with  smooth  edges,  which  must  have  admitted 
the  ready  flow  of  blood  through  it.  Whether  the  peculiar  whizzing 
sound — which  was  neither  loud  nor  constant — was  caused  by  this  open- 
ing, it  is  difficult  to  say,  but  judging  from  its  situation  and  character, 
this  is  not  improbable.  The  slight  thickening  of  the  flaps  of  the  mitral 
valve  did  not  seem  to  interfere  with  its  competency,  and  certainly  caused 
no  murmur. 

Few  well-observed  cases  of  patent  foramen  ovale  in  the  living  subject 
have  been  recorded.  In  one  recorded  by  Dr.  Markham,*  the  open  fora- 
men ovale  allowed  the  blood  to  pass  readily  from  the  right  to  the  left 
auricle,  but  not  in  the  opposite  direction,  excepting  through  two  narrow 
slits.  There  was  audible  during  life  a loud,  rough,  and  prolonged  sys- 
tolic murmur  over  the  whole  pericardial  region,  over  the  upper  part  and 
along  the  right  border  of  the  sternum,  and  in  the  whole  of  the  upper 
half  of  the  interscapular  space.  From  an  inquiry  by  Dr,  John  Oglef 
into  this  subject  when  he  was  Curator  of  the  Pathological  Museum  at  St. 
G-eorge’s  Hospital,  he  found  that  of  thirteen  cases  of  patent  foramen 
ovale,  it  was  stated  in  seven  that  no  murmur  synchronous  with  the  sys- 
tole existed.  The  size  of  the  openings  is  not  given.  In  one  other  case, 
a diastolic  murmur  was  present,  owing  to  undoubted  disease  of  the  aortic 
valves.  Hence,  of  the  whole  thirteen,  there  was  no  evidence  that  this 
lesion  produced  a murmur  at  ail.  Dr.  Markham’s  case  being  uncompli- 
cated and  well  observed,  affords  pretty  strong  evidence  that  a murmur 
may,  under  certain  conditions,  be  occasioned  by  open  foramen  ovale,  as 
does  the  one  now  recorded.  But  what  those  conditions  are,  as  well  as  a 
crowd  of  interesting  points  in  connection  with  them,  can  only  be  deter^ 
mined  by  future  observations. 

Since  the  above  observations  were  written.  Dr.  Foster  of  Birming- 
ham has  published  two  cases  of  patent  foramen  ovale,  in  children  with 
cyanosis,  in  both  of  which  a murmur  with  the  first  sound  was  audible 
over  the  base  of  the  heart.;};  Dr.  Reish,  also,  of  Vienna,  has  given  a case 

* British  Medical  Journal,  April  4th,  1857.  f Ibid..,  June  13th,  1857. 

X Dublin  Quarterly  Journal,  August  1863. 


38 


594 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


associated  with  mitral  lesion,  in  which  there  was  a loud  systolic  murmur 
at  the  apex  of  the  heart,  and  a weak  indistinct  second  sound.  Over  the 
lowest  part  of  the  sternum  no  murmur  was  audible,  but  two  w^eak 
sounds  were  heard.*  Here  the  case  being  complicated,  nothing  very  de- 
finite was  arrived  at. 

PaLhology  of  Valvular  and  Organic  Diseases  of  the  Heart. 

The  lesions  producing  valvular  disease  of  the  heart  are  various,  and 
may  be  referred  to  mechanical  violence,  to  the  effects  of  exudation,  acute 
or  chronic,  to  deposition  of  fibrin,  and  to  the  different  forms  of  degene- 
ration of  texture.  But  however  occasioned,  they  all  tend  to  produce 
subsequent  changes  in  the  texture  and  vital  actions  of  the  heart  itself; 
above  all,  hypet  trophy  and  fatty  degeneration  of  its  muscular  walls,  with 
increased,  diminished,  or  irregular  contractions  of  its  cavities.  Although 
it  is  with  these  latter  that  the  physician  has  principally  to  do,  a know- 
ledge of  the  former  is  essential  to  the  correct  appreciation  and  proper 
treatment  of  every  individual  case. 

Mechanical  injuries  not  unfrequently  occasion  sudden  disease  or  rup- 
ture of  the  valves  (Cases  XCIX.  and  CXIV.),  separating  their  attach- 
ments, and  causing  subsequent  adhesions  and  fibrinous  depositions.  Grreat 


muscular  exertion  has  also  occasioned  similar  results.  (See  Case  CHI.). 
Four  cases  of  this  are  recorded  by  Hr.  B.  Quain,f  in  one  of  which  a 
smith,  when  working  vigorously,  experienced  “ an  uneasy  shaking  of  the 
heart,”  shortness  of  breath,  and  heard  a peculiar  noise  “ up  his  chest, 
neck,  and  in  his  ears.”  On  examination,  a loud  ringing  musical  murmur 
was  heard  over  the  aortic  valves  with  the  second  sound,  and  there  was  a 
softer  blowing  with  the  first  sound.  After  suffering  two  years,  during 

* Edinburgh  Medical  Journal,  February  1863,  p.  752. 

f Monthly  Journal  of  Medical  Science,  December  1846. 


Fig.  436.  Conjoined  attachment  of  two  of  the  aortic  valves  at  or,  separated  from 
the  aorta  at  h.  Here  the  wall  of  the  vessel  was  raised  into  a superfici.al  elevation.  At 
0,  the  margin  of  one  valve  was  slightly  everted,  and  studded  with  small  granulations. — 
{R.  Quaini) 


VALVULAR  DISEASES  OF  THE  HEART. 


595 


wliich  the  sounds  underwent  different  modifications,  followed  by  cardiac 
hypertrophy,  he  died,  and  on  dissection,  the  conjoined  attachments  of 
two  of  the  valves  to  the  aorta  were  found  to  be  separated  from  the  wall 
of  that  vessel,  so  that  they  dropped  below  the  level  of  the  third,  which 
retained  its  connections  (Fig.  436).  Cases  of  this  kind  would  perhaps 
be  more  frequently  observed,  if  the  origin  of  valvular  diseases  were  more 
carefully  looked  for. 

Exudation  into  or  on  the  surface  of  the  valves^  constituting  the  endo- 
carditis of  systematic  writers,  is  a common  cause  of  valvular  disease.  If 
acute,  it  may  appear  in  the  form  of  minute  granulations,  or  forming  a 
layer,  varying  in  thickness  and  shape,  on  the  surfaces  or  on  the  edges  of 
the  valves.  If  chronic,  they  are  firm,  and  not  unfrequently  associated 
with  an  exudation  which  has  also  occurred  in  the  texture  of  the  valve 
itself,  causing  more  or  less  thickening  or  induration  in  its  various  parts. 
In  the  same  manner  the  chordae  tendineae  may  become  thickened  and 


shortened  from  interstitial  exudation.  As  a result,  the  edges  of  the 
valves  do  not  come  into  accurate  contact,  and  become  incompetent  to 
fulfil  their  functions.  After  a time,  in  consequence  of  excess  of  exuda- 


Fig.  439. 


tion  and  subsequent  contraction,  the  orifices  are  narrowed,  and  mechan- 
ical obstructions  offered  to  the  free  passage  of  the  blood  through  them. 

Fig.  43Y.  A,  Aortic  orifice  with  one  valve  of  a funnel-shape,  seen  from  the  front. 

The  same  valve  seen  from  above,  showing  the  original  septa  of  the  valve  united 
togeth  er.  — {Peacock. ) 

Fig.  438.  Two  valves  at  the  aortic  orifice,  with  a rudimentary  one  interposed. — 
{Peacock.) 

Fig.  439.  Congenital  malformation  of  the  aortic  valves.  A,  The  aorta  slit  up 
length-ways.  B^  Transverse  section  of  the  aorta  just  above  the  valves. — {Brinton.) 


596 


DISEASES  OF  THE  CIRCULATORY  STSTE3I. 


In  the  aortic  valves,  in  addition  to  the  thickenings  and  contractions, 

adhesions  may  occur, 
with  or  without  the 
lacerations  of  septa 
formerly  noticed.  In 
this  manner  there  may 
he  two,  rarely  only 
one  valve  from  lacera- 
tion of  the  attachment 
to  the  aorta  and  sub- 
sequent adhesion  of  the 
Fig,  440,  broken  edges.  In  Fig. 

437  the  union  of  all  the  valves  has  resulted  in  the  formation  of  one 
valve  of  a funnel-shape.  In  Fig.  436,  two  valves  have,  as  it  appears, 
been  broken  into 
one  another  and 
united  together, 
so  as  to  form  one. 

In  Fig.  439,  one 
of  the  valves 
seems  to  have 
been  abortive,  or 
not  developed. 

Again,  the  num- 
ber of  valves  may  Fig.  441. 

be  multiplied  in  consequence  of  adhesions  being  formed,  and  extra 


Fi-.  442.  Tie-  . ,,  , 

inches  thereby  estahlished.  Thus  four  valves  are  occasionally  met 
Fig.  440.  Four  valves  at  the  aortic  orifice,  from  adhesion  of  one  to  the  waU  of  the 

issel?  so  as  to  form  two  pouches.  ^ r * -v,  +Trn  vqlves 

Fig.  441.  Five  valves,  formed  from  adhesions  and  production  of  septa  in  two  vaivcs. 

Mitral  orifice,  constricted  so  as  to  form  an  elongated  and  rigid  slit  re- 
mblhig  a button-hole.  Seen  from  the  auricle. 

Fi"  443.  Mitral  orifice,  ccreatlv  constricted,  so  as  to  form  an  oval  aperture,  at  the 
Dttom  of  a funnel-shaped  depression.  Seen  from  the  auricle. 


VALVULAR  DISEASES  OF  THE  HEART. 


597 


with,  as  in  Fig.  440.  Sometimes  these  are  of  unequal  size,  and  are  then 
most  oomniouly  the  result  of  disease.  But  I have  seen  four  valves,  all 
exactly  like  oue  another,  in  which  case  the  malformation  appears  to  be 
congenital.  I only  know  of  one  instance  in  which  five  valves  existed  at 
the  aortic  orifice,  and  that  is  given  by  Dr,  Peacock,  in  his  valuable  work 
on  “ Malformation  of  the  Human  Heart,  1858,”  and  which  is  copied 
(Fig.  441).  The  excess  is  owing  to  the  division  of  two  valves,  the  super- 
numerary segment  being  imperfect. 

The  mitral  valves,  in  addition  to  roughnesses  and  thickenings  of  the 
valves  themselves,  and  various  alterations  of  their  edges  in  consequence 
of  shortening  of  the  chordae  tendineae,  present  in  chronic  cases  a great 
tendency  to  contraction  of  the  orifice.  On  looking  down  into  the  auricle 
these  constrictions  of  the  auriculo-ventricular  orifice  are  seen  to  assume 
two  shapes,  the  one  being  only,  however,  a greater  degree  of  contraction 
than  the  other.  In  the  first  it  exhibits  a slit,  or  button-hole  appearance, 
in  the  other  a rounded  or  oval  aperture — both  openings  being  at  the 
base  of  a funnel-shaped  depression,  caused  by  the  adhesion,  thickening, 
and  contraction  of  the  edges  ot  the  two  valves. 

Deposition  of  fibrin  from  the  blood  may  occur  on  the  valves  in  con- 
sequence of  laceration,  or  of  exudations ; but  sometimes,  so  far  as  can 
be  ascertained,  without  organic  lesion.  It 
has  been  experimentally  proved,  that  the 
introduction  of  a thread  across  the  aortic 
aperture,  will  cause  the  precipitation  upon 
it  of  the  fibrin  of  the  blood. — {Simon). 

Any  rough  surface  will  produce  the  same 
effect.  Indeed,  there  is  every  reason  to 
suppose  that  when  the  blood  abounds  in 
fibrin,  as  especially  occurs  in  acute  rheu- 
matism, such  deposits  may  take  place  on 
the  valves  themselves,  without  any  pre- 
vious lesion  of  them,  an  occurrence  which 
would  serve  to  explain  the  relation  be- 
tween rheumatic  and  cardiac  disorders. 

Be  this  as  it  may,  there  can  be  little  doubt 
that  such  rheumatic  constitution  of  the 
blood  once  established,  fibrinous  deposits 
are  apt  to  be  thrown  down,  which  con- 
stitute the  vegetations  so  frequently  found 
at  the  edges  of  the  valves,  resembling 
soft  warty  tumors,  obstructing  the  ori- 
fices, and  occasionally  hanging  down 
by  peduncles  into  the  ventricle.  (Fig. 

444).^  Fig.  444. 

Degeneration  of  the  valves  may  occur  in  various  ways,  and  in  its 
nature  be  albuminous,  fatty,  or  mineral.  Thus  the  thickening  and  in- 

* See  some  excellent  lectures  on  this  subject  by  Dr.  Richardson.  British  Medical 
Journal,  1860,  p.  21. 

Fig.  444.  Fibrinous  vegetations,  and  atheromatous  degeneration  of  an  aortic  valve 
with  rupture. 


598 


DISEASES  OF  THE  CIECULATORY  SYSTEM. 


durations  owing  to  chronic  exudation,  may  assume  a density  equal  to 
ligament  or  fibro-cartilage.  Or,  on  the  other  hand,  they  may  soiten, 
undergo  the  fatty  degeneration,  and  at  length  ulcerate,  forming  one  or 
more  perforations  through  the  membranous  portion  of  the  valve  (Fig. 
444).  Lastly,  it  is  by  no  means  uncommon  to  find  that  the  thickened 
valves  have  undergone  the  mineral  degeneration,  presenting  nodules  and 
masses  of  earthy  matter,  varying  in  size,  more  or  less  rough,  resembling 
concretions,  and  obstructing  the  orifice  in  proportion  to  their  size. 

The  immediate  result  of  all  these  different  lesions  is,  that  the  valves 
being  incompetent,  and  not  closing  perfectly,  the  blood  regurgitates  back 
into  the  ventricles  or  auricles  at  each  systole  or  diastole,  according  to  the 
valve  affected ; or  if  there  be  contraction  and  obstruction  at  the  orifice 
it  is  propelled  forwards  with  difficulty.  In  either  case,  increased  mus- 
cular effort  is  required  to  carry  on  the  circulation,  and  the  result  is  the 
greater  or  less  enlargement  of  the  heart  or  hypertrophy. 

Hypertrophy  of  the  heart  may  arise  from  several  causes ; but  by  far 
the  most  common  is  disease  in  one  or  more  of  its  valves.  In  this  case, 
it  follows  the  law  of  increased  growth  formerl}^  referred  to  (p.  186), 
whereby  parts  subjected  to  unusual  exertion  or  increase  of  function  aug- 
ment in  bulk.  Hence  either  disease  of  the  aortic  or  mitral  valves  in- 
duces hypertrophy,  with  dilatation  of  the  left  ventricle,  from  the  neces- 
sity of  increased  action.  The  same  causes  operate  on  the  other  parts  of 
the  organ.  Chronic  bronchitis  and  emphysema,  by  impeding  the  circu- 
lation in  the  lungs,  produce  similar  enlargements  in  the  right  ventricle, 
and  so  on.  In  chronic  heart  diseases,  it  is  rare  that  the  lesion  is  con- 
fined to  one  cavity,  because,  as  it  advances,  it  produces  increasing  em- 
barrassment in  the  others.  Thus  hypertrophy  of  the  left  ventricle,  in 
consequence  of  aortic  disease,  after  a time  induces  enlargement  of  the 
left  auricle ; this  embarrasses  the  return  of  the  blood  from  the  lungs, 
caudng  congestions  and  derangement  of  those  organs.  These  in  turn 
induce  enlargement  of  the  right  cavities  of  the  heart,  and  then  the  return 
of  blood  from  the  systemic  circulation  is  impeded,  causing  congestions  in 
the  liver  and  other  viscera.  In  consequence  of  the  over-distention  of  the 
venous  capillaries  so  occasioned,  effusion  of  serum  occurs,  producing 
oedema,  and  more  or  less  anasarca.  As  the  dropsical  fluid  so  occasioned 
augments,  the  pressure  it  produces  interferes  still  more  with  the  action 
of  the  kidneys,  skin,  lungs,  etc.,  until  at  length  life  can  no  longer  be 
maintained.  These  eflfects  will  follow  more  rapidly  if,  in  addition  to  the 
aortic,  the  mitral  valves  are  disordered,  or  if  further  complications  add 
to  the  gravity  of  the  case.  Thus  the  triscuspid  orifice  may  also  be  afiected 
(Cases  CXlil.  and  CXIY.) ; or  there  may  be  adherent  pericardium,  or 
aneurism  of  the  large  vessels.  Again,  the  course  of  these  changes  may 
be  modified  or  inverted.  The  disease,  for  instance,  may  commence  in 
the  lungs  or  liver,  and,  by  the  obstructions  to  the  circulation  thereby 
occasioned,  may  affect  the  heart  secondarily.  Or,  conjoined  with  val- 
vular disease  and  cardiac  hypertrophy,  there  may  be  primary  lesions  of 
the  lungs,  kidney,  or  liver.  It  is  by  pathological  knowledge  alone  that 
the  influence  and  mutual  dependence  of  these  various  derangements  can 
be  understood,  and  a treatment  judiciously  directed  to  their  relief. 

Fatty  Degeneration  of  the  Heart. — The  heart  may  be  loaded  and 


VALVULAR  DISEASES  OP  THE  HEART. 


599 


even  more  or  less  infiltrated  with  adipose  tissue,  producing  one  form  of 
fatty  degeneration.  By  far  the  more  important  form,  however,  is  the 
.lesion,  for  a knowledge  of  which  we  are  indebted  to  the  recent  researches 
of  histologists,  and  more  especially  in  this  country  of  Paget,  Ormerod, 
and  Quain.  Of  its  nature  I have  already  spoken  (p.  254).  It  may 
occur  as  a sequela  of  every  form  of  cardiac  disease,  but  especially  when 
the  aortic  valves  are  affected,  as  well  as  from  a modification  in  the  general 
condition  of  the  system  leading  to  fatty  degeneration  of  a number  of 
other  organs.  It  may  be  observed,  for  instance,  in  cases  where  the 
liver  and  kidneys  are  fatty,  that  the  muscular  substance  of  the  heart  is 
commonly  fatty  also.  Indeed,  there  is  no  degeneration  of  texture  more 
common  than  that  of  fatty  heart,  which,  existing  in  various  degrees,  is 
dangerous  in  proportion  to  its  intensity,  extent,  and  complication  with 
other  diseases.  In  elderly  persons  more  especially  this  degeneration  may 
proceed  to  a great  extent  without  even  being  suspected,  and  then  some 
unaccustomed  exertion,  by  demanding  from  the  organ  more  forcible  mus- 
cular contractions  than  it  is  capable  of  exerting,  suddenly  arrests  its 
action,  and  fatal  syncope  is  the  result.  Many  cases  of  sudden  death 
formerly  ascribed  to  apoplexy,”  or  ‘ spasm  of  the  heart,”  may  now  be 
confidently  affirmed  to  have  been  owing  to  this  lesion.  Its  detection  in 
the  living  body  cannot  be  made  with  confidence.  Slowness  and  feebleness 
of  the  pulse  have  been  by  some  thought  diagnostic.  But  many  extreme 
cases  of  this  degeneration  have  died  under  my  observation  without  any 
such  symptom.  It  may  cause  rupture  of  the  heart  and  fatal  hemorrhage. 

Myocarditis^  or  true  inflammation  of  the  substance  of  the  heart,  is 
one  of  the  rarest  organic  diseases  known.  Whether,  in  cases  of  pericar- 
ditis, the  muscular  substance  below  the  serous  membrane  is  the  seat  of 
an  exudation,  is  yet  to  be  determined  by  histological  research.  The  intro- 
duction of  the  term  “ Parenchymatous  inflammation,”  employed  by  Vir- 
chow, can  only  cause  confusion,  without  in  any  way  advancing  our 
knowledge,  as,  in  truth,  it  is  no  inflammation  at  all,  but  the  fatty  de- 
generation of  the  muscular  fasciculi  just  referred  to. 

Treatment  of  Valvular  and  Organic  Diseases  of  the  Heart. 

That  the  various  lesions  of  the  valves  are  susceptible  of  being 
removed  by  drugs,  is  one  of  those  notions  which  the  advance  of  diag- 
nosis and  pathology  has  happily  expelled,  and  which  seems  now  almost 
universally  admitted.  All  that  the  practitioner  can  hope  to  accomplish, 
is  to  modify,  and,  if  possible,  check  those  resulting  phenomena  from 
which  real  danger  is  to  be  apprehended.  But  here  much  misconception 
has  prevailed  as  to  the  real  object  to  be  kept  in  view,  or  rather  the 
phenomena  themselves  have  been  wrongly  interpreted  by  medical  men. 
We  have  seen  that  valvular  disease  leads  to  dilated  hypertrophy;  this  is 
accompanied  by  excessive  action,  and,  especially  if  the  aortic  valves  are 
diseased,  by  a strong,  jerking,  and  hard  pulse.  The  notion  is  very 
general  that,  simply  because  the  pulse  is  stronjr,  it  is  the  mission  of  the 
practitioner  to  make  it  weak;  that,  because  the  heart  acts  violently,  it 
ought  to  be  made  to  beat  quietly  by  lowering  remedies.  But  the  strong 
pulse  and  enlarged  ventricle  in  the  one  case,  are  wise  provisions  of 


600 


DISEASES  OF  THE  CIKCULATOEY  SYSTEiL 


nature,  set  up  to  counterbalance  the  otherwise  fatal  consequences  of  the 
valvular  obstruction ; and  the  violent  action  of  the  heart  in  the  other  is 
a proof  of  weakness  rather  than  of  strength,  and,  instead  of  being  lessened 
by  bleeding  aud  antiphlogistics,  requires  for  its  removal  tonics,  nutrients, 
and  calmatives.  To  no  one  is  medicine  more  indebted  for  making  this 
proposition  intelligible  than  to  Dr.  Corrigan,*  and  his  views  and  prac- 
tice have  been  acted  upon  to  a great  extent  by  those  who  have  sedulously 
cultivated  the  physical  diagnosis  of  diseases  of  the  heart.  It  is  the  at- 
tempt to  treat  mere  symptoms  without  a knowledge  of  the  organic 
diseases  on  which  they  depend  that  leads  to  mistakes  among  medical 
men.  But  with  that  knowledge,  their  judicious  treatment  of  the 
effects  of  valvular  disease  of  the  heart,  forms  one  of  the  best  ex- 
amples of  a modern  scientific  as  distinguished  from  a former  empirical 
practice. 

What,  then,  we  have  principally  to  attend  to  in  valvular  diseases  of 
the  heart,  is  to  do  all  in  our  power  to  support  the  normal  strength  of 
the  economy,  and  avoid  agitating  the  patient,  instead  of  lowering  the 
pulse,  or  giving  mercury  under  the  idea  that  thereby  we  are  putting 
down  an  inflammation  or  causing  absorption  of  the  exudation.  In  this 
way  persons  affected  with  cardiac  disease  have  continued  to  live  quite 
unconscious  of  it  for  many  years  in  comfort.  If,  however,  it  occasion 
dyspnoea,  care  must  be  taken  to  avoid  sudden  or  great  exertion,  and 
violent  emotions ; while  by  means  of  diet  properly  regulated,  and  by 
gentle  exercise,  a due  supply  of  blood  is  maintained,  and  its  unequal 
distribution  between  the  lungs  and  liver  prevented.  Pain,  angina,  and 
paroxysmal  attacks  may  be  relieved  by  the  cautious  use  of  morphia, 
digitalis,  aconite,  and  other  sedatives,  used  as  palliative,  and  occasionally 
by  carminatives.  (Case  XCVIII.)  When  dropsy  appears,  we  may  delay 
its  advance,  and  often  get  rid  of  it  for  a time,  by  means  of  diuretics, 
sudorifles,  and  even,  if  the  strength  admit  of  it,  by  drastic  purgatives. 
According  to  Stokes,  the  action  of  these  remedies  may  occasionally  be 
assisted  by  mercurials.  For  any  other  purpose  they  are  useless.  When 
hypertrophy  exists  to  any  great  extent,  and  there  is  c/bvious  difficulty  in 
propelling  the  blood  through  the  lungs,  as  evidenced  by  excessive  dys- 
pnoea, lividity  of  the  face,  and  irregular  heart’s  action,  the  application  of 
a few  leeches,  or  cupping  to  the  extent  of  four  or  five  ounces  of  blood, 
frequently  gives  great  relief  for  a time.  Even  dry  cupping  is  often 
beneficial.  If  there  be  a tendency  to  faintness,  or  reason  to  suspect 
fatty  disease  of  the  heart,  in  addition  to  the  other  kinds  of  treatment 
referred  to,  a stimulant  should  always  be  at  hand  to  be  administered  at 
the  first  approach  of  syncope. 

FUNCTIONAL  DISORDERS  OF  THE  HEART. 

What  are  called  functional  disorders  of  the  heart,  are  in  fact  only 
symptoms  of  obscure  organic  diseases,  of  indigestion,  or  of  weakness  of 
the  general  system  from  alteration  of  the  blood.  They  assume  three 
principal  forms  : — 1st,  Angina  pectoris,  or  spasm  of  the  muscular  walls 

^ Edin.  Medical  and  Surgical  Journal,  vol.  xxxvii.,  1832. 


ANEUETSil. 


601 


of  tlio  heart,  causing  excruciating  pain  and  a feeling  of  sinking  difficult 
to  describe.  It  is  generally  induced  by  exertion.  We  have  seen  it 
accompany  organic  disease  of  the  organ  (Case  CIX.),  and  it  has  been 
frequently  observed  in  connection  with  fatty  heart  and  calcareous  de- 
generation of  the  coronary  valve.  2d,  In  chlorosis,  and  the  anaemia 
of  vouncr  women,  there  are  palpitations  with  a tendency  to  syncope, 
accompanied  by  a blowing  murmur  at  the  base  with  the  first  sound, 
of  soft  character  and  not  permanent.  It  is  propagated  in  the  course 
of  the  large  vessels,  on  placing  the  stethoscope  over  which,  a continuous 
buzzing  or  humming-top  murmur  is  audible  (^Bruit  de  diahle  of  the 
French).  The  cause  of  this  is  very  obscure,  and  is  by  some  said  to 
be  arterial,  and  by  others  venous.  (See  Diseases  of  the  Blood.)  3d, 
Similar  palpitations,  often  with  a small  heart,  in  young  men  who  follow 
sedentary  pursuits,  especially  students  of  the  learned  professions. 
Their  appetite  is  generally  defective,  the  body  weak  and  indisposed  to 
exertion,  the  mind  and  nervous  system  irritable,  and  the  sleep  pre- 
vented by  the  excessive  action  of  and  uneasy  sensations  attributed  to 
the  heart. 

The  treatment  in  all  these  cases  is,  when  it  is  dependent  on  weak- 
ness, to  increase  the  vigor  of  the  constitution  by  nutrients,  proper  exer- 
cise, and  the  administration  of  chalybeates.  In  chlorosis,  more  especially, 
the  different. preparations  of  iron  are  beneficial.  In  3mung  men  regulated 
exercise,  suspension  from  study,  attention  to  diet,  and  especially  re- 
moving the  attention  from  the  heart  at  night  by  cheerful  conversation, 
or  interesting  light  reading,  are  the  most  useful  means  of  removing  the 
disorder.  In  all  cases  the  concomitant  derangements  must  be  studied, 
and,  if  possible,  removed — such  as  amenorrhoea,  haemorrhoids,  sperma- 
torrhoea, dyspepsia,  etc.  etc. 


ANEURISM. 

Case  CXYII.'^ — Aneurism  of  Aortic  Valve,  coincident  ivith  a Systolic 
Murmur  at  the  Base  of  the  Heart — Pneumonia-Meningitis. 

History. — Margaret  Lament,  get.  86 — admitted  May  15th,  1861 — laboring  under 
all  the  signs  and  symptoms  of  acute  pneumonia,  of  six  days’  duration,  and  which,  on 
admission,  involved  the  whole  right  lung  from  apex  to  base.  Pulse  100,  of  moderate 
strength.  It  was  observed  that  the  first  sound  of  the  heart  was  prolonged,  but  unac- 
companied by  murmur.  She  was  treated  with  nutrients  and  a moderate  amount  of 
wine  ( § iv  daily). 

Progress  of  the  Case. — She  was  progressing  favorably,  the  greater  portion  of  the 
formerly  hepatized  lung  being  resonant  on  percussion,  and  giving  out  healthy  breath 
sounds,  when  on  May  22d  she  complained  of  severe  cephalalgia,  nausea,  and  febrile 
symptoms.  The  pulse  was  full,  regular,  and  slightly  jerking,  69  in  the  minute.  The 
chest  was  carefully  examined  physically  with  the  following  result.  “ There  is  still 
comparative  dulness  over  the  upper  third  of  right  lung  anteriorly.  Crepitation  has  dis- 
appeared from  every  part  of  the  chest.  There  is  now  a murmur  with  first  sound  of 
the  heart  at  its  base,  and  on  placing  the  stethoscope  above  the  right  clavicle,  between 
the  insertions  of  the  mastoid  and  trapezius  muscles,  there  is  a loud  blowing  murmur 
synchronous  with  the  pulse.”  May  23d — In  the  afternoon  experienced  a distinct 
rigor,  and  on  the  following  day  the  cephalalgia  was  much  increased,  and  all  the  symp- 
toms of  acute  meningitis  developed.  On  the  25^4  twelve  leeches  were  applied  to  the 
temples,  without  causing  any  relief.  On  the  26di  she  refused  all  food,  and  there  was 


* Reported  by  Mr.  John  Nicholson,  Clinical  Clerk. 


602 


DISEASES  OF  THE  CIKCULATORY  SYSTEM. 


delirium  night,  — Coma,  and  passage  of  evacuations  involuntarily.  On  the 

28^/i  diarrha^a,  sinking.  Died  on  the  29^/i  at  V a.  m. 

Sectio  Cadaveris. — Six  hours  after  death. 

Head. — Two  small  patches  of  yellow  purulent-looking  exudation  were  found  over 
the  posterior  part  of  the  right  hemisphere.  The  lateral  ventricles  contained  about  2 
oz.  of  fluid,  clear  at  the  top,  turbid  lower  down,  and  purulent  below.  There  was  no 
softening  of  the  septum  lucidum  or  central  parts  of  the  brain.  The  subarachnoid  space 
at  the  base  of  the  brain  was  inflltrated  with  purulent  matter,  as  far  back  as  the  upper 
part  of  the  medulla  oblongata. 

Thorax. — The  heart  was  of  natural  size.  The  aortic  valves  slightly  incompetent. 
When  the  aorta  was  laid  open,  a pouch  the  size  of  a field-bean,  of  a purple-red  color, 
projected  from  the  left  semilunar  valve.  The  most  prominent  portion  of  this  pouch 
was  very  delicate,  apparently  composed  only  of  an  expansion  and  prolongation  of  the 
endocardial  covering  of  the  valve — its  other  textures  having  been  lacerated.  The 
superior  half  of  the  upper-lobe  of  the  right  lung  was  condensed,  and  when  cut  into 
exhibited  the  red,  passing  into  the  grey  hepatization.  Many  of  the  granulations  were 
unusually  coarse,  presenting  small  collections  of  pus.  The  left  lung  was  healthy. 

Abdomen, — With  the  exception  of  a few  simple  cysts  in  the  ovaries,  the  abdominal 
organs  were  healthy. 

Commentary. — Though,  as  a pathologist,  I have  seen  several  exam- 
ples of  aneurism  of  an  aortic  valve,  this  is  the  only  one  in  which  the 
physical  signs  have  been  noted.  It  must,  from  its  appearance,  have  been 
of  recent  formation,  and  there  is  every  reason  to  believe  that  its  fornm- 
tion  was  coincident  with  the  blowing  murmur  heard  over  the  heart  on 
the  22d  of  May.  This  murmur  was  single,  synchronous  with  the  systole, 
and  was  probably  caused  by  the  impediment  offered  to  the  blood  when 
rushing  through  the  aortic  orifice.  Although  there  was  slight  incompe- 
tency of  the  valves  observed  after  death,  when  water  was  poured  into 
them  from  above,  this  could  not  have  occurred  during  life.  The  pouch- 
like formation  of  the  valve  still  permitted  it  to  perform  its  function,  and 
there  was  no  murmur  with  the  second  sound.  The  preparation  is  pre- 
served in  the  University  Museum,  although,  from  the  delicacy  of  the 
tissue  which  formed  the  aneurism — all  the  coats  of  the  valve  having  given 
Avay  except  the  endocardium — it  has  been  ruptured,  and  now  presents 
an  aperture  of  about  half  an  inch  in  diameter.  This  rupture  must  soon 
have  occurred  during  the  progress  of  the  case  had  life  been  prolonged. 
The  meningitis  following  pneumonia  is  similar  to  the  case  of  Murray  (p. 
367),  and  like  it  shows  the  lung  to  be  purulent,  although  the  exudation 
was  disappearing — a fact  the  importance  of  which  will  be  referred  to 
under  the  head  of  Pneumonia. 

Case  CXVIII.^ — Aneurism  of  the  Ascending  Arch  of  the  Aorta — Incompe- 
tency of  Aortic  Valves — Hypertrophy  of  Left  Ventricle. 

History. — Charles  Watt,  get.  31,  groom — admitted  June  19,  1850,  During  the 
last  eight  months  has  frequently  had  occasion  to  lift  heavy  Aveights,  and  has  occasion- 
ally felt  slight  pain  in  the  epigastrium.  This  suddenly  became  very  violent  on  the  8th 
of  June  ; and  the  next  day  on  walking,  he  exhibited  violent  dyspnoea.  On  the  11th 
he  was  cupped,  with  considerable  relief.  Has  been  aware  of  a pulsation  in  the  neck 
for  two  years,  but  never  suffered  any  inconvenience  from  it.  No  dysphagia. 

Symptoms  on  Admission. — The  cardiac  dulness  extends  three  inches  transversely. 
The  apex  beats  with  great  force  between  the  fifth  and  sixth  ribs,  two  inches  beloAA", 
and  a little  to  the  left  of  the  nipple.  A bellows  murmur  is  heard  with  the  second 


Reported  by  Mr.  David  Christison,  Clinical  Clerk. 


ANEUPJSir. 


603 


sound,  loudest  at  the  base.  The  first  sound  is  normal.  In  the  right  side  of  the  neck,  ■ 
immediiuely  above  the  sternum  and  clavicle,  there  is  a pulsating  tumor  the  size  of  a 
hen’s  egg,  extending  laterally  two  inches.  It  communicates  a strong  impulse  and  a 
pcculiai^tiirill  to  the  hand  placed  on  it,  and  over  it  there  may  be  heard  a loud  hoarse 
bellows  murmur,  synchronous  with  the  impulse  of  the  heart,  and  this  murmur  may  be  » 
heard  at  the  back,  extending  down  the  course  of  the  aorta.  Pulse  H,  regular,  hard, 
and  jerking,  alternating  with  the  impulse  at  the  apex,  stronger  in  the  right  than  the 
left  wrist.  Pain  in  the  epigastrium,  and  dyspnoea  on  exertion.  No  other  pulmonary 
symptoms.  Frequent  pain  in  the  left  temple,  extending  down  that  side  of  the  nose. 
Giddiness  on  rising  suddenly.  Frequent  muscae  volitantes. 

Progress  of  the  Case. — Continued  to  have  pain  in  the  epigastrium,  and  dyspnoea 
at  intervals.  He  was  treated  by  occasional  small  topical  bleedings,  which  always 
relieved  the  symptoms.  Blisters  also  were  now  and  then  applied,  and  latterly  small 
doses  of  aconite  given.  The  physical  signs  underwent  no  change,  but  the  distressing 
concomitant  symptoms  nearly  disappeared,  and  he  felt  so  well  that  he  was  dismissed, 
at  his  own  desire,  July  15. 

Commentary. — In  this  case  aortic  incompetency  was  proved  to  exist 
by  the  same  sign  as  we  have  seen  to  accompany  it  in  former  cases.  The 
visible  swelling,  dilfnse  pulsation,  and  bellows  murmur,  synchronous  with 
the  dilatation  of  the  vessel,  could  leave  little  doubt  that  an  aneurism  of 
the  aorta  existed.  It  became  a question,  however,  whether  the  iniiomi- 
nata  was  or  was  not  involved ; and  I am  inclined  to  consider  not,  from 
a variety  of  circumstances,  but  more  especially — 1st,  Because  the  pulse 
at  the  right  wrist  was  stronger  than  at  the  left ; 2d,  Because  the  pain  in 
the  head  and  face  was  on  the  left,  and  not  on  the  right  side  ; and,  3d,  Be- 
cause the  bellows  murmur  over  the  tumor  was  superficial,  anterior,  and 
propagated  down  the  back  in  the  course  of  the  aorta.  In  addition,  it 
could  be  argued  that  there  was  neither  dyspliagia  nor  dyspnoea,  while 
the  respiratory  murmurs  were  equally  loud  in  both  lungs.  Now  aneu- 
risms of  the  transverse  arch  of  the  aorta  press  against  the  most  convex 
part  of  the  trachea,  which  is  least  liable  to  compression,  whilst  the 
oesophagus  at  this  point  is  well  protected.  Hence  the  seat  of  the  aneu- 
rism explains  why  deglutition  and  respiration  were  not  interfered  with. 

Case  CXIX.^ — Aneurism  of  Ascending  Aorta  immediately  above  the  Aortic 
Valves — Ineompetency  of  Aortic  and  Mitral  Vahes—Uyyertropluj  of 
Left  Ventricle — Waxy  Kidneys — Pulmonary  Ilemorrliage. — Anasarca. 

History. — Kenneth  M‘Kenzie,  set.  ^2,  quarryman — admitted  October  31st,  1853. 
Has  been  more  or  less  subject  to  rheumatism  during  the  last  twelve  years.  Nine 
months  ago,  after  much  exposure  to  cold  and  v»^et,  he  complained  of  unusual  palpita- 
tion and  dyspnoea,  and  has  since  been  subject  to  paroxysms  of  breathlessness,  suffo- 
cation, and  a feeling  of  extreme  anxiety,  unattended  with  cough  or  expectoration. 
Three  weeks  ago  a mass  of  earth  and  loose  stones  fell  upon  his  back  between  the 
shoulders,  and  since  then  his  whole  body  has  been  painful  and  stiff,  and  the  other 
symptoms  much  aggravated. 

Symptoms  on  Admission. — The  impulse  of  heart  is  diffuse,  raising  more  espe- 
cially the  fifth  and  sixth  intercostal  spaces.  The  apex  beats  strongly  between  the 
fifth  and  sixth  ribs,  in  a vertical  line  below  the  left  nipple.  The  transverse  cardiac 
dulness  begins  at  the  margin  of  the  sternum,  and  extends  three  inches  and  a quarter 
outwards.  On  auscultation  a loud,  harsh,  but  somewhat  musical  murmur,  is  heard 
at  the  apex  with  the  first  sound,  immediately  followed  by  the  second  sound,  which 
is  rather  sharp  and  rough,  but  without  murmur.  At  the  base  there  is  a blowing 
murmur  with  both  sounds,  which  are  particularly  marked  over  the  articulation  of 
the  fourth  rib  with  the  sternum.  Over  the  great  vessels  at  the  root  of  the  neck,  a 

* Reported  by  Mr.  William  Calder  and  Mr.  Almeric  Seymour,  Clinical  Clerks. 


G04 


DISEASES  OF  THE  CIECULATOET  SYSTEM. 


single  blowing  murmur  is  heard  synchronous  with  the  pulse  at  the  wrist,  and  this  is 
heard  loudest  immediately  above  the  sternal  end  of  the  clavicle.  At  this  point  a dis- 
tinct impulse  may  be  felt  with  the  finger,  and  even  seen  by  the  eye,  but  no  circum- 
scribed swelling  can  be  made  out.  A similar  impulse  and  murmur  exists  above  the 
left  clavicle,  but  not  so  distinct.  Pulse  90,  strong,  and  rather  jerking.  Has  frequent 
palpitation  and  dyspnoea,  sometimes  coming  on  when  lying  quite  still,  and  always  on 
making  any  unusual  exertion.  Percussion  over  the  lungs  everywhere  good.  On  the 
right  side,  harsh  inspiration  both  anteriorly  and  posteriorly.  Has  a copious  expecto- 
ration of  frothy  mucus.  Breathing  somewhat  labored  and  wheezing.  The  appetite  is 
not  good,  but  the  digestive  system  is  otherwise  normal.  Has  occasional  headache  and 
a frequent  feeling  of  dizziness,  with  muscge  volitantes.  Palpitation  and  dyspnoea,  when 
severe,  often  occasion  faintness.  Other  functions  normal. 

Progress  of  the  Case. — During  the  month  of  November  there  was  little  change 
in  his  condition,  although  the  symptoms  were  somewhat  alleviated  by  quietude  and 
treatment.  December  %th. — Last  night  was  seized  with  pains  in  the  right  chest,  accom- 
panied with  great  difficulty  of  breathing.  To-day,  on  auscultation,  crepitating  rale  is 
mingled  wdth  harsh  inspiration,  and  sibilant  and  sonorous  rhonchi  on  expiration.  Per- 
cussion and  vocal  resonance  good.  No  rigor  or  fever.  Dec.  22c?. — Since  last  report, 
the  attacks  of  dyspnoea  have  become  more  urgent,  and  now  he  cannot  assume  the 
recumbent  posture.  Expectoration  is  copious  and  slightly  tinged  with  blood.  On  the 
13th  oedema  of  the  ankles  made  its  appearance,  and  on  examining  the  urine,  it  was 
found  to  be  highly  albuminous.  Pulse  60,  jerking.  Dec.  29?A. — (Edema  of  inferior 
extremities  has  now  extended  to  the  thighs  and  scrotum,  and  is  rapidly  increasing. 
Amount  of  urine  passed  daily  much  diminished,  and  highly  albuminous.  Orthopnoea 
at  night,  and  great  dyspnoea  at  all  times.  Sputum  largely  mixed  with  blood.  Dulness 
on  pci’cussion  over  lower  third  of  right  lung  posteriorly.  January  Mh. — Since  last  re- 
port there  has  been  general  anasarca,  with  great  distension  of  the  inferior  extremities 
and  scrotum.  Has  been  unable  to  assume  the  recumbent  posture,  and  been  obliged  to 
pass  the  night  leaning  forward  on  a table.  The  urine  has  continued  very  scanty,  and 
the  pulse,  though  still  jerking,  has  gradually  become  weak.  He  gradually  became  ex- 
hausted, and  died  Jan.  9th,  at  11  a.m.  The  treatment  consisted  at  first  of  abstraction 
of  small  quantities  of  blood  from  over  the  heart  or  lungs,  by  cupping  or  leeches,  which 
alv/ays  produced  temporary  relief.  Expectorants  and  anodynes  to  relieve  cough,  favor 
expectoration,  and  promote  sleep.  Antispasmodics  to  diminish  dyspnoea.  When  the 
dropsy  appeared,  diuretics  and  afterwards  hydragogue  cathartics  caused  relief,  and  for 
a time  diminished  the  accumulation  of  the  fluid. 

Sectio  Cadaver  is. — Twenty-jive  hours  after  death. 

Head. — Considerable  effusion  in  suljarachnoid  cavity.  Lateral  ventricles  contained 
3 iij  of  clear  serum.  Brain  otherwise  healthy. 

Thorax. — Heart  much  enlarged,  weighing  28  ounces.  This  was  owing  almost 
entirely  to  hypertrophy  of  the  left  ventricle,  its  cavity  being  dilated  and  w'alls  much 
thickened.  The  aortic  valves  were  shortened,  thickened,  and  incompetent.  The  mar- 
gins of  mitral  valve  were  thickened,  and  the  cliordm  tendineas  shortened  and  thickened. 
The  lining  membrane  of  the  aorta  was  rough  and  irregular  fi’om  atheromatous  and  cal- 
careous degeneration.  Immediately  above  the  sigmoid  valve,  which  is  next  the  right 
ventricle,  was  an  aneurismal  pouch  the  size  of  a walnut.  It  contained  no  coagula, 
w;as  formed  by  a dilatation  of  all  the  aortic  coats,  and  its  internal  surface  wms  rough 
from  atheromatous  degeneration.  The  entire  arch  of  the  aorta  was  also  rough  from  a 
similar  cause,  but  the  descending  aorta  was  normal.  Both  lungs  were  oedematous.  In 
the  right  lung  were  several  masses  of  coagulated  extravasated  blood,  generally  about 
the  size  of  a walnut. 

Abdomen. — The  kidneys  presented  the  waxy  degeneration.  Other  abdominal 
organs  healthy. 

Commentary. — This  case  is  an  example  of  a commencing  aneurism  at 
the  root  of  the  aorta,  although  it,  like  the  last,  may  be  regarded  essen- 
tially as  a cardiac  disease,  as  the  physical  signs  indicated  both  mitral 
and  aortic  incompetency.  It  was  the  loud,  single  blowing,  synchronous 
with  the  systole,  combined  with  the  distinct  impulse  felt  and  seen  over 
the  clavkle,  which  pointed  to  an  aortic  aneurism.  The  size  of  this 
aneurism  could  not  be  large,  as  percussion  failed  to  detect  any  dulness 


aneurism:. 


605 


over  the  chest;  and  although  he  at  first  said  that  deglutition  had  been 
slightly  impaired,  this  symptom  was  afterward  ascertained  not  to  be 
present.  The  aneurism  may  have  assisted  in  producing  the  iucompetency 
of  the  aortic  valves,  which,  with  the  aneurism  itself,  was  occasioned  by 
the  chronic  arteritis,  and  subsequent  atheromatous  degeneration  of  the 
arch  of  the  aorta.  At  what  time  the  mitral  disease  commenced  was  un- 
known, but  it  was  comparatively  subordinate  to  the  aortic  disease,  and 
was  followed  by  hypertrophy  of  the  left  ventricle,  and  the  pulmonary 
complication.  The  renal  lesion  came  on  when  he  was  in  the  ward,  and 
we  need  not  be  surprised  at  the  universal  and  rapid  anasarca  which, 
under  such  circumstances,  proved  fatal.  Treatment  under  such  circum- 
stances could  only  be  palliative. 

Case  CXX.'* — Aneurism  of  Ascending  Arch  of  Aorta — Chronic  Peri- 
carditis— Disease  of  Aortic  Valves — Great  Hypertrophy  of  Heart 
— Anasarca. 

History. — Robert  Laing,  aet.  53,  married,  a bookbinder — admitted  January  11th, 
1854.  States  that  he  never  had  rheumatism,  and  cannot  account  in  any  way  for  his 
illness,  which  he  dates  from  about  four  months  ago ; previously  to  that  time  he  was 
in  the  enjoyment  of  excellent  health.  Palpitation  and  dyspnoea  were  the  first  symp- 
toms he  noticed,  and  a strong  pulsation  in  the  back  was  observed  by  his  wife,  ffidema 
of  the  lower  limbs  came  on  about  a month  afterwards,  and  has  since  gradually  in- 
creased. During  his  illness  he  was  treated  with  diuretic  remedies,  which  produced 
temporary  diminution  of  the  dropsy.  A few  days  before  admission,  the  dyspnoea  be- 
came very  urgent,  but  was  somewhat  relieved  by  venesection  to  the  amount  of  a few 
ounces. 

Symptoms  on  Admission. — The  impulse  of  the  heart  is  Aveak  and  diffused  over  con- 
siderable part  of  the  fifth  intercostal  space,  being  felt  most  distinctly  in  a line  perpen- 
dicularly below  the  nipple.  Dnlness  on  percussion  extends  from  the  left  nipple  across 
the  chest,  nearly  as  far  as  the  right  nipple  ; upwards  on  the  left  side  it  extends  as  far 
as  to  the  third  intercostal  space,  but  above  that  line  percussion  is  normal.  On  the 
right  side,  dulness  extends  from  apex  to  base,  over  a space  bounded  by  the  sternum 
within,  and  a line  drawn  vertically  through  the  nipple  externally.  The  heart  sounds 
are  much  obscured  by  pulmonary  rales  ; in  the  usual  situation  they  are  feeble,  and 
their  precise  character  cannot  be  determined.  Over  the  upper  two-thirds  of  the  right 
side  of  the  chest,  as  far  out  as  the  nipple,  there  is  very  loud  hoarse  double  murmur ; 
no  impulse  can  be  felt  in  that  region.  Pulse  76,  and  of  jerking  aortic  character;  reg- 
ular, and  of  equal  strength  on  both  sides.  Posteriorly  the  chest  is  resonant  every- 
where, and  loud,  sonorous,  and  sibilant  rales  are  heard ; expiration  is  considerably 
prolonged.  Dyspnoea  considerable ; there  is  some  cough  with  frothy  mucous  expec- 
toration. The  inferior  extremities  and  scrotum  are  enormously  distended,  and  pit  on 
pressure ; the  abdomen  is  swollen,  and  fluctuation  can  be  detected ; the  face  is  pale 
and  somewhat  sallow.  Appetite  much  impaired  ; thirst  considerable.  He  can  lie 
only  on  his  back  or  his  right  side.  Has  considerable  difficulty  in  speaking.  Urine 
very  scanty  and  muddy  in  appearance. 

Progress  of  the  Case. — January  Wth  to  \Zth. — Was  treated  with  antispasmodics 
and  hydragogue  cathartics,  and  afterwards  with  leeches  to  the  praecordia,  which  last 
measure  relieved  the  dyspnoea  considerably.  On  the  morning  of  the  13th,  on  awaken- 
ing, he  called  the  nurse ; immediately  afterwards  he  fell  into  a state  of  stupor  from 
which  he  could  not  be  roused.  His  pulse  was  120,  weak  ; the  pupils  were  strongly 
contracted.  Brandy  and  carbonate  of  ammonia  were  administered,  but  he  continued 
in  the  same  state  for  two  hours,  and  then  died. 

Sectio  Cadaveris. — Twenty -seven  hours  after  death. 

Great  anasarca  of  the  body. 

Thorax. — The  veins  of  the  neck  greatly  engorged,  so  that  on  cutting  them  across 
a large  quantity  of  black  fluid  blood  escaped.  On  removing  the  sternum,  the 


* Reported  by  Mr.  Robert  Bird,  Clinical  Clerk. 


600 


DISEASES  OF  THE  CIECULATOEY  SYSTEM. 


I 

pericardium  was  seen  to  extend  in  a transverse  direction  from  nipple  to  nipple,  so  as 
to  measure  eight  inches  across.  On  being  opened,  it  was  found  to  contain  two  ounces 
of  serum.  Over  the  anterior  and  posterior  pericardial  surface  of  all  the  cavities,  but 
especially  the  anterior  surface  of  the  right  ventricle,  masses  of  old  lymph  were  attached 
■ — in  some  places  smooth,  in  others  rough  and  shaggy.  The  heart  was  enormously  en- 
larged ; the  cavities  of  both  ventricles,  but  especially  of  the  right,  were  increased  in 
size.  Their  walls  also  and  the  septum  were  much  thicker  than  natural.  The  aortic 
valves  were  thickened,  and  could  not  be  applied  against  the  walls  of  the  aorta  in  con- 
sequence of  masses  of  calcareous  matter  deposited  at  their  bases.  The  whole  internal 
surface  of  the  aorta  was  rough  and  thickened  by  atheromatous  degeneration.  Imme- 
diately above  the  semilunar  valves  was  an  aneurismal  pouch,  springing  from  the  aorta. 
The  opening  into  it  was  rather  larger  than  a crown-piece,  and  was  perfectly  round. 
Above  this  aneurism,  formed  by  a dilatation  of  all  the  coats  of  the  vessel,  was  another, 
formed  only  of  the  middle  and  external  coats.  Into  this  there  were  two  openings — 
one  above  the  size  of  a shilling,  the  other  a fourth  of  that  size.  This  second  pouch 
was  partly  filled  by  coagulated  blood.  Externally,  the  aneurism  was  applied  immedi- 
ately over  the  right  auricle,  was  of  a flattened  oval  form,  and  about  the  size  of  a cocoa- 
nut.  The  mitral  valve,  and  those  on  the  right  side  of  the  heart,  were  healthy.  The 
pleurse  on  the  left  side  were  thickened  and  universally  adherent.  At  the  lower  part 
of  upper  lobe  it  was  of  cartilaginous  consistence,  over  a space  the  size  of  a crown-piece. 
The  lung  was  slightly  emphysematous  at  its  anterior  margin.  Bronchi  contained 
mucopurulent  matter.  The  right  lung  was  not  adherent  anywhere.  At  the  apex  were 
numerous  emphysematous  bullm  the  size  of  peas.  Inferiorly  and  posteriorly,  the  pul- 
monary tissue  was  collapsed  in  several  places. 

Abdomen. — The  liver  and  kidneys  were  considerably  congested  ; otherwise  healthy. 
Other  organs  natural. 

Commentary. — In  this  case  the  aneurism  originating  from  the  ascend- 
ing portion  of  the  aortic  arch  was  the  size  of  a cocoa-nut,  and  was  formed 
on  the  right  side.  During  the  life  of  the  patient  it  was  supposed  to  be 
much  larger  in  consequence  of  the  extended  dulness,  which  was  afterwards 
determined  to  be  partly  dependent  on  the  dilated  pericardium.  The  chronic 
pericarditis  gave  rise  to  no  symptoms,  but  probably  assisted  in  causing  the 
heart’s  sounds  to  be  obscured,  which,  however,  were  sufficiently  masked  by 
the  bronchitic  rales.  The  loud  double  murmur  heard  on  the  right  of  the 
sternum  was  most  probably  owing  to  the  flux  and  reflux  of  the  blood  into 
the  first  aneurismal  pouch  ; for  although  similar  sounds  might  have  origin- 
ated from  the  diseased  aortic  orifice,  they  would  be  rendered  inaudible  by 
the  pericarditis  and  bronchitis.  The  complications  here  were  formidable, 
and  the  man  died  rather  from  the  heart  disorder  than  from  the  aneurism. 

Case  CXXI."^ — Large  Aneurism  of  the  Ascending  Arch  of  the  Aorta, 
causing  Absorption  of  a portion  of  the  Third  Rib,  and  bursting 
into  the  PeHcardium — Chronic  Pericarditis — Incompetency  of 
Aortic  Valves — Hypertrophy  of  Left  Ventricle. 

History. — James  M‘Killop,  ast.  24,  laborer,  of  intemperate  habits — admitted  Janu- 
ary 12th,  IBS'?.  He  says  that  two  years  and  a half  ago,  while  engaged  in  lifting  a heavy 
weight,  he  suddenly  felt  something  give  way  in  the  region  of  the  left  chest.  From  that 
period  he  became  subject  to  a beating  in  that  locality,  but  suffered  no  other  inconven- 
ience till  about  four  months  ago,  when  he  experienced  a numbness  down  the  left  arm. 
For  the  last  twelve  months  he  has  observed  his  left  chest  to  be  somewhat  swollen.  Six 
weeks  ago  he  first  felt  dyspnoea,  which  was  increased  on  exertion,  and  was  attended 
with  frequent  cough.  Two  weeks  afterwards,  he  observed  his  face  and  neck  begin  to 
swell,  and  this  has  gradually  gone  on  until  now.  Continued  to  work  till  six  weeks  ago. 

Symptoms  on  Admission. — Apex  of  heart  beats  between  the  fifth  and  sixth  ribs,  in- 
ternal to  and  below  the  left  nipple.  It  is  feeble  and  diffused.  A heaving  pulsation  is 
also  felt  over  the  upper  part  of  the  left  chest,  synchronous  with  the  cardiac  impulse, 

* Reported  by  Mr.  H.  N.  Maclaurin,  Clinical  Clerk. 


AXEUEISM, 


C07 


having  also  an  expansive  lateral  motion.  On  percussion,  at  a level  with  the  nipple, 
cardiac  transverse  dulness  is  three  inches.  Above  this  there  is  a dull  space,  bounded 
by  a curved  line,  which  passes  internally  to  mid-sternum,  superiorly  to  the  lower  bor- 
der of  the  first  rib,  and  externally  as  far  as  a line  passing  vertically  through  the  left 
nipple.  This  space  measures  four  inches  from  above  downwards,  and  five  inches 
transversely.  It  bulges  forwards  visibly  more  than  the  corresponding  part  on  the 
opposite  side,  especially  in  the  second  intercostal  space,  two  and  a half  inches  from 
the  sternum.  On  auscultation  at  the  heart’s  apex,  a double  blowing  murmur  is  audi- 
ble, which,  however,  evidently  originates  at  the  base,  where  it  is  loudest,  the  first 
murmur  being  rough,  and  the  second  comparatively  soft.  All  over  the  region  of  the 
pulsating  tumor  there  is  a double  murmur,  the  first  not  so  loud  as  the  second.  They 
are  most  distinct  towards  the  outer  margin  of  the  dull  space  formerly  described,  espe- 
cially at  a point  one  inch  above  the  left  nipple.  Over  both  clavicles  there  is  a single 
rough  blowing  murmur.  Posteriorly,  no  coni})arative  dulness  can  be  made  out  on  per- 
cussion. On  applying  the  hand  at  the  base  of  both  lungs,  fremitus  is  perceptible  with 
the  inspiratory  acts,  most  marked  in  the  left  side.  On  auscultation,  a double  murmur 
is  audible  all  over  the  left  back,  loudest  between  the  vertebra3  and  the  edge  of  scapula. 
Radial  pulse  108,  small  but  strong,  without  any  difference  in  the  two  wrists.  Both 
external  jugular  veins  are  somewhat  distended,  so  tliat  the  position  of  the  valves  may 
be  readily  perceived.  On  auscultation  over  both  lungs,  harsh  sonorous  rales  are  audi- 
ble, with  occasional  moist  sounds.  Expiration  much  prolonged.  Has  tickling  in  the 
larynx ; occasional  cough  of  a hard  and  somewhat  clanging  character ; expectoration 
is  mucous,  not  copious  ; considerable  dyspnoea,  especially  on  exertion,  and  pain  in  the 
left  chest  and  shoulder,  with  numbness  in  left  arm  ; sleep  is  disturbed  ; irides  normal ; 
strength  diminished  ; considerable  oedema  of  face,  neck,  and  chest  only ; eyelids  puffy ; 
skin  hot ; appetite  good ; deglutition  imaficcted.  Digestive,  urinary,  and  other  func- 
tions normal.  Eight  leeches  to  he  applied  over  tumor  in  left  chesty  a'tid  to  take  a table- 
spoonful every  two  hours  of  the  following  mixture ; — R Sp.  ^ther.  Sulph.  ; Sp.  Ammon. 
Aromat.  aa  3 j ; Tr.  Card.  comp.  3 iij  ; Aquam  ad  | iij.  M. 

Progress  op  the  Case. — January  \1th. — Little  benefit  followed  the  application  of 
the  leeches.  Yesterday  §v  of  blood  were  removed  by  cupping,  and  caused  great  relief. 
(Edema  of  the  face  lessened.  Jan.  22cZ. — Complains  of  pain  passing  from  tumor  to 
middle  of  left  back.  Venesectio  ad  3 x.  Jan.  24//i. — § xj  of  blood  were  taken  from 
the  arm,  causing  instantaneous  relief  from  the  pain  and  tingling  in  the  arm.  The  re- 
lief continued  till  to-day,  when  the  pain  has  returned.  Pulse  100,  sharp.  Other  symp- 
toms the  same.  Alorphia  and  Ether  draught.  Jan.  29th. — Pain  continues.  Dyspnoea 
and  cough  have  increased.  Face  and  neck  again  very  oedematous.  To  be  cupped 
over  left  breast,  and  § vj  of  blood  taken.  Eeb.  2(/.— Was  again  greatly  relieved  by 
the  cupping.  Complains  of  tickling  in  the  larynx.  The  tumor  has  extended  some- 
what upwards,  and  its  pulsation  is  distinctly  felt  at  the  right  border  of  the  sternum 
opposite  the  second  rib.  R Th/.ct.  LobcUcc  Infiatas  3 ij ; Sol.  Mur.  Morph.  3j; 
Aquam  ad  ^ vj.  M.  One  table-spoonful  three  times  in  the  night.  Expired  suddenly  at 
V P.M.  on  the  8th,  the  symptoms  having  undergone  little  change. 

Sectio  Cadaveris. — Thirty-two  hours  after  death. 

Body  not  emaciated.  Left  side  of  thorax  rather  fuller  than  right. 

Thorax. — There  was  some  oedema  of  the  parietes,  greater  upon  the  left  than  the 
right  side.  On  reflecting  the  soft  parts,  there  was  an  evident  prominence  in  the  left 
mammary  region,  rounded  in  form,  and  about  two  and  a half  inches  in  diameter.  The 
pericardium  was  much  distended,  and  contained  twenty  ounces  of  blood.  An  aneurism 
arose  from  that  portion  of  the  ascending  aorta  contained  within  the  pericardium,  com- 
mencing immediately  above  the  semilunar  valves  and  the  origin  of  the  coronary  arte- 
ries. The  aorta  below  this  point  was  not  dilated.  The  aneurism  anteriorly  appeared 
to  be  divided  into  two  lobes ; the  left,  much  larger  than  the  right,  and  of  the  size  of  a 
large  cocoa-nut,  passed  upwards  and  forwards,  its  long  diameter  being  nearly  parallel 
to  the  anterior  wall  of  the  thorax,  to  which  the  greater  part  of  its  surface  was  adherent ; 
the  right,  larger  than  a turkey’s  egg,  passed  backwards  and  a little  downwards,  its  long 
diameter  being  nearly  parallel  to  the  base  of  the  thorax.  The  anterior  extremity  of 
the  right  lobe  did  not  approach  within  two  inches  of  the  thoracic  wall.  Posteriorly  no 
such  division  into  lobes  could  be  seen,  but  merely  a single  large  aneurismal  sac  divided 
into  two  compartments  by  the  aorta.  The  left  pouch  was  found  adherent  to  the  poste- 
rior surface  of  the  sternum,  between  the  junctions  of  the  second  and  fourth  ribs,  and 


608 


DISEASES  OF  THE  CIECULATOKY  SYSTEM. 


to  the  cartilages  and  part  of  the  bodies  of  second,  third,  and  fourth  ribs.  Over  this 
space,  measuring  about  six  inches  across,  and  nearly  four  vertically,  the  sac  could  not 
be  separated  from  the  thoracic  parietes ; on  the  contrary,  the  finger  introduced  into 
the  sac  detected  rough  exposed  bone  in  various  situations,  corresponding  to  the  promi- 
nence observed.  Externally  there  was  a gap  in  the  thoracic  wall,  formed  by  the 
absoi’ption  of  a considerable  portion  of  the  third  rib,  external  to  its  junction  with  its 
cartilage.  The  recurrent  nerves  were  displaced  and  stretched,  especially  the  left,  in 
consequence  of  the  transverse  portion  of  the  arch  of  the  aorta  being  pushed  backwards. 
A rupture  of  the  aneurism  into  the  pericardium  had  taken  place  at  the  most  dependent 
part  of  the  larger  sac,  at  a point  corresponding  to  the  right  margin  of  the  sternum  be- 
tween the  junction  of  the  fifth  and  sixth  right  costal  cartilages  with  the  sternum,  but 
about  two  inches  behind  it.  The  orifice  was  of  a linear  form,  half  an  inch  in  length, 
and  immediately  overhanging  the  right  auricle.  Tlie  sac  contained  chiefly  loose  clots, 
but  some  imperfect  layers  of  decolorised  tough  fibrin  were  in  some  places  adherent  to 
its  walls.  The  heart  was  displaced  downwards  and  backwards.  The  larger  sac  inter- 
vened between  it  and  the  thoracic  walls,  so  that  its  base  was  on  a level  with  the  lower 
margin  of  the  fourth  rib,  and  five  inches  behind  it.  The  heart  was  hypertrophied,  but, 
as  it  was  kept  attached  to  the  preparation,  it  could  not  be  weighed.  The  hypertrophy 
was  most  marked  in  the  left  ventricle.  The  surface  of  the  heart  was  roughened  by 
shaggy  growths  of  old  plastic  lymph,  most  abundant  over  the  left  ventricle.  Pericar- 
dium not  adherent.  The  aortic  valves  were  evidently  incompetent,  being  opaque, 
thickened,  and  shortened.  There  was  a small  aneurism  of  this  portion  of  the  arch, 
between  the  origin  of  the  innominate  and  left  carotid  arteries,  and  partially  involving 
the  commencement  of  each  of  these  vessels.  It  was  about  the  size  of  a large  filbert. 
The  lining  membrane  of  the  thoracic  and  abdominal  aorta  was  but  slightly  atheroma- 
tous. The  larynx  was  quite  natural.  The  right  bronchus  was  compressed  at  the  point 
of  adhesion  between  the  lung  and  the  smaller  sac  The  substance  of  the  lungs  was 
quite  natural.  The  right  pleura  contained  a pint  and  a half  of  clear  serum. 

Abdomen. — Abdominal  organs  healthy. 

Commentary. — In  tins  case,  the  aneurismal  tumor  developed  itself 
on  the  left  side,  and  caused  a visible  swelling  with  protrusion  in  the  left 
chest.  It  was  of  larger  size,  and  of  older  growth  than  in  the  previous 
cases,  and  by  constant  pressure  forwards  on  the  ribs  had  occasioned 
caries  and  interstitial  absorption  of  the  bones.  In  consequence  of  press- 
ure posteriorly  on  the  bronchus,  and  recurrent  nerve,  it  occasioned  harsh 
cough  and  tickling  of  the  larynx.  Although  here  also  the  aortic  valves 
were  incompetent,  the  sounds  were  marked  by  a loud  double  blowing 
murmur,  evidently  connected  with  the  aneurism,  because  they  were 
audible  in  the  left  back.  Only  one  sound,  however,  could  be  heard  at 
the  root  of  the  neck  above  the  clavicles,  owing  to  a dilatation  of  the  aorta 
between  the  innominate  and  left  carotid  arteries.  In  this,  as  in  Case 
CXX.  a chronic  pericarditis  existed,  which  was  not  indicated  by  any 
symptoms.  The  relief  to  symptoms  by  small  abstractions  of  blood  was 
particularly  well  marked,  although  it  is  perhaps  almost  unnecessary  to 
say  that  the  real  disease  was  in  no  way  altered,  and  continued  its  march 
towards  a fatal  termination.  (For  a case  of  thoracic  aneurism  bursting 
into  the  pleura  see  Case  LXXIX.) 

Case  CXXII.'^ — Varicose  Aneurism  of  the  ascending  Aorta  communi- 
cating ivith  the  Pulmo7iary  Artery — Jaundice  and  Nutmeg  Liver. 

History. — Alexander  Calder,  set.  33,  a teacher — admitted  June  11th,  1855.  He 
had  always  enjoyed  good  health  until  the  beginning  of  last  February,  when  he  felt  a 
pain  under  the  ensiform  cartilage,  which'felt  like  the  pricking  of  a pin,  and  continued 
for  a week.  About  a fortnight  after  this,  while  walking  hastily,  he  felt  as  if  some- 
thing had  given  way  below  the  ensiform  cartilage,  which  caused  him  to  slacken  his 
pace,  and  produced  a sensation  of  weakness.  He  continued  to  feel  weak  for  a fort- 

* Reported  by  Mr.  Robert  Byers,  Clinical  Clerk. 


ANEURISM. 


609 


night,  and  then  resumed  his  duties,  though  far  from  well.  During  the  next  two  months 
he  occasionally  expectorated  a little  blood,  and  experienced  cardiac  palpitation.  Two 
months  ago  he  lost  blood  at  stool  (6  or  8 ounces  passing  at  a time  during  three  days), 
which  was  regarded  as  dysenteric.  He  has  long  been  subject  to  hemorrhoids.  Last 
April  his  feet  began  to  swell,  and  the  abdomen  to  enlarge,  symptoms  which  have  con- 
tinued more  or  less  since.  Latterly  the  palpitation  has  increased,  and  there  has  been 
considerable  dyspnoea  and  cough,  with  occasional  vomiting. 

Symptoms  on  Admission. — On  percussion,  the  transverse  dulness  of  the  heart 
measures  three  inches.  Its  impulse  is  diffused,  strong,  and  irregular.  On  ausculta- 
tion, a soft  blowing  murmur  is  heard  over  the  apex  with  the  first  sound,  and  the  second 
sound  is  distant  but  healthy.  At  the  junction  of  the  third  costal  cartilage  with  the 
sternum,  the  first  sound  is  loud,  prolonged,  and  blowing ; the  second  is  short,  abrupt, 
and  rasping.  Over  the  manubrium  of  the  sternum  there  is  a rough  continuous  blow- 
ing murmur,  occupying  the  period  of  both  sounds.  The  same  murmur  is  audible  under 
both  clavicles  and  to  the  right  of  the  manubrium,  but  is  there  softer  and  more  distant. 
Pulse  90,  irregular,  but  of  natural  strength.  He  has  considerable  dyspnoea  on  going 
up  stairs,  and  a trifling  cough.  Over  the  anterior  surface  of  chest  the  respiratory 
murmurs  are  harsh,  but  otherwise  percussion  and  auscultation  furnish  no  signs  of 
pulmonary  disease.  Pressure  over  the  stomach  is  painful.  Tongue  clean ; vomits 
once  or  twice  a day  after  coughing.  Abdomen  rather  tumid,  but  percussion  and  pal- 
pation discover  nothing  abnormal.  The  feet,  legs,  and  thighs,  are  oedematous,  pitting 
strongly  on  pressure.  Urine  small  in  quantity  and  high  in  color.  It  contains  a super- 
abundance of  lithates,  but  no  albumen.  Sp.  gr.  1025.  The  other  functions  are  well 
performed.  He  has  taken  a variety  of  remedies ; at  one  time  drastic  purgatives,  and 
at  another  the  strongest  diuretics,  all  of  which  have  only  produced  temporary  relief. 
U Sp.  ^ther.  Nit.  3 ij  ; Tinct.  Hyoscyami  3 ij  ; Ammon.  Acetat.  3 ij  ; Aquee 
§ vj.  M.  Habeat.  § j ter  die. 

Progress  of  the  Case. — June\%th. — The  restand  quietude  he  now  enjoys  have 
apparently  benefited  him,  but  he  sleeps  little.  I^  Sp.  JEther  Sulpli.  min.  xv ; Sol. 
Mur.  Morph,  min.  xx.  Ft.  haustus.  To  be  taken  at  bed-time.  June  \^th. — The 
breathing  is  more  embarrassed,  and  the  oedema  of  the  lower  extremities  increased. 
The  cough  also  is  more  severe,  and  he  has  vomited  every  meal.  Pulse  100,  weak. 
U Sp.  yEther.  Nit.  3j;  Sol.  Mur.  Morph.  3j;  Mist.  Camphor ce  3jss.  AT.  Half 
to  be  taken  at  5 p.m.,  the  rest  at  bed-time.  June  'list. — Since  last  report  the  skin  has 
gradually  become  jaundiced,  and  the  features  are  now  shrunk  and  anxious,  pulse  128, 
weak.  Vomiting  was  checked  by  the  medicine  ordered,  but  he  is  unable  to  take  food, 
or  stimulants.  ^ Ammon.  Carb.  gr.  v ; Tinct.  Card.  Comp.  3 ij ; Mist.  Camph. 
§ iss  ; half  to  be  taken  immediately.^  and  the  other  half  in  an  hour.  June  ^1d. — Con- 
tinues to  sink,  notwithstanding  tin;  liberal  administration  of  stimulants  and  nutrients. 
Died  at  half-past  two  on  the  morning  of  June  23d. 

Sectio  Cadaveris. — Thirty-four  hours  after  death. 

External  Appearances. — The  general  surface  and  conjunctivse  of  a yellow  tinge 
— lower  extremities  oedematous ; and  several  phlyctenae,  filled  with  sanguinolent  serum, 
existed  on  the  trunk  and  upper  part  of  the  thighs. 

Thorax. — The  pericardium  was  natural  ; it  contained  § ss  dark-colored  serum. 
On  removing  the  heart  a bulging  was  observed  between  the  aorta  and  pulmonary 
artery.  Seen  externally  it  appeared  to  rise  from  the  latter  vessel.  It  was  of  a 
rounded,  rather  flattened  form,  somewhat  smaller  than  a chestnut ; when,  however, 
the  finger  was  passed  down  the  aorta  it  entered  this  bulging,  which  proved  to  be 
an  ancurismal  sac,  rising  from  the  root  of  the  aorta.  A stream  of  water  passed 
down  the  aorta  escaped  rapidly  at  first ; but  the  latter  portion  was  retained  by  the 
semilunar  valves,  which  proved  competent.  On  laying  open  the  aorta,  the  aneurism 
was  found  to  commence  immediately  above  the  semilunar  valves.  Its  opening  into 
the  vessel  was  circular,  and  rather  smaller  than  a florin.  The  sac  itself  was  of 
an  irregularly  rounded  form,  its  greatest  diameter  (from  above  downwards)  being 
two  inches.  Its  capacity  about  that  of  a large  walnut.  The  sac  was  empty,  and 
contained  no  trace  of  a clot.  At  the  apex  of  the  tumor  was  found  an  opening, 
which  passed  into  the  pulmonary  artery.  (The  sac,  as  already  mentioned,  was 
closely  applied  to  this  vessel.)  When  the  pulmonary  artery  was  cut  open,  the  com- 
munication became  more  distinct.  This  opening  was  about  four  lines  in  length, 
and  the  lips  a line  and  a half  apart,  so  that  it  was  oval  in  form,  with  its  margin 
slightly  rounded  off.  It  was  situated  transversely  to  the  length  of  the  pulmonary 


610 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


artery,  and  was  rather  more  than  an  inch  higher  up  than  the  point  of  union  of  two 
of  the  pulmonary  semilunar  valves.  The  whole  of  the  cardiac  valves  were  natural. 
The  left  ventricle  was  rather  more  capacious  than  usual ; its  walls  were  of  the  normal 
thickness.  The  right  ventricle  was  also  a little  dilated  ; its  walls  were  more  decidedly 
hypertrophied.  The  heart  weighed  15-^  ounces.  On  section  of  both  lungs,  they  were 
seen  to  contain  several  diffused  patches  of  extravasated  blood,  recent  and  confined  to 
the  air  cells. 

Abdomen. — In  the  cavity  of  the  abdomen  was  about  a pint  of  turbid  serum.  The 
liver  when  cut  into  exhibited  congestion  of  the  portal  capillaries,  causing  the  so-called 
nutmeg  appearance.  The  spleen,  kidneys,  and  other  abdominal  organs,  were  healthy. 

Commentary. — Cases  of  aneurism  communicating  with  the  pulmonary 
artery  are  very  rare,  and  the  physical  signs  to  which  they  give  rise  have, 
as  far  as  I can  discover,  only  been  recorded  in  three  other  instances. 
Of  five  cases  collected  by  Mr.  Thurnam,*  there  is  only  one  in  which  the 
sounds  v/ere  accurately  observed.  It  was  published  by  Dr.  Hope,f  and 
was  communicated  to  him  by  Dr.  David  Monro  of  Edinburgh.  In  that 
case  the  size  of  the  aneurism  is  not  given ; it  is  vaguely  called  “ large,” 
but  it  “ communicated  by  two  openings  with  the  pulmonary  artery,  the 
larger  capable  of  receiving  the  point  of  the  little  finger,  the  smaller  of 
transmitting  a crow’s  quill.  The  edges  of  both  were  regular,  round,  and 
cartilaginous.  Nearer  the  arch,  a third  small  opening  was  discovered, 
with  thin  rugged  edges.”  “All  the  valves  were  health}^,  excepting  the 
semilunar  at  the  mouth  of  the  aorta,  which  was  thickened.”  We  are  not 
informed  to  what  extent  the  aortic  valves  were  thickened,  and  whether 
such  thickening  produced  incompetence  in  their  action.  But  we  are  told 
that  “ the  first  sound  was  accompanied  by  a loud  blowing  murmur,  most 
distinct  at  the  middle  of  the  sternum,  but  audible  over  the  whole  fore- 
part of  the  chest,  and  over  the  back  on  both  sides  of  the  spine.  The  sec- 
ond sound  was  short,  and  much  obscured  by  the  first.”  This  account 
renders  it  probable  that  the  murmur  was  synchronous  with  the  ventricu- 
lar contraction,  was  caused  by  the  rushing  of  blood  through  the  laceration 
of  the  aneurism  into  the  pulmonary  artery,  and  w^as  not  owing  to  the 
valvular  disease.  In  a case  of  Professor  Smith’s  of  Dublin, J the  pul- 
monary artery  communicated  with  the  aorta  by  a small  opening  at  the 
origin  of  the  latter  vessel.  The  edges  of  this  opening  were  thickened  and 
rounded  off.  There  was  dilatation  of  the  aorta  at  the  point  of  opening, 
with  distinct  signs  of  arteritis.  The  auriculo-ventricular  openings  were 
healthy.  A loud  blowing  murmur  accompanied  the  first  sound,  and  an  in- 
tense purring  tremor  could  be  felt  over  the  whole  cardiac  region.  Where 
this  blowing  murmur  was  heard  loudest  is  not  stated,  and  we  are  at  a loss 
to  determine  whether  it  was  owing  to  the  wave  of  blood  rushing  through 
the  dilated  and  roughened  aorta,  or  its  passing  through  the  orifice  into 
the  pulmonary  artery.  Of  the  second  sound  nothing  is  said  The  purring 
tremor  may  have  been  occasioned  by  the  rapid  gush  of  blood  through 
the  small  opening  of  the  aneurism,  and  a similar  tremor  was  observed 
by  Mr.  Thurnam,  Dr.  Williams,  and  Dr.  Hope,  in  a case  where  an  aortic 
aneurism  communicated  with  the  right  ventricle  of  the  heart,  by  two 
small  rounded  apertures.  That  such  tremor  should  occur  where  the 
opening  is  large,  appears  to  me  improbable. 

* Medico-Chir.  Trans.,  vol.  xxiii.  p.  349  et  seq. 

f Diseases  of  the  Heart,  3d  edit.  p.  469. 

i Dublin  Journal  of  Medical  Science,  vol.  xviii.  p.  164 ; and  Stokes  on  the  Dis- 
eases of  the  Heart  and  Aorta,  p.  654. 


ANEURISJtr. 


611 


In  the  pre.^eiit  state  of  our  knowledge  as  to  the  signs  which  accom- 
pany an  aortic  varicose  aneurism  communicating  with  the  pulmonary 
artery,  the  case  of  Calder  appears  to  me  to  be  of  great  value,  as  the 
physical  sig  is  were  examined  with  great  care,  and  recorded  at  my  dicta- 
tion by  the  clerk  at  tlie  bed-side.  At  the  time  they  were  exceedingly 
puzzling,  because  the  idea  suggested  by  the  double  sound  heard  at  the 
base  of  the  heart — which,  under  ordinary  circumstances,  would  have 
indicated  aortic  disease  with  stricture — was  negatived  by  the  fact  that 
the  second  sound  was  distinctly  audible  at  the  apex  clear  and  healthy. 
At  the  same  time,  the  manner  in  which  the  disease  occurred,  the  ana- 
sarca indicating  impeded  circulation,  the  dyspnoea  and  irregularity  of 
pulse  gave  evidence  of  a profound  lesion  of  the  heart,  although  its 
nature  was  very  mysterious,  the  more  so  as  no  thrill  or  tremor  could  be 
detected.  The  case,  however,  was  at  once  made  clear,  and  the  nature 
of  the  sounds  explained,  by  the  examination  of  the  body  after  death.  All 
the  valves  were  healthy,  and  hence  the  double  sound  must  have  been 
entirely  owing  to  the  flux  and  reflux  of  blood  through  the  communkation 
between  the  aneurism  and  pulmonary  artery.  The  murmurs  were  heard 
loudest  over  the  seat  of  the  communication,  below  the  junction  of  the 
third  left  costal  cartilage  with  the  sternum  ; became  continuous  as  they 
were  propagated  upwards;  but  interiorly  at  the  apex  of  the  heart,  only 
the  systolic  blowing  was  audible,  together  with  the  natural  sound  of  the 
semilunar  valves.  The  size  of  the  laceration  or  connecting  opening 
explains  the  absence  of  whiz  and  tremor.  Tnese  facts  appear  to  me 
very  valuable  as  distinctive-  of  such  a lesion  when  the  valves  are 
healthy.  If,  as  frequently  happens,  they  are  diseased,  there  must 
always  exist  excessive  difficulty,  if  not  an  impossibility,  of  ever  dis- 
tinguishing such  a form  of  aneurism  in  the  living  subject.  Mr.  Thur- 
nam,  in  his  excellent  paper,  appears  to  me  rather  too  sanguine  on  this 
point. 

The  other  phenomena  presented  by  the  case  are  at  once  explained, 
by  reflecting  on  what  is  likely  to  happen  by  a considerable  quantity  of 
blood  being  propelled  from  the  aorta  through  a large  opening  into  the 
pulmonary  artery,  and  thus  sent  to  the  lungs  again  without  having 
passed  through  the  systemic  circulation.  As  stated  by  Mr.  Thurnam, 
the  effects  are  referable  to  one  or  more  of  three  circumstances  : — 1st, 
Loss  of  blood  to  the  systemic  circulation,  and  as  a result,  feeble,  occa- 
sionally jerking  pulse,  debility,  tendency  to  syncope,  and  diminution  of 
animal  heat.  2d,  Impediment  of  the  return  of  venous  blood  from  the 
distant  veins,  and,  as  a result,  venous  congestion  of  the  liver,  mucous 
membrane,  and  extremities,  with  engorgement  and  dilatation  of  the 
right  side  of  the  heart,  and  as  a result,  dropsical  effusions,  and  espe- 
cially anasarca.  3d,  Excessive  stimulation  of  the  lungs  by  the  recep- 
tion of  arterial  instead  of  purely  venous  blood,  and  hence  dyspnoea, 
cough,  pulmonary  congestion,  and  extravasation  of  blood.  All  these 
effects  were  observed  in  the  case  we  have  had  before  us.  A retro- 
spective view  of  the  facts  and  phenomena  of  this  and  similar  cases  must 
impress  upon  us  the  truth  that  drastic  purgatives  and  diuretics,  how- 
ever they  may  relieve,  cannot  be  expected  to  pr  )duce  any  permanent 
benefit.  Indeed,  whenever  general  anasarca  is  evidently  dependent  on 
organic  disease,  it  seems  to  us  that  the  mildest  remedies  should  be 


612 


DISEASES  OF  THE  CIKCULATOKY  SYSTEM. 


employed,  especially  taking  care  by  their  use  not  to  lower  the  general 
powers  of  the  constitution,  so  that  life  may  be  prolonged  as  much  as 
possible. 

Since  the  above  Commentary  was  published  in  the  last  edition  of 
this  work,  another  case  has  been  accurately  observed  by  Dr.  Wade  of 
Birmingham,  and  diagnosced  by  him  during  life.  It  was  read  to  the 
Medico-Chirurgical  Society  of  London,  June  11,  1861.^  A man,  aged 
35,  two  weeks  before  admission  to  the  hospital,  made  a sudden  and 
violent  exertion,  producing  temporary  faintness  without  marked  cardiac 
symptoms. 

Physical  examination. — Cardiac  dulness  increased  vertically.  Apex 
seen  and  felt  in  the  sixth  intercostal  space.  Over  the  cartilage  of  the 
left  fourth  rib  a loud  murmur  replaced  both  sounds,  that  with  the 
second  being  of  a hissing  character,  and  so  prolonged  as  to  continue  till 
the  commencement  of  the  next  first  sound.  Usual  second  sound  inau- 
dible there.  Marked  thrill  at  this  spot  coincident  with  second  murmur. 
First  murmur,  a loud  bruit  de  soufilet.  Both  murmurs  heard  in  the 
carotids  and  over  the  upper  chest.  At  the  apex,  a single  murmur  with 
first  sound ; normal  second  sound  very  distinct.  No  venous  distention. 
Thrill  in  the  carotids,  pulsation  of  which  was  visible.  Mucous  rales  in 
back  of  both  lungs.  Liver  enlarged. 

From  this  combination.  Dr.  Wade  concluded — 1,  That  blood  escaped 
either  from  the  aorta  or  pulmonary  artery  during  their  systole  ; 2,  That 
it  was  probably  from  the  aorta  that  the  blood  escaped;  3d,  That  it  did 
not  regurgitate  into  either  ventricle ; 4,  That  it  regurgitated  into  one  of 
the  auricles,  or  else  into  the  pulmonary  artery;  6,  That  it  did  not  regur- 
gitate into  the  left  auricle ; 6,  That  the  opening  was  into  the  pulmonary 
artery,  rather  than  into  the  right  auricle  ; 7,  That  the  communication 
was  probably  due  to  aneurismal  perforation  of  the  aorta,  at  or  near  its 
origin. 

On  the  14th  of  June  he  was  seized  with  faintness  and  violent  cardiac 
perturbation,  which  continued  till  the  28th,  when  he  died.  The  post- 
mortem examination  showed  an  aneurism  of  the  size  of  a small  hen’s  egg 
very  near  the  root  of  the  aorta,  with  a rounded,  smooth,  thickened  open- 
ing into  the  pulmonary  artery  at  its  origin,  and  another,  fissured,  ragged, 
evidently  recent  one  into  the  right  ventricle.  The  valves  were  all  healthy. 

This  case,  in  conjunction  with  that  of  Calder,  will  serve  to  establish 
the  physical  diagnosis  of  this  rare  lesion.  In  both  there  were  the  same 
signs — viz.,  a whizzing  or  lisping  murmur  replacing  both  sounds  over  the 
aneurism,  while  the  first  and  second  sounds  of  the  heart  were  heard  nor- 
mal at  the  apex  and  at  the  root  of  the  carotids. 

Case  CXXIII.f — Aneurism  of  the  After ia  Innominata. 

History. — Catherine  Syme,  aet.  56,  a sempstress — admitted  May  2,  1853.  She 
says  that  her  habits  have  always  been  temperate  and  regular.  Fifteen  years  ago  she 
had  an  attack  of  acute  articular  rheumatism,  which  afterwards  became  chronic,  and 
rendered  her  incapable  of  working  for  eighteen  months.  For  six  years  past  she  has 


* Brit.  Med.  Journal,  July  6,  1861. 
f Reported  by  Mr.  Robert  Brown,  Clinical  Clerk. 


ANEURISM. 


613 


been  subject  to  occasional  attacks  of  giddiness  and  swimming  in  the  head,  accom- 
panied by  a loud  noise  like  the  clanging  of  machinery.  Fourteen  months  ago,  in 
the  ui<dit,  she  was  seized  with  a fit  of  intense  dyspnoea,  threatening  suffocation  and 
accompanied  with  a loud  crowing  noise  on  inspiration.  The  attack  lasted  about  eight 
minutes.  Three  mouths  afterwards,  she  experienced  a somewhat  similar  but  milder 
attack  also  in  the  night,  during-  sleep.  She  now  observed  that  her  voice  was  becoming 
rou"h  and  hoarse ; and  a few  months  later,  she  felt  slight  difficulty  in  swallowing,  at 
a point  corresponding  to  the  upper  border  of  the  sternum.  In  the  early  part  of 
January  1853,  after  unusual  exposure  to  cold,  the  dyspnoea  returned  every  morning, 
gradually  became  urgent,  and  generally  terminated  in  the  expectoration  of  a small 
quantity  of  mucus.  There  were  also  palpitations,  and  she  became  subject  to  sudden 
startings  from  sleep.  A week  ago,  all  these  symptoms  became  so  much  aggravated, 
that  she  wms  unable  to  leave  her  bed. 

Symptoms  on  Admission. — The  cardiac  dulness  measures  two  inches  across.  The 
apex  beats  between  the  fifth  and  sixth  ribs,  a little  to  the  inside  of  the  nipple.  Heart’s 
impulse  is  somewhat  diffused,  rhythmical,  and  of  good  strength.  A blowing  murmur 
accompanies  both  cardiac  sounds,  tliat  with  the  first  sound  being  loudest  at  the  apex, 
and  that  with  the  second  being  loudest  at  the  base.  Immediately  above  and  towards 
the  outer  side  of  the  right  sterno-clavicular  articulation,  a pulsating  tumor,  about  the 
size  of  a hen’s  egg,  is  visible  to  the  eye.  It  is  felt  beneath  the  sternal  and  inner  por- 
tion of  the  clavicular  origins  of  the  sterno-mastoid  muscle,  presents  a distinctly 
rounded  outline,  and  anteriorly  slightly  overlaps  the  trachea  immediately  above  the 
upper  border  of  the  sternum.  The  impulse  is  strong  and  diffused,  and  a loud,  clear, 
abrupt  murmur  is  heard  over  it,  synchronous  with  the  second  sound  of  the  heart. 
Tiie  jmlse  is  regular,  106,  of  good  strength,  equal  at  both  wrists.  There  is  a paroxys- 
mal cough,  harsh,  prolonged,  and  of  a clanging  metallic  character,  always  worst  in  the 
morning,  when  it  is  accompanied  by  urgent  dyspnoea,  and  a loud  crowing  inspiration. 
Sputum  scanty  and  gelatinous,  containing  a few  flocculi  of  pus.  Voice  hoarse  and 
weak.  Chest  everywhere  resonant  on  percussion,  but  not  unusually  arched.  Respira- 
tory murmurs  very  faint,  but  normal  in  character.  Expiration  much  prolonged. 
Appetite  impaired.  When  swallowing  solid  food,  she  says  the  bolus  seems  to  meet 
some  obstruction  at  a point  corresponding  with  the  upper  border  of  the  manubrium 
of  the  sternum.  The  countenance  is  anxious,  face  livid,  and  the  superficial  veins  of 
the  chest  and  lower  part  of  the  neck  are  very  large  and  turgid.  Sleep  restless  and 
easily  disturbed.  Other  functions  normal. 

Progress  of  the  Case. — The  symptoms  previously  noticed  continued,  wuth 
occasional  remissions,  until  the  20th  of  June,  On  that  day  it  was  observed  that  the 
blowing  murmur  synchronous  with  the  second  sound  at  the  base  of  the  heart,  was 
much  less  distinct,  and  that  the  murmur  with  the  first  sound  at  the  apex  was  replaced 
by  one  with  the  second.  The  veins  over  the  upper  part  of  the  chest  have  been 
gradually  enlarging.  On  the  Oih  of  July a careful  examination  elicited  the  following 
results : — Pulse  88,  soft,  equal  in  both  wrists.  The  impulse  is  very  strong  over  the 
tumor,  and  on  auscultation  thei-e  are  now  heard  two  sounds,  the  second  being  loud, 
abrupt,  and  exceedingly  clear — no  blowing  audible.  These  sounds  diminish  gradually 
in  intensity  as  the  stethoscope  approaches  the  left  edge  of  the  manubrium  of  the 
sternum,  where  the  two  cardiac  sounds  are  heard  quite  normal.  As  the  instrument 
descends  towards  the  heart’s  apex,  the  second  sound  gradually  assumes  a soft  blow- 
ing character,  which  at  the  apex  is  loud  and  distinct.  The  first  sound  is  quite  normal. 
Posteriorly  above  the  right  scapula,  the  sounds  of  the  tumor  arc  heard  at  a distance, 
but  disappear  towards  the  centre  of  the  back,  and  are  inaudible  along  the  vertebral 
column.  July  ^th. — For  the  last  few  days  the  dyspnoea  in  the  morning  has  boon 
very  urgent,  and  the  cough  coarser,  and  of  a metallic  clanging  sound.  To-day  the 
paroxysm  continued  15  minutes,  and  even  now',  at  the  visit,  the  breathing  is  noisy, 
labored,  and  hurried,  the  dyspnoea  urgent,  and  the  paroxysm  of  cough  severe  and  at 
short  intervals.  She  cannot  expectorate  easily.  The  voice  is  feeble,  and  the 
countenance  expressive  of  great  anxiety.  To  relievo  these  symptoms  tracheotomy 
w'as  attempted  by  Mr.  Syme;  but,  having  made  two  incisions,  and  cut  through  the 
integument  and  subcutaneous  fat,  such  an  amount  of  venous  hemorrhage  occurred 
that  he  desisted,  applied  a ligature  to  the  large  veins,  and  declined  to  perform  laryn- 
gotomy.  July  0th. — The  loss  of  blood  caused  considerable  relief,  and  she  passed  a 
tolerable  night.  A double  blowing  murmur  is  now  audible  both  at  the  apex  and  base 


614 


DISEASES  OF  THE  CIKCULATur.Y  SYSTEM. 


of  the  heart.  That  accompanying  the  second  sound  is  loudest  over  the  apex,  vhile 
the  one  accompanying  the  first  is  heard  loudest  over  the  ensiform  cartilage.  Juhi  Vlih. 
— Last  night  about  half-past  eleven  p.m.,  a severe  paroxysm  of  dyspnoea,  threateninc^ 
sufibcation,  came  on.  The  house-surgeon,  Dr.  Dobie,  enlarged  the  incision  made  by 
Mr.  Syme,  upwards,  and  inserted  a common-sized  tube  into  the  trachea  and  larynx, 
alter  dividing  the  cricoid  cartilage.  To-day  she  is  again  better,  the  operation  having 
been  followed  with  immediate  relief.  She  still  breathes,  however,  with  difficulty 
through  the  tube.  The  countenance  is  livid  and  anxious,  extremities  cold,  pulse 
feeble  and  fluttering,  surface  bedewed  with  a clammy  sweat.  She  now  gradually 
sank,  and  died  at  half-past  eleven  p.m.,  on  the  14th,  embarrassment  of  the  respiration 
being  apparently  increased  by  the  difficulty  of  expectoration.  Immediately  before 
expiring,  she  ejected  through  the  tube  about  |j  of  dark  grey-colored  foetid  pus,  of 
the  consistence  of  thick  cream. 

The  treatment  throughout  the  progress  of  the  case  was  directed  to  alleviating  the 
cough  and  expectoration,  by  means  of  anodynes  and  expectorants,  and  diminishing  the 
paroxysms  of  dyspnoea  by  means  of  diffusible  stimuli.  Cupping  over  the  sternum,  and 
the  occasional  application  of  leeches,  were  employed,  and  for  some  time  these  remedies 
undoubtedly  caused  great  relief.  The  surgeons  of  the  Infirmary  were  unanimously  of 
opinion  that  the  aneurism  did  not  admit  of  relief  from  any  operation.  Latterly  the 
propriety  of  tracheotomy  or  laryngotomy  was  discussed  as  a palliative,  and  ultimately 
tried  with  the  effect  already  described. 

8ect'io  Cadaveris. — Thirteen  hours  after  death. 

The  edges  of  the  wound  through  which  the  larynx  had  been  opened  were  thick- 
ened, the  surrounding  muscles  discolored  and  infiltrated  with  pus. 

Thorax. — The  heart,  aorta,  and  parts  connected  with  the  aneurism,  w'ere  removed 
en  77iasse,  and  carefully  dissected,  with  the  following  results: — The  heart  and  its 
valves  cpiite  healthy,  with  the  exception  of  slight  thickening  of  the  margin  of  one 
aortic  valve.  The  arch  of  the  aorta  immediately  above  the  valves  considerably 
dilated,  and  the  whole  of  its  internal  surface  thickly  studded  with  atheromatous  and 
calcareous  plates.  The  whole  arteria  innominata  dilated  into  an  aneurismal  swelling 
of  a round  and  somewhat  flattened  form,  having  a diameter  of  fully  three  inches.  The 
trachea  is  pushed  by  it  towards  the  left  side,  as  represented  in  the  accompanying 
figure,  in  consequence  of  which  the  incision  that  was  made  in  the  median  line  during 
the  operation,  was  within  one-eighth  of  an  inch  of  the  aneurism.  The  tumor,  by 
pressing  on  the  right  side  of  the  trachea,  caused  much  bulging  into  and  diminution  of 
its  calibre.  The  left  imiominate  vein  was  nearly  obliterated.  The  remains  of  its  in- 
terior contained  a softened  clot  resembling  pus,  which  communicated  by  a small  open- 
ing through  the  aneurismal  sac  with  a portion  of  the  laminated  clot,  which  occupied 
about  three-fourths  of  its  internal  cavity.  The  opening  into  the  sac  from  the  aorta 
was  about  the  size  of  half-a-crown,  and  presented  a sharp  circular  margin.  Posteriorly 
the  nerves  were  reddened,  and  for  the  most  part  enlarged,  and  firmly  united  to  the 
posterior  wall  of  the  tumor.  The  superior  laryngeal  nerve  was  healthy,  being  above 
the  tumor  ; but  the  inferior  was  compressed  and  imbedded  in  thickened  cellular  tissue. 
The  posterior  half  of  right  lung  was  partially  covered  with  recent  l}mph,  not  adherent, 
and  the  pleural  sac  contained  two  or  three  ounces  of  sero-purulent  fluid.  The  lower 
lobe  of  the  right  lung  was  hepatized ; and  on  cutting  into  it,  several  abscesses  up  to 
the  size  of  a cherry  were  found.  The  left  lung  was  oedematous,  and  its  bronchi  were 
filled  with  muco-purulent  matter — otherwise  healthy. 

Ardomen. — The  liver  presented  the  incipient  waxy  appearance.  The  spleen  was 
dark  in  color,  and  pulpy,  almost  diffluent  in  consistence.  The  kidneys  were  crowded 
with  minute  cysts,  and  the  cortical  substance  considerably  atrophied. 

Commentary. — This  case  terminated  in  the  usual  way,  by  pressure 
on  the  nerves  of  respiration,  causing  dyspnoea,  and  at  length  partial 
latent  pneumonia. 

The  double  clear  sound  over  the  aneurismal  tumor  I have  been  in 
the  habit  of  attributing  to  the  flux  and  reflux  of  the  blood  over  a sharp 
vibrating  opening  into  the  tumor.  In  few  aneurisms  were  these  sounds 
more  decidedly  present  than  in  the  case  under  consideration,  and  few 


ANEURISM. 


615 


d 


after  death  presented  an  opening  having  the  margin  in  question  better 
formed.  In  another  case  of  aneurism  of  the  innominate  artery  (that  of 
John  Hunter),  examined  at  the 
commencement  of  the  winter  ses- 
sion 1856-57,  the  tumor  was  very 
distinct  in  the  neck  above  the 
clavicle,  but  without  sound  of  any  f 
kind.  It  was  determined  after 
death  that  the  arteria  innominata 
was  dilated  to  the  size  of  a thumb, 
and  gave  origin  to  the  aneurism, 
which  was  globular  and  four  in- 
ches in  diameter,  without  any 
circular  margin,  but  rather  by 
means  of  a narrow  neck,  as  in 
Fig.  446. 

The  sounds  heard  over  the 
heart,  however,  in  the  case  of 
Catherine  Symo,  changed  their 
character  as  the  disease  advanced. 

At  first,  double  valvular  disease 
was  suspected,  but  latterly,  when 
the  murmurs  became  reversed, 
and  it  was  most  carefully  deter- 
mined, by  repeated  examinations, 
that  the  murmur  at  the  apex  was 
with  the  second,  and  that  at  the 
base  was  with  the  first,  sound, 
they  were  attributed  to  propaga- 
tion downwards  from  the  aneu- 
rismal  tumor.  I am  by  no  means  satisfied,  however,  that  this  theory  is 
correct  with  regard  to  cardiac  murmurs,  so  distinct  as  those  in  the  pre- 
sent case,  associated  with  aneurismal  tumors  and  a healthy  heart.  I 
content  myself,  therefore,  for  the  present,  with  placing  the  facts  on  re- 
cord, as  their  accuracy  is  undoubted,  and  they  were 
confirmed  not  only  by  my  own  repeated  examina- 
tions, but  by  those  of  the  clinical  class  and  of  the 
^ . ..  clerks,  all  of  whom  took  great  interest  in  the  case. 

The  question  of  putting  a ligature  on  the  vessel 
f ^ % having  been  decided  by  the  Infirmary  surgeons  in  the 

^ negative,  the  only  other  question  of  treatment  was  the 
^ I prolongation  of  life.  The  source  of  danger  was  evi- 
Fig.  446.  dently  the  dyspnoea,  and  the  frequent  attacks  of  spas- 

modic laryngeal  obstruction,  so  common  in  aneurismal  cases  from  pressure 
of  the  tumor  on  the  recurrent  nerve.  The  trachea  was  also  considerably 


Fig.  44.5.  Rough  sketch  of  the  aneurism  and  adjoining  parts ; a,  opening  into  the 
larnyx ; 6,  line  of  original  incision  which  inferiorly  came  close  upon  the  tumor ; c, 
aneurismal  tumor ; c?,  point  where  the  obstructed  vena  innominata  had  ulcerated  into 
the  tumor  ; right  carotid  ; /,  right  Jugular  vein  ; y,  left  carotid  ; A,  left  subclavian. 

Fig.  446.  Diagram  of  an  aneurism  of  the  arteria  innominata,  in  which  the  tumor 
sprang  from  the  dilated  vessel  with  a narrow  neck,  and  in  which  no  sounds  were 
audible. 


616 


DISEASES  OF  THE  CIRCULATORY  SYSTEJI. 


pressed  upon  and  pushed  aside,  but  this  could  not  have  accounted  for 
the  paroxysms  of  suffocating  dyspnoea,  for  though  diminished  in  calibre, 
it  was  still  largely  open  for  the  admission  of  air.  On  the  other  hand, 
the  recurrent  nerve  was  found  after  death  thickened,  and  embedded 
in  dense  cellular  tissue  immediately  behind  the  tumor.  Under  such  cir- 
cumstances it  has  been  proposed,  by  passing  a tube  into  the  larynx  or 
trachea,  to  avert  the  effects  of  these  spasms.  In  the  present  case, 
tracheotomy  could  not  be  performed;  and  whenever  the  deep-seated 
venous  obstruction  is  of  such  a character  as  to  cause  enlargement  of  the 
superficial  veins,  laryngotomy  is  the  operation  that  should  be  attempted. 
This  at  length  was  accomplished,  with  momentary  relief ; but  I have  no 
hesitation  in  saying  that  the  difficulty  of  expectoration,  and  the  conse- 
quent clogging  of  the  air-tubes,  led  to  results  equally  distressing  and  fatal 
as  the  spasmodic  attacks.  It  has,  indeed,  been  said,  that  in  these  cases 
the  operation  is  generally  delayed  too  long,  and  that  by  waiting  until 
there  is  much  secretion  of  mucus  and  diminution  of  strength,  no  very 
good  effects  can  be  reasonably  expected.  But  in  cases  of  aneurism,  it  is 
at  best  only  to  be  considered  as  a palliative ; and  considering  how  very 
difficult  expectoration  must  always  be  under  such  circumstances,  I con- 
sider it  very  doubtful  whether  it  is  ever  justifiable  except  as  a dernier 
resort.  Certainly  the  case  now  recorded  is  anything  but  favorable  to 
the  practice. 

In  this  case  it  was  observable  that  after  the  incisions  in  the  integu- 
ment were  made,  without  tracheotomy  having  been  performed,  great 
relief  was  occasioned,  which  continued  upwards  of  two  days.  Was  this 
owing  to  the  few  ounces  of  blood  lost  during  the  operation,  or  to  the  idea 
which  she  had  adopted  that  the  operation  would  cause  relief?  However 
it  may  be  explained,  there  can  be  no  doubt  that  the  excessive  dyspnma 
and  other  urgent  symptoms  were  alleviated  as  if  by  a charm,  in  conse- 
quence of  the  unsuccessful  attempts  to  open  the  trachea. 

Case  CXXIV,'^ — Aneurism  of  Transverse  Aortic  Arch — Chronic  Peri- 
carditis with  effusion  - Tubercular  Lungs — Anasarca — Former  Popli- 
teal Aneurism  cured  by  compression. 

History. — George  Fairweather,  set.  32,  a laborer — admitted  January  20th,  1854. 
Originally  a farrier,  he  entered  the  army  in  1839,  and  served  twelve  years.  In  1842, 
while  in  India,  he  was  laid  up  with  rheumatic  pains.  A year  ago,  while  employed  in 
the  Edinburgh  police  force,  he  was  obliged  to  run  a great  distance  in  the  discharge  of 
his  duty.  Shortly  afterwards,  an  aneurism  made  its  appearance  in  the  right  popliteal 
space.  Of  this  he  was  cured  in  the  Glasgow  Infirmary  by  means  of  compression.  He 
has  since  been  troubled  with  cough  and  pain  in  the  breast,  and  between  the  shoulders. 
Last  August  he  became  very  hoarse,  and  entered  the  Glasgow  Infirmary,  where  he  re- 
mained for  two  months.  Towards  the  close  of  that  period  he  noticed  that  his  feet 
were  swollen,  and  began  to  suffer  from  palpitation,  with  pain  in  the  priecordial  region. 
He  was  dismissed  from  the  hospital  as  incurable.  The  swelliug  in  the  ankles  now 
increased,  and  passed  up  the  legs  to  the  abdomen.  On  the  1st  of  December  last  he 
returned  to  the  Glasgow  Infirmary,  and  left  it  three  days  ago,  without  having  experi- 
enced any  relief.  Since  then  his  urine  has  become  much  diminished,  and  yesterday  it 
was  entirely  suppressed. 

Symptoms  on  Admission. — The  point  where  the  apex  of  the  heart  beats  cannot  be 
made  out ; the  cardiac  impulse  is  not  felt  in  its  usual  position  ; and  the  cardiac 
sounds  are  inaudible  over  the  region  of  the  apex.  At  the  base  of  the  heart  the 
sounds  are  quite  healthy,  and  iilso  over  the  centre  of  the  sternum.  The  transverse 


* Reported  by  Mr.  Almeric  Seymour,  Clinical  Clerk. 


ANEURISM. 


617 


cardiac  dulness  is  fully  four  inches.  There  is  an  unusual  dulness  above  the  left  nipple, 
extending  over  a space  about  the  size  of  the  palm  of  the  hand ; here  the  normal 
cardiac  sounds  are  heard.  They  are  also  heard,  unaltered  in  character,  all  over  the 
manubrium  of  the  sternum  as  high  as  the  first  intercostal  space.  Pulse  66,  very  weak 
and  irregular,  and  somewhat  stronger  in  the  right  wrist  than  in  the  left.  Over  the 
right  lung  percussion  is  normal ; posteriorly  there  is  dulness  at  the  lower  two-thirds 
of  the  left  side.  Loud,  sonorous,  and  sibilating  rales  audible  over  most  of  the  chest 
on  inspiration  and  expiration ; the  latter  movement  being  much  prolonged.  Cough 
troublesome,  and  accompanied  with  a peculiar  crowing  sound.  Sputum  frothy, 
gelatinous,  and  tinged  with  blood.  When  the  cough  comes  on  he  has  great  dyspnoea, 
and  respiration  is  accompanied  by  a wheezing  laryngeal  sound.  He  cannot  lie  upon 
his  right  side,  from  a sensation  of  choking  that  comes  on ; he  feels  easier  when  in  a 
semi-erect  position,  or  on  the  leftside  ; dyspnoea  is  most  troublesome  at  night.  Tongue 
moist  and  furred ; appetite  good ; has  a feeling  of  oppressive  tightness  in  the  epi- 
gastrium after  taking  food ; hepatic  dulness  four  inches ; bowels  rather  loose.  A 
small  quantity  of  urine  has  been  passed  since  last  night ; it  deposits  a pink  sediment, 
which  clears  up  on  being  heated  ; sp.  gr.  1022.  Tiie  whole  surface  of  the  body  is 
oedematous;  abdomen  and  scrotum  much  distended;  face  and  hands  livid,  and  cold 
to  the  touch  ; feels  cold  all  over  the  surface  of  the  body.  Inf  m.  Dir/italis  ~ iss ; 

Sp.  her.  Nitric.  3 iij  ; Acet.  Potaasoe  3 iss  ; Aqiue  § iv.  M.  one  ounce  to  be  taken 
three  times  a day. 

Progress  of  the  Case. — January  21.s^  to  2^th. — Has  continued  the  above  mix- 
ture, and  was  ordered  to  apply  very  strong  infusion  of  digitalis  over  the  abdomen. 
The  anasarca  is  much  diminished,  fifty  ounces  of  urine  having  been  passed  within  the 
last  twenty-four  hours.  Hands  rather  cold.  Physical  signs  as  before.  Pulse  120,  of 
better  strength.  No  difference  in  the  pulse  of  either  wrist.  The  cough  being  very 
troublesome,  last  night  he  was  ordered  a mixture  containing  Sp.  uEther.  Nitric,  and 
Sol.  Mur.  Morphim.  Considerable  dyspnoea  after  taking  solid  food.  A bedsore  has 
formed  on  the  left  gluteal  region,  from  his  always  lying  on  that  side,  ft  Potassce 
Bitart.  3 j quater  in  die.  Jan.  26^/i  to  Feh.  Is^. — The  dropsy  has  become  much  less, 
having  entirely  left  the  legs ; the  size  of  the  abdomen  is  also  diminished ; there  is 
more  anasarca  on  the  riglit  side  of  the  chest,  on  which  he  generally  lies,  than  on  the 
left.  On  one  occasion,  the  amount  of  urine  passed  amounted  to  150  ounces  in  the 
twenty-four  hours.  On  the  31st  he  had  great  pain  under  the  left  clavicle,  with  fric- 
tion at  the  base  of  right  lung ; six  leeches  were  applied  over  the  painful  sq/ot.  As  the 
cough  is  very  troublesome,  let  him  take  a drachm  of  Tr.  Opii  Camph.  at  bedtime. 
Continue  the  digitalis  internally.^  but  stop  the  external  applicatioyi.  Feb.  Is^  to  QtJt. — 
Cough  has  been  very  troublesome,  but  has  been  relieved  by  opium.,  Sp.  Mother.  Nit. 
and  chloroform  internally.  &th. — The  cardiac  sounds  may  be  heard,  normal  in 
character,  over  the  right  side,  commencing  from  the  third  rib  ; the  impulse  may  also 
be  seen  and  felt  in  that  locality.  There  is  also  dulness,  which  may  be  observed  as 
high  as  the  top  of  the  sternum,  extends  in  a sloping  direction  to  the  third  rib,  and  can 
be  elicited  down  the  whole  right  side.  Feb.  \Mh. — Almost  total  dulness  and  want  of 
expansion  over  the  left  side  before  and  behind  ; nor  is  any  respiration  heard  except  at 
the  apex.  Apply  a blister  (6  by  5)  to  the  middle  and  inferior  part  of  the  left  side. 
P'eb.  \%th  to  25^A. — On  the  16tli  had  a violent  paroxysm  of  coughing,  lasting  for  ter 
minutes,  and  attended  with  profuse  purulent  expectoration.  Ordered  the  following  : — 
ft  Misturce  Scillce  § v ; Tr.  Opii  Camph.  3 j.  A tablespoonf  ul  to  be  taken  when  the 
cough  is  urgent.  A morphia  draught  at  bedtime.  These  remedies  relieved  the  cough. 
The  sputum  became  more  frothy  and  gelatinous.  He  also  slept  better.  On  the  25th, 
there  is  almost  total  dulness  over  a space  nearly  three  inches  in  diameter,  in  the  left 
sterno-clavicular  angle,  with  gradually  increasing  clearness  towards  the  outer  sub- 
clavian space.  There  is  no  respiration  in  the  former  region,  and  moderate  natural 
respiration  in  the  latter.  Over  the  rest  of  the  left  side,  in  front  and  laterally,  ])ercus- 
sion  is  very  dull,  and  respiration  all  but  absent.  There  is  general  dulness,  and  very 
feeble  respiration  in  the  upper  half  of  the  left  back,  with  prolonged  sibilation  after 
coughing ; respiration  is  bronchial  and  feeble  in  the  lower  half.  On  the  right  side, 
percussion  is  clear,  with  puerile  respiration,  both  before  and  behind,  except  for  about 
three  inches  to  the  right  of  the  upper  sternum,  where  percussion  is  somewhat  dull 
He  has  still  occasionally  a difficult  and  copious  expectoration  of  a tough  mucous 
matter.  Cardiac  sounds  natural,  except  a very  slight  tendency  to  reduplication  of  the 
second.  Feb.  2Mh  to  March  Ath. — Continued  in  much  the  same  state  till  the  evening 
of  March  3d,  when  another  fit  of  coughing  and  dyspnoea  came  on.  Sulphuric  ether. 


618 


DISEASES  OF  THE  CIRCULATOKY  SYSTEM. 


and  others  of  the  medicines  mentioned  above,  were  administered.  He  sank,  however, 
and  died  at  half-past  11  a.m.,  March  4th. 

Sectio  Cadaveris. — Forty-eight  hours  after  death. 

Thorax. — The  pericardium  was  much  distended,  and  contained  12  oz.  of  clear 
serum.  Its  lining  membrane  was  vei-y  hard  in  some  places,  from  the  presence  of 
chronic  lymph.  The  heart  and  its  valves  were  healthy.  Between  the  arteria  inno- 
minata  and  the  left  carotid  was  a small  dilatation  of  the  arch.  Immediately  below 
the  origin  of  the  left  subclavian,  an  aneurism,  the  size  of  a large  orange,  of  rounded 
form,  and  three  inches  in  diameter,  originated  from  the  aorta  by  a thick  neck.  It 
pressed  forward  and  to  the  left  side,  immediately  above  the  pericardium,  slightly  com- 
pi’essing  the  trachea  and  left  bronchus.  The  recurrent  nerve  was  seen  to  pass  in 
front  of  the  aneurism  uninjured.  On  examination  of  the  aneurism,  it  was  found  that 
the  internal  and  middle  coats  of  the  aorta  had  given  way,  the  pouch  being  foimed  of 
the  outer  coat,  and  of  condensed  areolar  tissue.  Above  the  aortic  valves,  and  over 
the  arch,  the  inner  layers  of  the  vessel  were  atheromatous.  In  the  cavity  of  the  left 
pleura  were  two  pints  of  serum  and  some  chronic  bands  of  lymph.  The  left  lung  was 
universally  condensed,  and  on  section  was  seen  to  contain  a large  quantity  of  tubercle, 
generally  in  masses  the  size  of  a pea  and  larger.  Some  of  these  had  softened,  but 
there  was  no  cavity.  The  intervening  pulmonary  tissue  was  condensed  and  hepatized. 
Bight  lung  was  voluminous,  with  a few  miliary  tubercles  scattered  through  it. 

Abdomen. — Abdominal  organs  healthy. 

Commentary. — In  this  case  during  life  it  was  carefully  determined 
that  the  cardiac  sounds  were  healthy,  that  the  cardiac  dulness  was  in- 
creased to  twice  its  normal  extent,  and  that  there  was  unusual  dulness 
above  the  1 ft  nipple  in  the  sterno-clavicular  region.  These  facts  were 
subsequently  explained  by  the  demonstration,  on  dissection,  of  a healthy 
heart,  of  chronic  pericarditis  with  effusion,  and  of  a large  aneurism 
springing  from  the  transverse  aortic  arch,  stretching  towards  the  left 
side.  Over  the  aneurism  in  this  case  no  sounds  were  audible,  a circum- 
stance probably  attributable  to  the  thick  neck,  by  which  it  came  off  from 
the  main  vessel,  as  explained  in  the  last  commentary.  The  limb,  which 
was  the  seat  of  the  popliteal  aneurism  cured  by  compression,  was  subse- 
quently injected  and  dissected  with  care,  and  may  be  now  seen  forming 
a very  fine  preparation  in  the  surgical  collection  of  Mr.  Spence  of  this 
city.  The  popliteal  artery  is  completely  occluded,  the  circulation  having 
been  maintained  through  the  enlarged  anastomosing  vessels. 

Case  CXXV."^ — Aneurism  of  Lower  Portion  of  the  Thoracic  Aorta.,  ’press- 
ing on  the  Thoracic  Pact — Aneurism  of  Ahdominal  Aorta — Chronic 
Ulcer  of  Stomach — Chronic  Tubercular  Abscesses  of  Liver  and  Right 
JCidneij — Liver  and  Left  LCidney  Waxy — Leucocythemia. 

History. — Janet  Young,  cet.  50 — admitted  June  16th,  1854.  States  that  her 
appetite  has  been  impaired  for  the  last  three  years,  that  she  has  been  subject  to 
chronic  rheumatism,  and  last  September  had  a severe  bowel  complaint,  which  lasted 
fourteen  weeks.  For  the  last  ten  years  has  suffered  from  vomiting,  which  has  been 
more  or  less  constant,  and  the  matters  ejected  have  occasionally  been  of  a dark  copper- 
color.  Since  the  occurrence  of  the  diarrhoea  she  has  become  very  emaciated. 

Symptoms  on  Admission. — The  whole  body  is  extremely  emaciated,  and  she  is  very 
weak.  Tongue  moist  and  clean.  Appetite  pretty  good.  No  vomiting  at  present. 
Comjilains  of  pain  and  tenderness  in  the  epigastrium,  and  on  palpation  a distinct 
tumor  can  be  felt,  with  a strong  impulse,  a little  to  the  right  of  the  mesial  line  in  the 
liositiou  of  the  pylorus.  It  is  apparently  solid,  of  uneven  shape,  about  the  size 
of  a hen’s  egg  ; but  its  limits  cannot  be  accurately  determined.  On  auscultation 
over  the  tumor  a loud  blowing  sound,  S3uichronous  with  the  aortic  pulse,  is  audible. 
Bowels  regular.  Apex  of  heart  beats  between  sixth  and  seventh  ribs.  Its  size  and 
sounds  are  normal.  Pulse  88,  of  good  strength.  Urine  pale,  sp.  gr.  1010,  slightly 

* Keported  by  Mr.  T.  Walker,  Clinical  Clerk. 


ANEURISM. 


619 


coagulable  on  the  addition  of  heat  and  nitric  acid.  Respiration  and  other  sjTnptoms 
’lormal.  Habeat  Syr.  lodnl.  Ferri  mhi.  x ter  indies. 

Progress  of  the  Case. — On  the  19th  of  June  she  commenced  vomiting,  a symp- 
tom which  continued,  with  slight  intermissions,  during  the  rest  of  the  month,  generally 
coming  on  four  hours  after  taking  a meal.  There  was  also  considerable  [>ain  in  the 
region  of  the  tumor,  which  was  relieved  by  the  occasional  application  of  two  leeches, 
foflowed  by  warm  fomentations.  Various  remedies  were  given  with  a view  of  checking 
the  vomiting,  of  which  small  pieces  of  ice  allowed  to  dissolve  in  the  mouth  appeared 
most  elfectual.  Nourishment  was  frequently  given  in  small  quantities.  During  the 
months  o'i  August  and  September.,  the  vomiting  became  far  less  frequent,  although  oc- 
casionally still  distressing.  All  this  time  nutrients  were  constantly  administered  with 
wine,  and  although  these  were  frequently  retained,  and  even  taken  with  appetite,  the 
emaciation  progressively  increased.  On  examining  the  blood,  it  was  found  to  possess 
an  increased  number  of  colorless  corpuscles.  A series  of  observations  also  was  made 
to  determine  whether  fat  was  passed  in  the  faeces,  but  they  were  quite  healtliy,  and  the 
bowels  on  the  whole  were  regular.  She  also  slept  well.  During  the  months  of  Sep- 
tember., October.,  and  November,  she  remained  much  in  the  same  condition,  occasionally 
complaining  of  a little  more  local  pain  in  the  epigastric  tumor  and  abdomen,  and 
latterly  of  cough  and  palpitation.  For  the  next  three  months  there  was  at  times  severe 
vomiting,  but  otherwise  no  marked  change.  The  urine  remained  coagulable  and  of 
low  s[)ecitic  gravity,  occasionally  presenting  under  the  microscope  a few  waxy  casts 
and  pus  corpuscles.  During  March  the  emaciation  was  apparently  extreme,  the  pnl.se 
weak,  and  nutritive  injections  by  the  rectum  were  added  to  the  nutrients  and  wine 
given  by  the  mouth.  The  vomiting  was  greatly  diminished,  but  for  some  days  she 
suffered  from  conjunctivitis.  There  was  also  restle.ssness  at  night,  which  was  relieved 
by  morphia  draughts.  Her  weakness  very  gradually  increased,  and  without  any  other 
symptom  she  expired,  April  16th,  1855. 

Sectio  Cadaveris. — Forty  hours  after  death. 

Thorax. — Roth  lungs  had  some  puckerings  near  the  apex,  and  contained  some  old 
tul)ercular  matter.  The  heart  was  healthy.  Near  the  lower  j)art  of  the  thoracic  aorta 
was  an  aneurismal  dilatation,  about  the  size  of  a walnut,  which  projected  to  the  left  of 
the  vertel)ial  colutim,  directly  over  the  thoracic  duct,  which  it  appeared  to  compress. 

Abdomen. — •Arising  from  the  anterior  part  of  the  abdominal  aorta,  at  the  root  of 
the  cceliac  axis  and  superior  mesenteric  artery,  Avas  an  aneurism  of  a rounded  form, 
about  two  inches  in  diameter,  which  projected  forwards,  and  was  nearly  filled  Avith 
firm  layers  of  fibrin.  Both  the  vessels  named  Avere  thrust  forwanl,  separated  to  the 
extent  of  an  inch,  but  were  in  themseh'es  healthy.  (University  Museum,  Prep.  2333, 
a.)  The  stomach  Avas  of  natural  size  ; on  its  lesser  curvature,  about  half- Avay  between 
the  cardiac  and  pyloric  orifices,  but  rather  nearer  the  latter,  there  Avas  an  ulcer  of  an 
oval  form  Avith  depressed  surface,  callous  margins  and  base,  and  about  the  size  of  a 
filbert.  The  edges  were  smooth,  and  dense  as  ligament,  presenting  on  section  a Avhite 
glistening  appearance,  and  in  some  places  Avere  a quarter  of  an  inch  thick.  The  liver 
Aveighed  2 lbs.  On  section  it  contained  a number  of  masses  of  tubercular  matter. 
Some  of  them  had  softened  and  given  rise  to  abscesses.  The  hepatic  tissue  itself  Avas 
waxy.  The  right  kidney  Avas  very  small,  being  inches  long  and  1|-  inch  broad. 
Oil  section  there  escaped  a yelloAvish  Avhite  fluid  and  some  cheesy  matter.  The  tissue 
of  the  kidney  vvas  quite  gone,  and  its  place  supplied  by  the  cavities,  Avhich  presented 
the  usual  appearance  of  scrofulous  abscesses.  This  kidney  weighed  one  ounce.  The 
left  kidney  was  of  large  size  and  Avaxy.  The  spleen  was  natural. 

Commentary. — On  the  admission  of  this  woman  it  became  a question 
whether  the  tumor  in  the  pyloric  region  was  an  aneurism  or  a can- 
cerous ma.ss  lying  over  the  aorta.  The  symptoms  were  those  of  organic 
disease  of  the  stomach.  As  the  disease  progressed  and  the  emaciation 
became  more  urgent,  the  tumor  could  be  more  easily  handled,  and  its 
rounded  form  and  marked  impulse  favored  the  opinion  of  its  being 
aneurismal.  The  frequent  vomiting,  however,  still  pointed  to  disease 
of  the  stomach,  and  served  to  explain  much  of  the  emaciation  which 
existed,  but  not  altogether,  as  it  was  observed  that  she  still  retained  a 
considerable  amount  of  nourishment,  especially  at  some  lengthened 


620 


DISEASES  OF  THE  CIKCULATORY  SYSTEM. 


periods  when  the  stomach  was  quiescent.  The  .idea  was  then  formed 
that  there  might  be  some  disease  at  the  head  of  the  pancreas ; but  after 
careful  examination,  no  unusual  amount  of  fat  could  be  detected  in  the 
stools.  Latterly  the  vomiting  was  comparatively  trifling,  but  still  the 
emaciation  was  progressive,  and  became  at  length  extreme.  On  dissec- 
tion after  death,  these  facts  were  explained  by  the  discovery  of  a small 
thoracic  aneurism  pressing  upon  the  thoracic  duct  in  addition  to  the 
abdominal  one,  which  had  become  rounder  and  harder  than  when  first 
observed.  The  lungs  and  liver  exhibited  well-marked  examples  of  tuber- 
cular and  scrofulous  deposits  which  had  been  arrested  in  their  progress. 
The  diminution  of  the  stomachic  symptoms  also  was  accounted  for  by 
the  gradual  healing  and  cicatrization  of  the  gastric  ulcer.  It  might  have 
been  supposed  that  the  abdominal  aneurism  was  progressing  toward  a 
spontaneous  cure,  as  it  was  nearly  filled  with  dense  coagulated  fibrin. 
The  commencement  of  a thoracic  aneurism  above,  however,  sufficiently 
accounts  for  this,  as  will  be  explained  more  particularly  in  the  commen- 
tary on  the  next  case. 

Case  CXXYI.* — Aneurism  of  the  Superior  Mesenteric  Artery  mid  Aorta — 
Ohscure  Aneurism  of  JJescendiny  Thoracic  Aorta — Treatment  hy  the 
method  of  Valsalva — Pleuritis — Caries  of  the  Vertehree^  softening  of 
Spinal  Cord  and  Paraplegia — Sudden  death  hy  Poisoning  with 
Tincture  of  Aconite. 

History. — Henry  Smith,  a:t.  85,  sailor — admitted  Deeember  19th,  1849.  States 
that,  al)oiit  twelve  months  ago,  while  r.t  sea,  he  received  a severe  blow  on  the  back 
from  the  tiller  of  the  vessel.  He  was  knocked  down  and  lay  insensible  for  a short  time. 
Since  then  he  has  experienced  pain  in  the  abdomen  and  back,  and  latterly  pulsation 
in  the  abdomen,  and  a sensation  of  tingling  and  numbness  in  the  thighs,  legs,  and  feet, 
especially  on  the  left  side.  States  that  about  three  weeks  after  the  accident,  he  was 
admitted  into  the  Liverpool  Inlirmary,  where  he  remained  for  about  eleven  mouths. 
He  was  treated  by  opiates  and  other  anodynes,  and  latterly  also  by  leeching  and  cup- 
ping over  the  pained  part  of  the  abdomen.  From  this  treatment  he  did  not  receive 
much  benefit. 

Symptoms  on  Admission. — On  admission,  he  is  of  a dark  complexion  ; appearance 
strong  and  robust.  A tumor  is  distinctly  seen  pulsating  in  the  left  hypochondriac 
region.  It  is  of  an  oval  form,  and  measures  about  three  inches  transversely  ; its  long 
diameter  cannot  be  ascertained,  as  its  superior  jiortion  ascends  below  the  ribs;  but  the 
inferior  and  lateral  margins  can  be  distinctly  felt.  He  complains  of  great  pain  and 
tenderness  in  the  region  of  the  tumor,  and  of  a beating  which  is  increased  on  exertion, 
and  also  upon  assuming  the  erect  posture.  He  feels  easiest  when  lying  doubled  up, 
resting  on  his  elbows  and  knees,  and  in  this  position  he  is  generally  seen  during  the 
day.  The  pulsation  of  the  tumor  is  forcible,  synchronous  v ith,  or  immediately  suc- 
ceeding, the  heart’s  impulse.  On  auscultation,  a soft  bellows  murmur  is  distinctly 
heard  over  the  tumor,  and  is  loudest  at  the  lower  part.  The  apex  of  the  heart  beats 
about  an  inch  below  the  nipple.  Impulse  tolerably  strong.  On  percussion,  the  cardiac 
dulness  extends  transversely  about  two  and  a h.alf  inches.  On  auscultation,  the  sounds 
are  normal  in  character;  the  first  is  heard  loudest  over  the  apex,  just  below  the  nip- 
ple ; and  the  second  is  most  distinct  at  least  three  inches  above  and  to  the  inside.  He 
has  no  cough  or  expectoration.  The  right  side  of  the  chest  is  more  resonant  on  per- 
cussion than  the  left,  both  in  front  and  behind.  On  auscultation  the  respiiatory  mur- 
murs are  normal.  Appetite  tolerably  good.  Bowels  regular.  L^rine  natural  in  (pum- 
tity  ; sp.  gr.  1025,  not  coagulable  ; presents  a deposit  of  lithate  of  ammonia.  Ordered 
a morphia  draught  at  nieiht. 

Progress  of  the  Case. — December  2dd. — Has  never  slept  properly  since  his  ad- 
mission. States  that  it  requires  a very  large  opiate  to  produce  any  effect  upon  him. 
Ordered  to  he  hied  to  syncope.^  and  his  diet  to  be  as  follows : Breakfast.,  Bread,  four 

* Ivcported  by  Messrs.  II.  M.  Balfour,  W.  Clark,  and  A.  Dewar,  Clinical  Clerks. 


AXEURISM. 


621 


ounces  ; milk,  eight  ounces.  Dinner^  Steak,  two  ounces ; bread,  two  ounces.  Supper^ 
Bread,  two  ounces ; tea,  eight  ounces.  24^A. — He  was  bled  to  thirty  ounces  without 
syncope  or  nausea  being  induced.  The  blood  drawn  exhibits  a distinct  buffy  coat, 
r.ulse,  88,  weak  and  soft.  Pain  easier,  and  sleeps  better  at  night.  2oth. — Dislikes 
beef  for  dinner,  and  would  prefer  a little  rice  pudding  with  the  bread  at  dimier.  To 
have  one  ounce  of  mutton  and  three  ounces  of  rice  pudding  for  dimier.  Twelve  leeches 
to  he  applied  over  the  tumor.  26^/i. — Leeches  bled  freely,  and  he  is  now  easier.  Urine 
still  presents  a deposit  of  lithates.  %^th. — Complains  of  constipation  ; pain  in  abdo- 
men rather  increased.  To  have  Elect.  Sennce  3 j daily.  Ten  leeches  to  he  a2)plied  to 
the  region  of  the  tumor.  31.s^. — Leeches  did  not  bleed  so  well.  Pain  still  severe. 
Applicet.  Emplast.  Cantharid.  (3  x 3)  parti  dolenti. 

1850,  January  2d. — Blister  gave  some  relief.  Pulse  stronger.  Ordered  to  he  hied 
to  I xij.  3d — The  blood  exhibited  the  buffy  coat,  but  in  a less  marked  degree  than 
formerly.  No  faintness  or  nausea  was  induced.  Two  ounces  of  bread  to  he  taken  off 
his  breakfast  and  half  an  ounce  off  his  supper.  To  he  allowed  a bottle  of  lemonade 
daily.  *lth. — Sleeps  very  badly.  1^  Sol.  Mur.  Morph.  ; Tinct.  Hyoscyam.  aa  3 ss ; 

Aquce  § ss.  Jd,  to  he  taken  every  evening,  'dth. — Sleeps  rather  better.  Pain  in 
tumor  somewhat  increased.  Eight  leeches  to  he  applied.  10th. — Leeches  gave  relief. 
13^A. — Still  complains  of  constipation.  To  have  a colocynth  and  hyoscyamus  pill  dcdly. 
10th. — States  that  for  the  last  three  or  four  days  he  has  felt  much  stronger,  and  the 
pain  and  pulsation  in  the  tumor  have  increased  proportionally.  Ten  leeches  to  he 
applied.  11th. — Leeches  gave  relief,  but  still  he  does  not  sleep  well.  21st. — Pulse 
tolerably  strong.  Ordered  to  he  hied  to  syncope.  22d. — He  wms  hied  yesterday  to 

twenty-six  ounces,  without  inducing  faintness  or  nausea.  To-day  his  pulse  is  weak  and 
soft,  and  he  expresses  himself  much  easier.  The  blood  exhibited  a distinct  buffy  coat. 
Urine  loaded  with  lithates.  2oth. — Yesterday  he  was  ordered  to  be  bled  until  some 
faintness  was  induced,  and  28  oz.  were  abstracteil  before  that  effect  was  occasioned. 
To-day  the  blood  is  cupped,  the  pulse  weak,  and  the  urine  loaded  with  lithates.  A 
chloroform  draught  at  night.  20th. — Again  bled  to  10  oz.  Eeh.  Qth. — Great  pain  in 
the  tumor  at  night,  preventing  sleep,  for  which  sedative  draughts  and  enemas  afford 
little  relief.  20  oz.  of  blood  were  in  consequence  taken  from  the  arm  to-day,  which  pro- 
duced faintness,  and  at  otic e removed  the  pain.  — Size  and  impulse  of  tumor 

evidently  diminished.  Does  not  think  he  is  much  weaker  since  admission,  but  is  un- 
able to  sit  up  so  long.  Pulse  small.  To-day  pain  returned  in  tumor.  12  leeches  to 
he  applied.  March  2d. — Bled  yesterday  to  14  oz.,  without  inducing  syncope.  Blood 
not  buffed.  10th.. — Pain  returned  with  violence.  Again  bled  to  23  oz.  10th. — Again 
hied  to  8 oz.  He  has  continued  on  the  low  diet,  which  was  altered  to-day  as  follows  : — 
Breakfast,  1 biscuit  (1-^  oz.) ; tea,  half  a pint.  Dinner,  2 biscuits  (2-^  oz.) ; eggs,  2. 
Su-pper,  1 biscuit  (1|-  oz.) ; tea,  half  a pint.  The  analysis  of  the  blood  drawn  on  the 
10  th  is  as  follows  : — 


Specific  gravity  of  serum 1028 

Solids  in  1000  parts  : — 

Fibrin 4‘6 

Globules 42-7 

Serous  solids  .......  88’2 

Water  ..........  864'5 


Total  1000 

April  0th. — Bled  again  to  13  oz.  l^th. — Was  strong  enough  to  wntlk  in  the  back- 
green,  but  felt  exhausted  after  it.  21st. — Bled  yesterday  to  34  oz.,  at  his  urgent  re- 
quest, insisting  that  he  felt  nothing,  until  he  fell  back  in  a state  of  syncope,  from 
which  he  slowly  recovered.  To-day  appearance  anemic,  pulse  feeble,  feels  weak. 
May  Wi. — Has  been  suffering  from  constipation,  which  has  been  relieved  by  colocynth 
and  henbane  pills.  Pulsation  in  the  tumor  evidently  diminishing.  To-day,  com- 
plains of  shooting  pains  in  the  back,  between  the  shoulders,  and  down  the  arms.  As 
he  dislikes  the  eggs,  4 oz.  of  calves’-foot  jelly  were  ordered  instead,  the  other  articles 
of  diet  remaining  the  same.  June  1st. — Considerable  pain,  and  no  sleep  for  three  days. 
8 leeches  to  he  applied.  11th. — 2 oz.  of  meat  instead  of  the  calves’-foot  jelly.  July 
11th. — Has  occasionally  been  walking  a little  in  the  open  air,  which,  however,  causes 
some  pain.  Apply  12  leeches.  Aug.  0th. — Pain  on  walking,  caused  by  hemorrhoids, 
for  which  injections  of  cold  water  have  been  ordered  with  benefit.  10th. — Pain  in 
tumor  returned.  Apply  12  leechxs,  which  caused  faintness,  for  which  § ij  of  wine 


622 


DISEASES  OF  THE  CIECULATORY  SYSTEM. 


were  given.  SOth. — Went  out  of  the  house  yesterday  by  permission.  Od.  20fh. — 
Has  been  allowed  to  go  out  of  the  house  once  a week  for  exercise.  To-day  pain  in 
tumor  severe.  Apply  8 leeches.  2bth. — The  tumor  was  observed  to  be  movable  to- 
day. When  he  lies  on  his  left  side,  the  prominence  is  concealed  below  the  cartilages 
of  the  ribs,  but  when  he  turns  on  his  back,  it  moves  three  or  four  inches  towards  the 
right  side.  He  says  he  has  only  noticed  this  mobility  during  the  last  week.  Wov. 
20ih. — Complains  of  a sharp  pain  under  the  left  clavicle,  and  six  leeches  were  applied 
thei'e  in  consequence.  2i)th. — Pain  under  clavicle  continues,  but  was  removed  by 
cupping  on  the  22d  and  to-day.  Dec.  2*lth.-^Bled  to  3 viij,  to  remove  pain  in  tumor. 

1861,  February  \*~dh. — Since  last  report,  has  continued  to  feel  pain  in  the  tumor. 
Again  bled  to  3 viij.  2{)th. — Present  diet : Breakfa.d,  one  roll  and  tea ; Dinner^  part 
of  a fowl  and  two  potatoes ; Bupjnr.,  one  roll  and  tea,  wine  § iv.  The  tumor  now 
feels  hard  and  solid,  is  the  size  of  a pigeon’s  egg.  March  ZOth. — Bled  to  § vj.  Apn'il 
2d. — Bled  to  § xij.  The  bleeding  generally  relieved  the  severity  of  the  pain,  but  on 
this  occasion  failed  to  do  so,  and  a blister  was  applied.  May  2d. — Bled  to  3 x,  with 
relief.  Z^th. — 11  leeches  were  applied.  June  l.st — No  relief  followed  the  application 
of  leeches.  To  be  cupped  on  the  bad:  to  3 vj.  June  Zth. — Pain  not  diminished,  and 
he  was  bled  to  3 xij,  which  caused  great  relief.  2Mh. — Cupped  to  3 viij.  2>6th. — 
Bled  to  5 xij.  Oct.  2^th. — Bleeding  has  been  occasionally  resorted  to,  to  relieve  pain ; 
otherwise  he  has  remained  the  same.  Diet  at  present  is : Breakfast.,  one  roll  and  a 
pint  of  tea  ; Dinner.,  one  flounder  and,  two  potatoes ; Supper,  one  roll  and  pint  of  tea, 
brandy,  3 iij.  Dec.  12th. — Since  last  report  has  been  comparatively  easy,  getting  up 
daily,  and  feeling  pain  only  for  about  two  hours  after  rising  in  the  morning.  To-day, 
the  pain  having  increased,  12  leeches  were  applied. 

1852,  January  IDth. — Complains  of  weakness,  so  that  he  is  obliged  to  use  a stick 
in  walking.  Ihth. — Tumor  fully  the  size  of  a walnut.  Aneurismal  murmur  greatly 
diminished.  Complains  of  numbness  in  left  side,  and  pain  in  right  leg.  ^^"alking  is 
more  difficult.  Bled  to  3 viij.  2Zd. — Weakness  in  lower  extremities  during  walking 
increased.  On  the  29th,  was  seized  with  general  coldness,  without  distinct  rigor.  He 
had  also  severe  pain  in  the  left  side  of  the  chest,  increased  on  inspiration.  30t'7i.^ — 
There  is  fre(iuent  cough,  and  copious  expectoration  not  tinged  with  blood.  The  left 
shoulder  is  also  very  painful.  Skin  hot,  total  loss  of  appetite,  great  thirst,  pulse  feeble, 
great  prostration.  On  percussion,  the  Avliole  of  the  left  side  of  the  chest  is  dull  through- 
out. On  auscultation,  the  respiration  is  feeble  superiorly,  and  inaudible  inferiorly.  A 
friction  noise  is  heard  external  to  the  nipple.  No  crepitation  can  be  discovered  ante- 
riorly or  posteriorly.  Mixture  of  ipecacuanha  and  morphia  ordered.  31sd — Cough 
and  pain  diminished.  B'eb.  2d. — Sputum  slightly  tinged  with  blood.  4,th. — Cough  and 
expectoration  diminished.  Sputum  consistent,  free  from  blood.  Friction  still  present 
anteriorly,  aagophony  posteriorly.  Qth. — Beturn  of  pain  in  chest  and  shoulder.  Fliy- 
sical  signs  the  same.  Blister  to  left  side.  lQ>th. — Dulness  less  below  left  clavicle,  and 
slight  motion  of  ribs  observed  there  during  respiration.  March  Isd — Friction  now 
audible  over  the  wliole  of  left  side  of  chest  posteriorly,  and  over  apex  of  lung  anteri- 
orly. I’ercussion  clear  over  upper  third  of  lung,  but  still  completely  dull  inferiorly. 
Fain,  cough,  and  febrile  symptoms  have  now  disappeared.  A bedsore  has  formed  in 
the  sacral  region,  which  has  been  poulticed,  and  now  exhibits  a disposition  to  slough. 
The  abdominal  aneurism  has  undergone  no  change.  Decided  paralysis  ol  motion  in 
the  inferior  extremities,  but  their  sensibility  is  unaffected.  March  Zth. — Slough  has 
separated  from  sacrum.  April  Hth. — Since  last  report,  parrdysis  in  inferior  extremi- 
ties has  become  complete.  He  has  lost  all  voluntary  povrer  over  them,  and  when  they 
are  pinched  or  pricked,  no  sensation  is  produced.  He  experienced,  however,  twiteh- 
ings  and  startings  in  the  paralysed  limbs,  but  no  pain.  His  evacuations  are  passed  in 
bed,  and  the  sore  on  the  sacrum  continues  to  discharge.  In  this  state  he  continued 
uiitil  May  31st, — the  lower  limbs  paralysed,  but,  wdth  the  exception  of  increasing 
weakness,  much  the  same  as  at  last  report.  To-day  he  sw’allowmd  a considerable  por- 
tion of  a liniment,  containing  one-fourth  its  volume  of  tincture  of  aconite.  He  rapidly 
became  pulseless.  The  intelligence,  for  three  or  four  minutes,  was  unaffected.  The 
respiration  was  embarrassed,  and  he  w'as  dead  in  a period  variously  estimated  at  from 
five  to  seven  minutes. 

Sectio  Cadaveris. — Twentij-five  hours  after  death. 

Tii.ORAX. — General  firm  adhesions  between  pleurae  on  the  left  side  ; on  the  right 
side,  slight  adhesions  betw'een  pleurae  at  the  apex.  The  pericardium  contained  three 
and  a half  ounces  of  straw-colored  serum  ; the  blood  everywhere  fluid ; heart 


ANEURISM. 


623 


healthy ; right  lung  mostly  crepitant,  with  considerable  induration  and  puckering  at 
the  apex.  On  section,  several  cretaceous,  encysted  concretions  existed  in  the  pul- 
monary tissue  at  the  apex,  surrounded  by  considerable  carbonaceous  deposit.  Here 
and  there  also  small  portions  of  the  lungs  were  collapsed.  The  left  lung  somewhat 
cwnpressed  posteriorly,  but  otherwise  crepitant,  and  apparently  normal.  It  is  at- 
tached at  the  posterior  part  of  lower  lobe  to  a sacculated  tumor,  the  size  of  a foetal 
head,  in  front  of  the  dorsal  vertebrae,  evidently  arising  from  the  descending  aorta. 
The  tumor  is  situated  more  to  the  left  than  to  the  right  side,  and,  on  being  cut 
into,  is  found  to  be  only  partially  filled  with  recently  coagulated  blood.  At  that 
part  of  the  sac  which  is  adherent  to  the  lungs,  its  wall  is  strengthened  by  the  depo- 
sition of  fibrin  in  laminas,  the  whole  at  its  thickest  part  being  an  inch  thick.  The 
bodies  of  the  5th,  6th,  7th,  and  8th  dorsal  vertebrae  were  to  a great  extent  absorbed, 
being  apparently  scooped  out,  leaving  the  intervertebral  cartilages  prominent 
between  them.  The  caries  had  also  affected  the  heads  of  the  corresponding  ribs  on 
the  left  side.  Posteriorly  the  tumor  had  projected  about  an  inch,  presenting  an 
oval,  rounded  surface,  which  had  compressed  the  spinal  cord  for  about  an  inch  and  a 
half  of  its  length  opposite  the  8th  and  9th  dorsal  vertebrm.  On  I’emoving  and 
bisecting  the  cord,  its  medullary  substance  at  the  compressed  portion  was  somewhat 
softened,  an  alteration  much  more  marked  for  two  inches  both  above  and  below 
where  it  w’as  pultaceous,  gradually  passing  into 
the  spinal  medullary  matter  of  normal  con- 
sistence. The  softening  was  white  throughout, 
with  no  red  spots. 

Abdomkn. — The  pancreas  is  stretched  over 
an  abdominal  tumor,  the  size  of  a small 
cocoa-nut,  in  front  of  the  aorta,  which 
is  movable,  and  tolerably  resistent  and  firm. 

The  stomach  was  healthy,  and  about  a third 
full  of  pultaceous  lumpy  matter,  smelling 
strongly  of  linimentum  saponis.  The  other 
abdominal  organs  were  healthy.  On  dissecting 
the  tumor,  it  was  ascertained  to  be  an  aneu- 
rism formed  at  the  root  of  the  superior  mesen- 
teric arteiy,  and  partly  involving  the  anterior 
w^all  of  the  descending  aorta.  It  was  of  an 
oval  shape,  with  one  extremity  resting  on  the 
vertebne,  the  other  lying  immediately  below 
the  integuments.  Its  long  diameter  measured 
four,  and  its  transverse  three  inches.  On 
taking  off*  a thin  slice  on  the  left  of  the 
tumor,  so  as  not  to  interfere  with  the  exit 
of  the  mesenteric  ai’tery,  it  was  seen  to  be 
almost  wholly  occupied  by  concentric  layers 
of  fibrin,  except  where  a channel,  larger  near 
the  aorta,  but  becoming  smaller  at  its  distal 
extremity,  allowed  a free  communication  of 
blood  with  the  efferent  vessel.  Fig.  447.  (Uni- 
versity Museum,  Prep.  2229). 

Microscopic  Examination.  — Portions  of 
the  spinal  cord  when  examined  under  the  mi- 
croscope, with  a power  of  250  diameters  linear, 
were  everywhere  ascertained  to  consist  of  broken 
up  medullary  tubes.  Many  of  the  varicosities 
had  enlarged  and  separated,  forming  round, 
oval,  and  variously-shaped  transparent  corpuscles,  with  double  lines,  mixed  with 
fragments  of  the  tubes,  and  numerous  molecules,  granules,  oil  globules,  and  broken- 
down  ganglionic  cells.  Xo  granular  corpuscles  wmre  anywhere  visible. 

Commentartj . — This  case  was  in  the  Infirmary  two  years  and  a half, 
and  during  the  whole  of  that  time  its  progress  excited  unusual  interest. 
AVehad  to  do  with,— 1st,  A thoracic  aneurism;  2d,  An  aneurism  of  the 


Fig.  447.  AHew  of  the  thoracic  and  abdominal  aneurisms,  the  carious  vertebral,  etc. 


624 


DISEASES  OF  THE  CIKCULATORY  SYSTEM. 


superior  mesenteric  artery;*  3d,  The  treatment  of  aneurism  by  Valsalva’s 
method;  4tli,  Acute  passing  into  chronic  pleurisy ; 5th,  Gradually  in- 
creasing, and  at  length  complete  paraplegia;  and  6th,  Poisoning  by 
aconite,  and  the  most  rapid  death  by  that  drug  on  record.  I shall  notice 
the  principal  facts  of  his  case  in  succession,  point  out  the  difficulties  of 
the  diagnosis,  the  effects  of  the  treatment  employed,  and  state  what  oc- 
curs to  me  with  regard  to  the  mode  of  his  death. 

The  Thoracic  Aneurism, — The  thoracic  aneurism  in  Smith’s  case  was 
not  suspected  durir.g  life.  On  looking  back  upon  the  facts  observed 
when  he  was  admitted  I find  that,  after  receiving  the  injury  which  pro- 
duced the  disease,  he  complained  of  pain  in  the  back,  as  well  as  the 
abdomen.  It  is  also  stated  that,  when  admitted  into  the  Infirmary, 
“ the  right  side  of  the  chest  is  more  resonant  on  percussion  than  the  left, 
both  in  front  and  behind.”  These  facts  were  too  vague  at  the  time  to 
enable  me  to  distinguish  a thoracic  aneurism  in  addition  to  the  abdomi- 
nal one,  more  especially  as  the  respiratory  murmurs  were  normal ; there 
was  no  cough,  expectoration,  or  other  pulmonary  lesion.  The  idea, 
therefore,  of  a thoracic  aneurism  never  occurred  to  me,  nor,  if  it  had,  is 
it  likely  that  it  would  have  been  confirmed,  although  now,  on  looking 
back,  the  importance  of  the  facts  above  stated  are  apparent,  and  prove 
that  such  aneurism  really  existed  when  he  first  came  into  the  house. 
On  going  over  the  reports  which  were  kept  of  his  progress  during  the 
two  years  and  a half  he  was  in  the  Infirmary,  I find  it  stated  that,  on 
the  6th  of  April,  when  under  the  care  of  Dr.  Christison,  he  “ com- 
plained of  shooting  pains  in  the  back,  between  the  shoulders,  and  down 
the  arms.”  On  the  20th  of  November,  in  the  same  year,  when  under 
Dr.  Alison’s  care,  he  “ complained  of  a sharp  pain  under  the  left  clavicle.” 
On  both  occasions  the  pain  was  of  short  duration.  I can  find  no  other 
symptoms  which  could  be  attributed  to  the  thoracic  aneurism  until  the 
29th  of  January  1852,  when  he  was  seized  with  all  the  symptoms  of 
acute  pleurisy.  For  a long  time  previously  his  chest  had  not  been 
examined,  but  when,  on  this  occasion,  it  was  percussed,  the  whole  of  the 
left  side  was  found  to  be  dull,  both  anteriorly  and  posteriorly.  This,  as 
well  as  all  the  other  symptoms  noticed  at  that  time,  were  ascribed  to 
pleurisy  with  a large  amount  of  exudation,  and  on  carefully  weighing 
these  symptoms  and  physical  signs,  I do  not  see  how  we  could  have 
arrived  at  any  other  conclusion ; for  a pleurisy  did  certainly  exist,  as 
proved  by  the  friction  during  life,  and  by  the  dense  chronic  adhesions 
found  after  death,  although  now  we  can  have  little  doubt  that  the  dul- 
ness,  increased  vocal  resonance,  and  other  signs,  were  for  the  most  part 
dependent  on  the  aneurismal  tumor.  Another  symptom  usually  pre- 
sent in  thoracic  aneurism  was  absent,  viz.,  hsemoptysis,  or  bloody  sputum. 
On  one  occasion  only  was  this  observed,  viz.,  on  February  2d,  four  days 
after  the  pleurisy  was  established.  I remember  that  it  induced  me  to 
examine  his  chest  with  the  utmost  care,  with  a view  of  discovering  if 
pneumonia  also  existed  ; but  as  stated  in  the  report,  no  crepitation  could 

* For  other  cases  of  aneurism  of  the  superior  mesenteric  artery,  see  case  by  Dr. 
Donald  Monro,  in  “Observations  on  Aneurism,”  by  the  Sydenham  Society,  p.  130; 
l)v  Dr.  Eiiiotson,  in  Lancet,  August  29,  1835  ; by  Dr.  Arthur  Wilson,  Medico-Chir. 
Transactions,  vol.  xxiv. ; by  Mr.  James  Douglas,  in  Medical  Gazette,  February  25, 
1842;  by  Dr.  W.  Gairdner,  in  Monthly  Journal  of  Med.  Science,  January  1850;  by 
Dr.  John  Ogle,  in  Trans,  of  Fatholog.  Soc.,  vol.  viii.  ; and  by  Dr.  Haldane,  in 
Edinb.  Med.  Journal,  October  1858. 


ANEURISM. 


625 


anywhere  be  discovered.  I am  satisfied,  from  the  careful  examination 
at  that  time,  as  well  as  when  he  first  came  into  the  house,  that  there 
was  no  blowing  or  other  abnormal  sound  in  the  chest  caused  by  the 
aneurism.  It  is  not  to  be  wondered  at,  therefore,  that  from  this  period 
the  dulness  on  the  left  side  of  the  thorax,  unaccompanied  with  other 
symptoms,  should  be  referred  to  chronic  pleurisy,  rather  than  to  a thoracic, 
aneurism.  It  so  happened,  also,  that  there  was  a man  in  the  ward 
laboring  under  chronic  pleurisy  on  one  side,  who  presented  all  the 
thoracic  symptoms  and  signs  which  existed  in  Smith.  It  appears,  tliere- 
fore,  that  the  detection  of  the  aneurism  was  almost  impossible ; for, 
supposing  even  that  it  had  been  suspected,  and  that  attention  had  been 
directed  to  confirm  such  a theory,  I am  not  aware  of-  any  arguments  by 
which  it  could  be  supported.  An  idea,  however,  that  it  would  be  im- 
possible at  any  time  to  discover  such  an  aneurism,  would  be  erroneous, 
and  would  do  discredit  to  physical  diagnosis  ; for  there  can  be  little 
doubt  that  had  the  chest  been  carefully  re-examined — say  a short  period 
before  the  attack  of  pleurisy — I think  it  would  then  have  been  apparent 
that  a tumor  existed  in  the  chest,  and  if  so,  that  tumor,  from  its  seat 
and  concomitant  circumstances,  would  have  been  declared  to  be  aneurism 
low  down  in  the  thorax.  It  was  simply  because  no  suspicion  of  its 
existence  occurred  to  us,  and  because  no  physical  examination  of  the 
chest  was  made  at  that  time,  that  the  tumor  was  not  detected  during 
life. 

The  Abdominal  Aneurism. — When  Smith  entered  the  house  the 
abdominal  aneurism  was  of  considerable  size.  It  measured  three  inches 
across.  Its  inferior  and  lateral  margins  only  could  be  felt,  the  superior 
portions  being  covered  by  the  ribs.  The  impression  conveyed  to  me  by 
examining  the  tumor,  however,  was  that  it  was  about  the  size  of  a 
cocoa-nut.  It  was  prominent,  especially  when  he  stood  up,  and  pulsated 
strongly.  There  can  be  no  doubt  that  its  volume  must  have  undergone 
considerable  diminution ; for,  previous  to  his  death,  it  felt  through  the 
inteofuments  about  the  size  of  a small  hen’s  eo-s:  ; — in  some  of  the  re- 
ports,  it  is  said  of  a pigeon’s  egg,  and  of  a walnut.  Yet,  as  you  see,  it 
is  the  size  of  a large  orange,  elongated.  Its  form  is  a long  oval,  one 
extremity  of  its  long  axis  resting  deep  upon  the  vertebrae,  the  other 
directed  toward  the  skin.  Hence,  during  life,  we  could  only  feel  one  of 
its  rounded  ends.  You  observe,  however,  that  the  whole  tumor  is  dense 
and  resistent, — and  on  section  it  presents  numerous  concentric  laminae 
of  coagulated  fibrin,  with  a small  canal  running  through  the  centre, 
keeping  up  the  communication  between  the  aorta  and  the  superior 
mesenteric  artery.  The  man  presented  habitually  a jaundiced  skin, 
which  was  doubtless  owing  to  the  pressure  of  the  tumor  on  the  duo- 
denum and  biliary  ducts. 

The  Paraplegia  and  Spinal  Softening. — He  first  complained  of 
weakness  in  the  lower  extremities  early  in  January  1852;  at  the  end 
of  that  month  my  period  of  attendance  on  the  wards  ceased.  In  the 
leport  of  March  1st,  I find  it  stated  that  there  was  decided  paralysis  of 
motion  in  the  inferior  extremities,  while  sensation  still  resulted  when 
they  were  touched.  On  April  8th,  the  paralysis  was  complete — that 
is,  volition  failed  to  cause  movement  in  the  lower  extremities,  and  sti- 
40 


626 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


muli  applied  to  them  failed  to  induce  sensation.  Involuntary  move- 
ments,  however,  occurred,  consisting  of  twitchings  and  startings,  but  he 
never  had  pain  in  the  limbs.  In  cases  of  myelitis  the  usual  symptoms 
are,  pricking  and  tingling  in  the  soles  of  the  feet.  These  symptoms 
were  absent,  and  the  reason  of  this  may,  I think,  be  found  in  the  nature 
of  the  softening  in  the  spinal  cord.  It  contained  no  granular  cells,  the 
result  of  exudation,  and  its  transformation  into  fatty  granules ; but  the 
tubular  substance  of  the  cord  was  broken  down,  forming  round  and  oval 
fragments  of  the  tubes.  Hence  it  was  a mechanical  softening,  the  result 
of  gradual  pressure  merely.  These  distinctions  have  not  been  hitherto 
gufl&ciently  attended  to  in  pathology.  (See  p.  358.)  You  will  observe 
that  the  aneurismal  tumor  commenced  pressing  on  the  left  side,  and 
from  before  backwards,  and  the  symptoms  indicate  that  weakness  was 
felt  in  the  left  inferior  extremity  before  the  right  one  was  affected, — and 
that  motion  was  paralysed  first,  sensation  last. 

Treatment  hy  Vahalva''s  Method. — A short  time  previous  to  the 
admission  of  Smith,  I treated  another  case  of  abdominal  aneurism  by 
the  method  of  Valsalva,  for  a period  of  forty  days, — at  the  expiration 
of  which  time,  he  walked  out  of  the  house,  with  little  assistance,  to  the 
nearest  cab-stand,  a distance  of  nearl}*  250  yards,  and  left  the  city.^  In 
the  case  of  Smith,  therefore,  the  bleedings  were  more  frequently  repeated, 
and  greater  in  amount,  while  the  diet  was  even  more  diminished  ; and 
yet,  after  nearly  a month’s  treatment,  the  pulse  was  of  such  good  strength, 
that  I ordered  venesection  to  syywope — an  effect  that  was  not  produced 
after  the  loss  of  twenty-six  ounces  of  blood — so  that  the  clerk,  afraid  to 
proceed  further,  bound  up  the  arm.  Three  days  afterwards,  twenty- 
eight  ounces  of  blood  were  removed,  with  the  effect  of  only  producing  a 
feeling  of  faintness.  Similar  bleedings  were  practised  at  no  distant  inter- 
vals, besides  numerous  applications  of  leeches,  and  the  restricted  diet ; 
and  yet  the  report  of  21st  April  1850  is,  that  “he  was  bled  to  thirty- 
four  ounces.,  at  his  urgent  request,  insisting  that  he  felt  nothing,  until  he 
fell  back  in  a state  of  syncope.”  I am  induced  to  suppose,  therefore, 
that  in  this  case,  as  in  the  preceding  one,  the  treatment  had  not  been 
carried  out  to  its  full  extent.  The  nurse,  indeed,  now  informs  me,  that 
perhaps  during  the  first  two  months  his  diet  was  really  limited ; but  she 
thinks  so,  simply  because  at  that  period  he  suffered  great  pain,  and  seemed 
very  anxious  to  follow  the  advice  given  to  him.  Subsequently,  there  is 
every  reason  to  suppose  that  he  obtained  food  from  his  companions,  or 
from  some  other  source.  I find  from  the  reports,  indeed,  that  whilst  his 
diet  was  still  nominally  at  a very  reduced  amount  up  to  July,  he  was  at 
the  same  time  walking  about  with  considerable  vigor.  From  my 
attempts  at  carrying  out  Valsalva’s  treatment  in  these  two  cases,  I con- 
clude that  it  is  impossible  to  practise  it  on  patients  in  an  open  ward,  or 
indeed  under  any  circumstances,  without  a degree  of  surveillance  that  it 
would  be  very  difficult  to  obtain. 

The  good  effects  of  the  treatment,  notwithstanding  its  imperfect 
nature,  were  so  evident  as  to  strike  all  who  witnessed  it,  and  to  cause 
the  patient  continually  to  r(jquest  that  he  might  be  bled.  In  fact,  after 
every  general  bleeding,  the  aragging  pains,  and  other  uneasy  sensations 
* See  Monthly  Journal,  February  1850,  p.  169. 


ANEURISM. 


62i 


fio  experienced  in  the  abdomen,  invariably  left  him,  and  he  enjoyed 
longer  or  shorter  periods  of  perfect  ease ; then,  as  the  pain  gradually 
returned,  and  it  became  unbearable,  he  was  again  relieved  by  bleeding ; 
and  so  on.  During  the  progress  of  his  case,  also,  it  was  observed  that 
the  abdominal  tumor  gradually  diminished  in  size,  and  became  harder. 
In  October,  the  tumor  was  ascertained  by  Dr.  Christison  to  be  some- 
what movable  ; but  in  the  following  December,  when  I examined  it,  it 
was  again  stationary.  During  the  whole  of  1851  he  enjoyed  compara- 
tive comfort, — occasionally,  however,  feeling  abdominal  pain,  which  was 
relieved  by  leeches  or  bleeding.  At  the  beginning  of  1852,  the  general 
opinion  of  all  who  examined  him  was,  that,  on  the  whole,  this  case  was 
a remarkable  example  of  the  good  effects  of  Valsalva’s  treatment.  Then, 
however,  the  paraplegia  came  on,  indicating  that  the  disease  was  really 
not  conquered,  but,  by  its  pressure  backwards,  was  affecting  the  spinal 
cord.  Then  came  the  attack  of  pleurisy  and  the  paraplegia : and  from 
this  period  it  was  evident  the  disease  would  terminate  fatally. 

The  examination  of  the  body  after  death  was,  in  this  case,  not  only 
important,  as  determining  the  nature  of  the  aneurism,  and  in  a diagnostic 
point  of  view ; but  it  served,  in  1113^  opinion,  to  point  out  what  value 
ought  to  be  attributed  to  Valsalva’s  treatment.  It  affords  an  example 
of  a wide  generalisation  to  which  the  cultivators  of  rational  medicine 
have  been  gradually  tending, — viz.,  that  not  oidy  is  the  examination  of 
the  body  after  death  necessary  for  diagnosis  and  pathology,  but  that  it 
is  essential,  in  order  that  we  may  properly  appreciate  therapeutics,  and 
the  utility  of  different  plans  of  treatment.  Let  us  suppose,  for  instance, 
that  this  man  had  died  at  the  commencement  of  1852  from  the  attack  of 
pleurisy,  and  that,  as  so  often  happens,  we  had  been  refused  permission 
to  open  the  body,  my  conviction  is,  that  under  such  circumstances  this 
case  would  have  been  recorded  in  the  annals  of  medicine  as  a successful 
instance  of  cure  by  the  method  of  Valsalva.  But  now,  when  all  the 
facts  are  before  us,  it  is  evident  that  the  diminution  of  the  abdominal 
swelling  was  owing  to  the  increa.se  of  the  thoracic  one  ; and  that,  as  the 
force  of  the  current  of  blood  became  lessened  by  the  enlargement  of  the 
aneurismal  dilatation  above,  so  the  flow  of  blood  was  retarded  in  the 
tumor  below.  In  consequence,  the  concentric  depositions  of  flbrin,  the 
lessened  size  of  the  abdominal  swelling,  and  the  more  permanent  relief  of 
pain,  instead  of  being  attributable  to  the  treatment,  as  we  had  supposed, 
must  now  be  more  rationally  ascribed,  to  the  increase  of  a thoracic 
aneurism,  not  detected  during  life,  which  had  produced  these  results 
mechanically,  and  altogether  independently  of  art. 

The  treatment  of  internal  aneurisms  by  the  method  of  Valsalva,  has 
for  some  time  been  discouraged  in  this  country,  on  the  ground  that 
it  gives  rise  to  a general  irritability,  and  to  .symptoms  of  a distressing 
nature,  which  are  often  intolerable ; whilst,  on  the  other  hand,  it  is 
seldom  attended  by  a permanently  good  effect.  In  the  case  before  us,  as 
well  as  in  that  I formerly  treated,  no  unpleasant  symptoms  could  fairly 
be  ascribed  to  the  practice ; but,  on  the  contrary,  it  produced  (especially 
the  bleedings)  well-marked  relief.  The  question  of  the  permanency  of 
these  good  effects  is,  I admit,  in  no  way  supported  by  my  experience. 
But  another  important  practical  point,  namely,  the  temporary  relief 


628 


DISEASES  OF  THE  CIRCULATOKY  SYSTEM. 


which  bleeding  causes,  without  arresting  the  progress  of  organic  malar 
dies,  here  meets  with  an  excellent  illustration. 

Poisoning  Toy  Aconite. — The  facts  which  I have  been  able  to  make 
out  regarding  the  poisoning  of  this  man  are  as  follows  : — On  Monday, 
May  31st,  about  11  o’clock  in  the  morning,  the  attention  of  Mr.  Broad- 
bent  (non-resident  clerk)  and  of  Dr.  Murchison  (resident  clerk),  both  of 
whom  were  at  the  time  in  the  ward,  was  directed  to  Smith,  by  a groan 
or  cry.  He  was  then  observed  to  be  sitting  up  in  bed,  leaning  forward, 
and  groaning  like  a man  laboring  under  colic  pains.  Mr.  Broadbent, 
who  was  nearest  at  the  time,  went  to  his  bedside,  and  asked,  “ What  is 
the  matter  ? ” Smith  made  no  immediate  reply,  but  continued  to  groan, 
and  moved  his  arms  in  a feeble  manner,  and  it  was  noticed  by  Mr.  B. 
that  his  hands  dropped  considerably  when  the  arms  were  raised.  He 
then  tried  to  reach  the  spit-box,  but  not  being  able  to  do  so,  it  was  given 
to  him,  and  he  seized  it,  raised  it  to  his  mouth,  and  spat  into  it.  He 
then  said,  with  short  pauses  between  his  words,  “ Is  there  anything 
wrong  with  my  face  ? — it  is  very  painful ; what  medicine  have  I been 
taking?”  On  being  asked  to  point  out  the  bottle  on  the  shelf,  he  did 
so,  saying,  “ That  little  bottle  there.”  On  looking  at  it,  Mr.  Broadbent 
saw  by  the  label  that  it  was  a liniment,  composed  of  Tr.  Aconiti  § ss ; 
Lin.  Saponis  c.  Opio  gjss.  Dr.  Murchison,  on  being  informed  what 
had  happened,  also  went  to  Smith,  found  him  pulseless,  and  on  letting 
go  his  arm  observed  that  it  fell  down  powerless  at  his  side.  Smith  then 
repeated  more  than  once,  “ Can  nothing  be  done  for  me  ? — -What  can 
you  do  for  me  ? — Can  you  get  me  a vomit  ? ” etc.  An  emetic  of  sulphate 
of  zinc  was  immediately  sent  for,  and  it  was  further  observed  that  the 
pupils  had  undergone  no  marked  change,  that  there  was  no  lividity  of 
the  lips  or  other  part  of  the  countenance,  that  no  impulse  could  be  felt 
in  the  cardiac  region,  and  that  the  respiration  was  more  slow  and  labo- 
rious than  usual.  Dr.  Murchison  now  left  the  patient  to  get  a stomach- 
pump,  and  Mr.  Broadbent  saw  Smith  retch  twice,  as  if  endeavoring 
voluntarily  to  vomit.  He  therefore  went  into  the  side-room  to  get  a 
feather,  or  some  object  to  tickle  his  fauces  with,  but  was  immediately 
summoned  back  by  the  intelligence  that  Smith  was  worse.  On  returning 
to  the  bedside  he  found  that  the  patient  had  fallen  on  his  bed,  the  head 
thrown  back,  face  and  lips  remarkably  pale,  a little  saliva  running  from 
the  corner  of  the  mouth,  the  respirations  occurring  at  long  intervals 
with  gasping,  the  pupils  neither  dilated  nor  contracted,  and  the  eyelids 
paralysed,  when  opened  remaining  fixed,  and  not  contracting  on  blowing 
into  the  eye.  He  was  now  insensible,  and  consequently  the  emetic, 
which  at  this  time  arrived,  could  not  be  given.  About  a minute  after. 
Dr.  Murchison,  on  hurrying  back  with  the  stomach-pump,  found  him 
dead.  Notwithstanding,  more  than  a pint  of  semi-pultaceous  matter  was 
immediately  drawn  off  from  the  stomach,  smelling  strongly  of  the  lini- 
ment, and  artificial  respiration  was  kept  up  in  vain  for  five  minutes. 

The  period  that  elapsed  from  first  noticing  Smith’s  cry  or  groan  until 
Dr.  Murchison’s  return,  when  he  was  dead,  is  differently  estimated  by 
the  gentlemen  concerned  at  five  and  seven  minutes.  The  liniment  con- 
sisted originally  of  Liniment.  Sapon.  C.  Opio  3 jss ; Tr.  Aconiti  | ss,  and 
it  is  believed  that  the  whole  of  this  quantity  (viz.  two  fluid  ounces),  was 


ANEURISil. 


629 


in  the  bottle  when  Smith  began  to  drink  it.  There  were  found  in  the 
bottle  afterwards  five  drachms  remaining,  so  that  the  presumption  is, 
that  he  swallowed  three  drachms  of  laudanum,  and  upwards  of  two 
drachms  of  tincture  of  aconite. 

Whether  Smith’s  death  arose  from  accident,  or  whether  he  com- 
mitted suicide,  is  not  likely  ever  to  be  known.  Those  who  knew  him 
best  in  the  ward,  as  well  as  the  nurse,  are  of  the  latter  opinion,  based 
principally  on  the  character  of  the  man,  which  was  such  as  to  prevent 
his  mistaking  a liniment  for  a draught.  It  seems  also,  that  no  one  was 
more  habitually  careful  as  to  the  medicines  he  took, — that  the  liniment 
was  not  ordered  for  him  ; that  he  took  it  from  a patient  in  a neighbor- 
ing ward,  and  kept  it  on  his  shelf  for  some  days ; and  lastly,  that  since 
the  paraplegia  had  become  complete,  he  had  been  unusually  despondent 
and  morose.  With  regard  to  the  phenomena  produced,  it  is  most  likely 
that,  immediately  after  swallowing  the  poison,  he  experienced  those 
violent  tingling  and  stinging  sensations  in  the  mouth  and  fauces  which 
aconite  produces,  and  hence  the  pain  complained  of  in  his  face.  Being 
already  paraplegic,  nothing  is  known  as  to  how  far  the  poison  affected 
the  muscles  of  the  lower  extremities ; but  it  is  evident  that,  whilst  the 
intelligence  remained  perfect,  the  arms  became  weak,  then  powerless. 
Subsequently,  he  could  not  support  himself  in  the  sitting  posture ; and, 
on  his  falling  back,  the  muscles  of  the  face  and  of  respiration  were 
paralysed,  and  he  died  asphyxiated.  Previous  to  this,  however,  a 
powerful  sedative  effect  had  been  produced  on  the  heart,  for  when  first 
noticed  he  was  pulseless,  and  shortly  after,  no  impulse  could  be  felt  in 
the  cardiac  region. 

According  to  Dr.  Christison,  the  least  variable  symptoms  of  poison- 
ing by  aconite  in  the  human  subject  are,  “ first,  numbness,  prickling, 
and  impaired  sensibility  of  the  skin,  impaired  or  annihilated  vision, 
deafness,  and  vertigo — also,  frothing  of  the  mouth,  constriction  at  the 
throat,  false  sensations  of  weight  or  enlargement  in  various  parts  of  the 
bod}^, — great  muscular  feebleness  and  tremor,  loss  of  voice,  and  labori- 
ous breathing, — distressing  sense  of  sinking,  and  impending  death, — a 
small,  feeble,  irregular,  and  gradually-vanishing  pulse, — cold  clammy 
sweat,  and  pale  bloodless  features,  together  with  perfect  possession  of 
the  mental  faculties,  and  no  tendency  to  stupor  or  drowsiness ; finally, 
sudden  death  at  last,  as  from  hemorrhage,  and  generally  in  a period 
varying  from  an  hour  and  a half  to  eight  hours.”*  Although  in  this 
case  many  of  the  symptoms  just  mentioned  were  not  noticed,  it  must 
be  evident  that  the  leading  ones,  indicative  of  the  physiological  action 
of  the  drug,  were  observed.  When  the  large  dose  of  the  poison  is  con- 
sidered, and  the  great  rapidity  of  its  effects,  it  may  be  easily  under- 
stood how  the  minor  symptoms,  and  especially  those  having  reference 
to  the  sensations  of  the  patient,  were  not  ascertained,  if  indeed  they 
really  existed. 

Dr.  Fleming  considers  that  aconite  may  cause  death,  “ first,  by  pro- 
ducing a powerful  sedative  impression  on  the  nervous  system  ; second, 
by  paralysing  the  muscles  of  respiration  ; and  third,  by  producing 
syncope.”  He  observes,  “ that  the  second  mode  of  death  has  never  been 
On  Poisons,  fourth  edition,  page  871. 


630 


DISEASES  OF  THE  CIRCULATOKT  SYSTEM. 


recognised  in  man ; the  quantity  of  the  poison  taken  in  no  case  having 
been  suflBcient  to  exert  such  an  effect  on  the  nervous  and  muscular 
systems  as  is  necessary  to  induce  it.”*  The  case  of  Smith,  indeed,  is 
the  only  one  of  this  description,  so  far  as  I am  aware,  that  has  ever 
occurred  in  which  the  dose  of  poison  was  so  large,  and  the  death  so 
rapid.  It  is  difficult  to  separate  the  effects  of  syncope  from  those  of 
asphyxia  in  such  a case,  as  the  first  condition  must  induce  the  other. 
Both  were  apparently  combined.  It  is  also  difficult  to  determine  how 
far  the  effects  on  respiration  were  occasioned  by  paralysis,  creeping  from 
below  upwards,  as  in  the  case  of  Gow,  formerly  given  (Case  XL VI II.,  p. 
459).  There  are  some  facts,  however,  noticed  by  Dr.  Christison,  which 
lend  support  to  such  a doctrine ; and  it  will  be  observed  that  paralysis 
of  the  hands  and  arms  preceded  that  of  the  muscles  of  the  back  and 
face  in  the  case  of  Smith. 

The  general  diagnosis  of  thoracic  aneurisms  has  always  been  con- 
sidered a matter  of  great  difficulty.  When,  indeed,  a tumor  with  a 
distinct  impulse  is  perceptible,  we,  in  the  majority  of  cases,  know  with 
what  disease  we  have  to  do.  But  even  here  occasional  errors  by  men 
of  the  greatest  experience  have  sufficiently  proved  that  the  art  of  detect- 
ting  these  tumors  with  exactitude  is  imperfect.  Again,  when  aneuris- 
mal  tumors  are  seated  at  the  upper  part  of  thorax,  it  is  important 
to  determine  whether  they  arise  from  the  aorta,  or  from  the  large 
vessels  coming  from  it,  and  if  the  latter,  which  vessel  is  affected.  Then 
aneurisms  originating  from  the  upper  part  of  the  descending  aorta  press 
upon  neighboring  nerves,  as  the  superior  and  inferior  laryngeal  and 
pharyngeal  branches  of  the  pneurno-gastric,  giving  rise  to  various  symp- 
toms ; or  they  compress  the  larynx,  trachea,  bronchus,  oesophagus,  or  the 
lung  itself,  and  so  occasion  laryngeal,  oesophageal,  or  pulmonary  symp- 
toms. Lastly,  when  deep  in  the  thorax,  their  progress  is  often  latent. 
Hence  the  signs  and  symptoms  of  thoracic  aneurisms  vary — 1st,  Ac- 
cording to  their  scat ; 2dly,  According  to  the  size  of  the  tumor  and 
its  pressure  upon  neighboring  parts ; 3dly,  On  the  character  of  the 
aneurism,  its  formation,  and  state  of  the  vessel. 

The  means  at  our  disposal  for  detecting  these  aneurisms  are, — 1st, 
Percussion  ; 2d,  Auscultation  ; 3d,  Palpation  ; 4th,  Symptoms. 

1.  Percussion. — That  the  situation  and  size  of  the  aorta  can  be 
accurately  determined  by  percussion,  was  first  proved  by  Piorry.f  I 
have  frequently  succeeded,  in  favorable  'cases,  in  marking  out  on  the 
chest  the  size  of  this  vessel.  To  do  so  with  accuracy,  it  is  first  necessary 
to  limit  the  margins  of  the  heart  in  the  manner  previously  explained 
(see  p.  56),  and  then  carrying  the  pleximeter  upwards  in  the  course  of 
the  aorta,  and  over  the  sternum,  the  dulness  of  the  vessel  when  com- 
pared with  the  resonance  of  the  lung  on  both  sides,  may  be  made  very 
apparent.  In  the  same  manner,  the  extent  of  saccular,  or  simple  aneu- 
risms by  dilatation,  may  frequently  be  determined  with  accuracy  when 
seated  in  the  ascending  or  transverse  arch.  In  such  cases,  however,  the 
existence  of  pain  often  renders  percussion  impossible,  and  at  all  times 

* An  Inquiry  into  the  Physiological  and  Medicinal  Properties  of  the  Aconitum 
Napellus.  Edinburgh,  1845.  P.  42. 

De  i’Examen  Plessimetrique  de  T Aorta,  etc.  1840. 


aneueism. 


o31 


it  should  be  conducted  with  great  gentleness.  When  an  aneurism  is 
seated  in  the  descending  thoracic  aorta,  its  limitation  is  more  difficult, 
as  we  have  then  to  percuss  through  the  lung  anteriorly.  But  careful 
. manipulation,  and  varying  the  force  of  the  blow,  together  with  percus- 
sion posteriorly,  will  frequently  enable  us  to  determine  the  position  and 
size  of  the  swelling.  If,  on  the  other  hand,  the  aneurism  be  small  and 
deep-seated,  while  the  lungs  are  healthy,  and  if,  at  the  same  time,  no 
suspicion  of  the  disease  be  entertained  by  the  practitioner,  he  is  very 
likely  to  overlook  the  importance  of  slight  dulness  on  one  side  of  the 
chest. 

2.  Auscultation. — There  may  be  no  sounds  heard  over  an  aneurism, 
and  when  present  they  may  be  either  single  or  double.  Considerable 
discussion  lias  taken  place  whether,  in  the  latter  case,  the  second  sound 
originates  in  the  tumor,  or  is  propagated  along  the  vessel  from  the  heart. 
This  is  a theoretical  point  which  is  not  yet  decided.  Whether  single  or 
double,  they  must  be  judged  of  according  to  their  character  and  seat. 
With  regard  to  their  character.,  they  maybe, — 1st,  Soft  and  blowing; 
2d,  Harsh  and  rough  (in  the  latter  case,  the  vessel  is  generally  diseased, 
and  its  lining  membrane  more  or  less  atheromatous  or  calcareous) ; 3d, 
There  mny  be  a peculiar  clink,  or  abrupt  harsh  resonance,  approaching 
towards,  but  never  reaching,  a metallic  sound.  It  is  generally  heard 
when  a saccular  aneurism,  free  from  coagula,  is  present,  with  a small 
opening,  having  thin  and  elastic  margins.  With  respect  to  the  seat  of 
these  sounds,  when  near  the  heart,  they  are  generally  synchronous  with 
those  of  that  organ,  and  their  discrimination  is  very  difficult.  When 
situated  in  the  arch  of  the  aorta,  there  is  a distinct  separate  source  of 
sound.  This  latter  can  only  be  successfully  studied  by  carefully  com- 
paring the  moment  of  impulse  of  the  heart  with  that  of  the  tumor,  as 
well  as  the  character  and  intensity  of  the  cardiac  and  aneurismal  sounds. 
You  should  carry  the  stethoscope  carefully  from  one  to  the  other,  and 
observe  the  diminution  and  increase  of  the  murmurs,  as  you  lengthen  or 
shorten  the  distance  from  the  origin  of  the  sounds.  It  is  necessary  also 
to  study  the  direction  in  which  the  sounds  are  propagated — those  of  a 
blowing  or  rasping  character  having  a tendency  to  pass  in  the  directiou 
of  the  current  of  blood.  Hence  in  aneurisms  of  the  innominata,  the 
murmur  is  prolonged  in  the  course  of  the  right  carotid  and  axillary 
arteries,  while  those  of  the  aortic  arch,  and  especially  its  descending 
portion,  may  be  heard  in  the  aorta,  on  applying  the  ear  to  the  back.  In 
this  manner  careful  and  repeated  auscultation,  conjoined  with  percussion, 
will  enable  you,  in  the  majority  of  cases,  to  determine  exactly,  not  only 
the  existence  and  seat  of  the  aneurism,  but  in  many  cases  its  form  and 
structure. 

3.  Palpation. — When  an  aneurism  points  externally,  at  umor  and 
an  expansive  impulse  can  be  felt  by  the  hand. 

The  position  of  the  tumor  varies  according  to  the  part  of  the  aorta, 
or  the  large  vessels  from  which  it  originates.  Thus,  saccular  aneurisms 
immediately  above  the  aortic  valves  pass  downwards.  When  situated 
in  the  innominata,  they  manifest  themselves  above  the  clavicle  on  the 
right  side.  If  originating  in  the  transverse  portion  of  the  arch,  there 
is  often  no  external  tumor ; and  when  it  does  occur,  it  generally 


632 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


appears  on  the  left  side  of  the  sternum,  above  or  below  the  sternoclavi- 
cular articulation.  Aneurisms  lower  down  in  the  arch  are  most  com- 
mon in  the  left  thoracic  cavity.  These  rules  are  by  no  means  absolute  ; 
for,  although  an  aneurismal  tumor  for  the  most  part  tends  to  enlarge 
in  the  direction  in  which  the  impulse,  from  the  course  of  blood,  is 
applied — this,  in  several  cases,  cannot  be  determined  in  the  living 
body. 

The  impulse  of  the  tumor  is  synchronous  with,  or  follows  the  systole 
of  the  heart.  Occasionally  there  is  no  impulse,  a circumstance  most 
frequently  observed  when  the  tumor  does  not  present  externally,  and  is 
only  determined  by  percussion.  The  pulse  of  arteries  connected  with 
the  aneurism  may  be  weakened  or  retarded.  The  pulse  at  both  wrists 
should  be  always  carefully  studied ; for  if  one  be  weaker  than  the  other, 
it  is  clear  that  an  interruption  exists  in  the  current  of  the  blood  in  the 
axillary  artery.  This  may  arise  from  two  causes — 1st,  From  the  vessel 
being  involved  in  the  tumor ; 2d,  From  its  being  compressed  by  it 
externally.  The  former  condition  exists  most  commonly  when  there 
is  aneurism  of  the  innominata,  when  the  weaker  pulse  will  be  on  the 
right  side.  In  aneurisms  of  the  arch,  on  the  other  hand,  the  feebler 
pulse  is  usually  on  the  left  side.  The  retardation  of  the  pulse, 
when  it  occurs,  is  owing  to  causes  very  similar  to  those  which  affect  its 
strength. 

4.  The  symptoms  which  are  present  in  cases  of  thoracic  aneurism  vary 
af’cording  to  the  size  of  the  tumor,  and  the  parts  on  which  it  presses. 
When  seated  at  the  upper  part  of  the  chest,  it  may,  by  pressure  on  the 
larynx,  produce  alteration  of  the  voice,  more  or  less  harsh  cough,  and 
stridiilous  respiration;  by  affecting  the  branches  of  the  eighth  pair, 
occasion  increase  or  diminution  of  their  special  functions;  impede 
deglutition  by  constricting  the  oesophagus;  or  modify  the  respiratory 
murmur  by  pressing  on  the  trachea  or  larger  bronchi.  Occasionally 
there  is  a crepitating  murmur  in  the  lung,  with  many  of  the  signs  and 
symptoms  of  pneumonia,  for  which  it  has  often  been  mistaken,  including 
rusty  sputum,  dulness,  and  increased  vocal  resonance.  Pressure  of  the 
tumor  on  the  axillary  vessels  and  nerves  may  induce  more  or  less 
oedema  of  the  extremities,  and  paralysis  more  or  less  complete.  Some- 
times there  are  dull,  gnawing,  or  lancinating  pains  in  various  parts  of  the 
chest ; but  nothing  is  more  remarkable  than  the  size  and  formidable 
nature  of  some  aneurisms  which  have  caused  little  pain.  Occasionally 
there  is  a feeling  of  oppression  and  constriction — dyspnoea  with  or  with- 
out exertion,  and  haemoptysis  to  a greater  or  less  extent. 

The  combination  of  the  results  obtained  by  percussion,  auscultation, 
palpation,  and  vascular  impulse,  and  the  functional  symptoms,  vary  in- 
finitely in  different  cases,  and  their  careful  detection,  combined  with  a 
knowledge  of  physiology,  will  in  the  majority  of  cases  enable  us  to  form 
a correct  opinion  as  to  the  nature  of  the  disease.  It  must  not  be  for- 
gotten, however,  that  there  are  some  cases  which  have  been  so  obscure 
as  to  baffle  the  efforts  of  the  most  able  physicians;  and  that,  generally 
speaking,  the  deeper  the  aneurism  the  greater  the  difficulty  of  detecting  its 
exact  nature,  and  the  complications  connected  with  it.  It  is  also  well  ascer- 
tained that  the  symptoms  may  be  simulated  by  a tumor  situated  out- 


ANEUKISSr. 


633 


side  and  upon  the  vessel ; and  occasional  mistakes,  made  by  the  most 
experienced  surgeons — men,  who,  during  their  professional  lives,  have 
carefully  examined  a large  number  of  these  tumors — prove  the  excessive 
difficulty  of  detecting  aneurisms,  even  when  situated  in  the  limbs  or  in 
the  necL  How  much  more  difficult  must  be  the  appreciation  of  these 
symptoms,  when  the  aneurisms  are  below  the  sternum  or  clavicles,  not 
to  speak  of  their  occurrence  deep  in  the  thorax.  Yet  these  very 
symptoms,  together  with  the  results  obtained  by  percussion  and  ausculta- 
tion, enable  the  physician  frequently  to  overcome  the  greatest  difficulties, 
and  to  demonstrate  what  may  properly  be  called  the  greatest  triumph  of 
his  art. 

The  physical  phenomena  most  distinctive  of  abdominal  aneurism  are 
a swelling  more  or  less  defined,  an  expansive  impulse  on  applying  the 
hand,  and  a bellows  murmur  synchronous  with,  or  immediately  following, 
the  heart’s  systole  on  applying  the  stethoscope.  This  bellows  murmur 
is  generally  loudest  over  the  tumor,  and  is  propagated  down  the  aorta — • 
although,  when  immediately  below  the  diaphragm,  it  may  be  confounded 
with  the  first  sound  of  the  heart.  The  symptoms  are  very  various,  con- 
sisting of  dragging,  or  other  pain,  more  or  less  acute  and  prolonged, 
owing  to  pressure  and  stretching  of  the  neighboring  nerves,  together  with 
functional  disturbance  of  one  or  more  of  the  abdominal  viscera.  Various 
cases  on  record,  therefore,  have  presented  a train  of  very  anomalous 
symptoms,  and  at  various  times  been  considered  as  difiPerent  diseases  by 
medical  practitioners.  A complete  re-investigation  of  the  symptoms 
and  signs  of  abdominal  aneurisms  is  much  required.  This  is  a task,  how- 
ever, which  will  require  a thorough  knowledge  of  all  that  is  now  known 
of  physical  diagnosis  and  morbid  anatomy,  combined  with  great  powers 
of  observation,  and  such  opportunities  as  fall  to  the  lot  of  few  individual 
members  of  the  profession. 

The  pathology  of  aneurism  is  sufficiently  treated  of  under  the  heads 
of  “ Vascular  Growths,’’  p.  216,  and  of  “ Fatty  Degeneration  of  Blood- 
vessels,” p,  256.  The  latter,  by  inducing  weakness  or  want  of  elasticity 
in  the  vascular  wall,  permits  of  its  dilatation  by  the  successive  impulses 
of  the  blood  on  the  enfeebled  tissue.  Occasionally  the  inner  coat  of  the 
vessel  is  lacerated  by  external  violence,  or  by  sudden  exertions,  when  a 
similar  morbid  condition  gives  rise  to  like  results.  As  the  aneurismal 
tumor  enlarges,  it  presses  more  and  more  upon  neighboring  parts,  giving 
rise  to  atrophy,  ulceration,  and  interstitial  absorption  of  parts,  and  occa- 
sioning a great  variety  of  symptoms,  according  to  the  situation  of  the 
tumor,  the  organs  and  tissues  influenced  by  it,  and  the  amount  and  kind 
of  pressure  exerted  on  the  textures  concerned  in  the  functions  of  nutri- 
tion and  innervation. 

The  treatment  of  aneurisms  may  be  curative  or  palliative.  The  for- 
mer is  carried  out  by  the  surgeon.  The  general  treatment  by  Valsalva’s 
method  has  already  been  alluded  to  (p.  611),  and  is  now  seldom  practised. 
All  the  physician  can  do  is  to  palliate  symptoms,  diminish  the  chances 
of  rupture,  and  favor  the  obliteration  of  the  enlarged  vessel ; to  this 
end  enjoining  quietude,  especially  avoidance  of  sudden  or  long  sustained 


634 


DISEASES  OF  THE  CIRCELATORY  SYSTEM. 


exertion.  Occasional  local  and  even  general  bleeding,  topical  applica- 
tions of  ice  or  warmth  as  may  be  found  most  useful,  and  sedatives,  tend 
to  diminish  pain.  Constipation  should  be  carefully  guarded  against,  and 
healthy  nutrition  secured  by  attention  to  the  various  animal  functions, 
gentle  exercise,  etc.  etc. 

DISEASES  OF  VEINS  AND  LYMPHATICS. 

Case  CXXVII.* — Phlebitis  of  the  Left  Iliac  Vein,  supervening  on 
Cancer  of  the  Stomach  and  (Esophagus. 

History. — Alexander  Henderson,  aet.  23,  baker — admitted  June  22d,  1863.  Pa- 
tient states  that  he  has  enjoyed  good  health,  until  about  a year  ago,  when  he  began  to 
be  troubled  with  heartburn.  This  annoyed  him  daily ; and  six  weeks  ago,  half  an  hour 
after  dinner,  he  vomited  for  the  first  time.  Since  then  he  has  vomited  every  time  he 
has  taken  food,  and  generally  immediately  on  swallowing  it,  experiencing  during  the 
act  of  deglutition  a feeling  as  if  the  bolus  was  obstructed  in  its  passage  to  the  stomach. 

Symptoms  on  Admission. — Tongue  pale  and  clean  in  front,  but  loaded  behind.  No 
appetite.  He  vomits  immediately  upon  sivallowing  food,  except  to-day  when  he  has 
been  able  to  retain  a little  beef-tea.  Any  bolus  of  solid  food  feels  as  if  suddenly  ob- 
structed in  its  course  down  the  oesophagus,  at  a point  about  two  or  three  inches  to  the 
left  of  the  xiphoid  cartilage,  and  this  sensation  is  succeeded  either  by  vomiting,  or  by 
his  distinctly  feeling  the  bolus  slip  downwards  into  the  stomach.  He  has  constant 
pricking  pain  in  the  epigastric  and  left  hypochondriac  regions,  which  is  increased  by 
pressure,  and  greatest  at  the  point  where  he  feels  the  obstruction  on  swallowing.  No 
tumor  can  be  felt.  Hepatic  dulness  inches.  Bowels  constipated.  Cardiac  impulse 
between  4th  and  5th  ribs,  one-half  inch  internal  to  and  below  the  nipple.  Its  dulness 
on  percussion  measures  transversely  24  inches.  A soft  blowing  murmur  aceompanies  the 
first  sound  at  the  apex.  Pulse  72,  very  weak.  Frequent  cough,  with  muco-purulent 
expectoration.  The  breathing  over  the  whole  back  is  somewhat  harsh,  and  expiration 
is  occasionally  accompanied  by  sibilation.  Considerably  emaciated.  Cheeks  of  a livid 
hue.  Other  functions  normal. 

Progress  of  the  Case. — The  gastric  symptoms  of  the  patient  were  greatly  alle- 
viated by  careful  arrangement  of  his  diet,  consisting  of  small  quantities  of  unirritating 
food  taken  four  or  five  times  a day.  The  vomiting  had  ceased,  and  he  was  walking 
about  the  ward  when,  at  3 p.m.,  July  13th,  he  experienced  a rigor,  followed  by  febrile 
symptoms,  and  in  the  evening  he  complained  of  severe  pain  in  the  epigastric  region, 
which  was  distended  and  tympanitic  on  percussion.  Has  no  appetite.  Face  much 
flushed.  Pulse  102,  very  weak.  lor  some  days  previously  he  had  noticed  slight 
oedema  of  the  ankles,  for  which  diuretics  had  been  ordered.  July  lAth. — The  febrile 
symptoms  diminished.  Pulse  84,  weak.  July  l^ih. — Has  had  repeated  shiverings 
during  the  day.  Pulse  82,  weak.  Complains  also  of  severe  pains  shooting  down  the 
left  leg  from  the  groin,  and  on  examination,  it  is  found  to  be  greatly  swollen,  pitting 
very  much  on  pressure.  Some  enlarged  lymphatic  glands  can  be  felt  in  the  left  groin. 
The  oedema  of  the  right  leg  is  much  diminished.  Urine  passed  during  24  hours,  20 
oz.,  containing  no  albumen.  A large  warm,  'poultice  to  he  applied  to  the  left  groin, 
July  18^7i. — Continues  to  have  occasional  rigors  followed  by  febrile  symptoms.  No 
appetite.  (Edema  of  the  legs  the  same  as  in  last  report,  the  left  leg  being  greatly,  while 
the  right  is  but  slightly,  swollen.  The  pain  in  the  left  groin  still  continues.  Jxdy 
207/i. — The  oedema  of  the  left  leg  is  increasing,  while  there  is  now  no  swelling  of  the 
right.  Still  eomplains  of  great  pain  shooting  down  the  left  leg.  Has  no  increase  of 
appetite,  but  the  feeling  of  obstruction  on  swallowing  is  now  absent.  Bowels  which 
have  been  hitherto  rather  constipated,  were  moved  last  night  by  castor-oil.  The  abdo- 
men is  distended  with  flatus.  Pulse  118,  weak,  and  occasionally  intermittent.  Urine, 
22  oz.  July  21s^. — Last  night  had  a rigor,  and  to-day  at  2 p.m.  he  is  found  in  a state 
of  high  fever,  the  face  flushed,  of  a deep  purple,  and  the  tongue  covered  ivith  a thick 
yellow  fur,  dry,  cracked,  and  fissured.  Pulse  130,  very  weak  and  intermittGiit.  Still 
no  appetite.  Has  no  pain  except  when  pressure  is  made  over  the  left  groin.  Is  very 


* Reported  by  Mr.  John  Wylie,  Clinical  Clerk. 


DISEASES  OF  VEINS  AND  LYMPHATICS. 


635 


restless.  No  pulsation  can  be  felt  in  the  left  groin,  but  there  is  induration  and  tender- 
ness on  pressure.  His  bowels  are  opened  regularlj^  every  second  day  by  castor-oil. 
July  22c?. — Lies  on  his  back ; his  eyes  fixed  and  glazed ; his  eyelids  half  closed.  The 
tongue  is  still  covered  with  the  dry  yellowish  fur,  and  is  protruded  with  great  difficulty 
Answers  when  spoken  to  and  says  he  has  very  little  pain,  but  has  some  uneasiness 
about  the  epigastric  region.  Pulse  140,  weak  and  intermittent.  Pain  and  restlessness 
at  night.  H Chlorodyne  TT  xv. ; 8p.  ^Ih.  Cldorici  3 ss  ; 3fist.  Camph.  3 vi.  M. 
To  he  taken  at  hed-time.  July  23c?. — Last  night  was  very  restless,  complaining  of  pain 
in  the  lower  part  of  the  back.  Got  the  draught  at  11  o’clock  and  became  easier,  but 
after  midnight  he  was  observed  again  to  become  restless,  and  at  4 o’clock  this  morning 
he  died. 

Sectio  Cadaveris. — Thirty-five  hours  after  death. 

Body  greatly  emaciated,  and  very  slightly  jaundiced. 

Thorax. — The  pericardium  contains  a considerable  quantity  of  yellow  serum. 

Heart. — Aortic  valves  competent.  Mitral  valve  somewhat  atheromatous.  Lungs 
contain  a few  soft  cancerous  nodules  of  the  size  of  marbles,  dispersed  in  their  substance. 

Abdomen. — Intestines  greatly  distended  with  flatus.  Liver. — On  making  sections 
through  the  organ,  it  is  found  to  contain  a few  cancerous  masses,  varying  in  size  from 
a marble  to  a hen’s  egg.  Stomach. — On  opening  into  the  stomach,  its  cardiac  orifice 
as  well  as  three  inches  of  the  lower  part  of  the  oesophagus,  is  found  to  be  surrounded 
by  hard  scirrhous  matter  which  is  ulcerated  on  its  internal  surface.  Pancreas  healthy. 
In  the  Mesentery.,  especially  near  its  root,  there  are  a few  scirrhous  masses  of  the  size 
of  marbles. 

The  left  external  iliac  vein  was  greatly  distended,  and  felt  like  a thick  cord.  On 
being  opened,  it  was  found  to  be  occluded  by  a clot  to  the  extent  of  four  inches.  The 
walls  were  one-eighth  of  an  inch  thick  over  this  portion,  and  adherent  to  the  clot.  This 
was  generally  of  a brick-red  color,  firm  externally,  but  soft  and  pultaceousin  the  centre, 
where  here  and  there  it  was  of  a fawn  color.  The  smaller  veins  communicating  with 
the  altered  vessel  were  also  obstructed  by  clots.  Other  organs  healthy. 

Microscopic  Examination. — The  harder  part  of  the  clot  was  composed  of  dense 
amorphous  matter,  and  broken-down  blood  globules.  The  soft  portions  were  composed 
of  diffluent  molecular  fibrin,  with  a few  colorless  cells,  resembling  those  of  pus. 

Commentary. — In  this  man,  who  was  weak  and  emaciated  in  con- 
sequence of  cancer  with  stricture  of  the  cardia,  there  occurs,  without  any 
obvious  cause,  intense  fever  followed  by  severe  pain  in  the  left  groin, 
and  oedema  of  the  left  inferior  extremity.  From  this  attack  he  never 
rallies,  and  dies  ten  days  afterwards.  On  dissection,  inflammation  of  the 
left  iliac  vein  is  found,  its  coats  thickened  and  adherent  to  a clot  which 
obstructed  the  vessel.  The  case  offers  another  illustration  of  severe  local 
inflammation  occurring  in  weak  emaciated  subjects,  which  proves  fatal 
from  the  want  of  vital  power  necessary  for  accommodating  the  system  to 
the  injury.  Phlebitis,  whenever  it  occurs,  tends  to  cause  obstruction  of 
the  vessels  involved,  and  as  a result  of  .this,  dropsy  occurs.  The  object 
of  treatment  should  be  to  support  the  strength  until  time  has  been  giveii 
to  establish  a collateral  circulation,  which,  if  the  patient  be  strong,  apd 
the  case  uncomplicated,  frequently  happens.  But  where,  as  in  the 
instance  before  us,  the  strength  is  gone,  from  the  results  of  gastric  cancer, 
it  could  only  hurry  on  the  fatal  termination. 

Case  CXXYIII.'^ — Anyio-Leucitis^  supervening  on  Rupia — Recovery. 

History. — John  Mercer,  aet.  32,  draper — admitted  February  19th,  1859,  with 
rupia,  which  followed  primary  and  secondary  syphihs  that  had  been  long  treated  with 
mercury.  He  has  been  of  dissipated  habits,  and  was  in  the  house  for  delirium  tremens. 
The  whole  skin  is  scattered  over  with  prominent  imbricated  dark-brown  scabs,  varying 
in  size  from  a small  pea  to  that  of  a sixpence  at  the  base.  Other  functions  are  normal. 

* Reported  by  Mr.  R.  T.  Land,  Clinical  Clerk. 


636 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


Five  grs.  of  Iodide  of  Potassium  to  he  taken  three  times  daily.  To  have  an  alkaline 
hath. 

Progress  op  the  Case. — Feh.  Toth. — Last  evening  complained  of  pain  on  the  flexor 
surfaces  of  both  arms,  extending  from  the  wrist  to  the  axilla.  To  day  the  pain  is  in- 
creased, and  bright  red  lines,  following  the  course  of  the  lymphatics,  may  be  seen  ex- 
tending from  the  wrist,  up  the  flexor  surfaces,  to  the  middle  of  both  arms.  The  skin 
between  them  is  erythematous.  The  tongue  is  furred ; there  is  no  appetite ; consider- 
able thirst,  but  no  rigor.  Pulse  80,  of  good  strength.  Gloths  steeped  in  warm  water 
to  he  applied  to  both  arms,  and  kept  moist  with  gutta-percha  sheeting.  Feb.  26^4. — 
Felt  much  relieved  from  the  moist  applications.  Flexor  surfaces  of  both  arms  were 
much  indurated,  but  otherwise  the  same.  Feh.  29i!A. — Last  night  at  12  o’clock  had 
severe  shivering  which  lasted  till  2 a.  m.,  with  pain  in  the  head,  and  general  feverish 
symptoms.  Both  forearms  are  to-day  m )re  swollen  and  painful,  the  bright  red  lines 
feel  like  cords,  and  the  erythematous  redness  is  intensified  and  somewhat  elevated  above 
the  surface  of  the  skin.  It  may  now  be  regarded  as  erysipelatous.  Warm  moist  ap- 
plications to  be  continued.  March  2(7. — Yesterday  the  pain  and  swelling  had  greatly 
diminished,  and  to-day  the  whole  has  disappeared.  The  rupia  also  has  greatly  bene- 
fited from  the  moist  applications,  the  scales  have  separated,  and  most  of  the  ulcers 
have  healed.  April  2d. — Since  last  report  has  continued  to  do  well,  the  rupia  having 
nearly  disappeared.  Last  night  complained  of  pain  on  the  inner  side  of  the  left  knee, 
with  slight  erythema  and  swelling.  Warm  moist  applications  to  he  made  to  the  part. 
This  gave  him  great  relief.  The  erythema,  pain,  and  swelling  continued,  however, 
four  days,  and  then  diminished,  without  having  especially  affected  the  lymphatics.  The 
rupia,  also,  is  well,  nothing  remaining  but  the  round  and  oval  cicatrices.  Dismissed 
April  11th. 

Commentary.- — It  is  very  possible  that  the  irritation  produced  by 
the  adherent  crusts  of  rupia  and  the  ulceration  existing  at  their  bases, 
may  have  been  the  exciting  cause  of  the  inflamed  lymphatics  in  this 
case.  No  relation,  however,  could  be  observed  between  particular  rupia 
crusts  and  the  aftected  vessels.  The  general  pain  and  local  symptoms 
were  very  intense  at  one  time,  but  yielded  to  warm  moisture,  applied 
locally,  which  caused  great  relief  to  the  pain,  while  the  disease  ran  its 
natural  course.  It  is  very  rare  that  such  a disease  appears  in  the 
medical  wards. 

The  most  remarkable  case  I ever  saw  of  lymphatic  disease,  is  one 
which  has  been  recorded  by  Dr.  A.  Buchanan  of  Glasgow.*  On  examin- 
ing the  affected  thigh  last  September  with  that  gentleman,  the  lymphatics 
appeared  to  me  to  be  varicose,  with  vesicles  scattered  on  the  skin  here 
and  there,  which,  on  being  punctured,  yielded  an  opaque  milky  fluid. 
Subsequently  I received  nearly  half  a pint  of  the  chylous  fluid  from 
Dr.  Buchanan,  discharged  from  the  lymphatics  on  the  thigh  of  this 
woman,  which,  on  microscopical  examination,  was  composed  of  a mole- 
cular basis,  with  a few  chyle  corpuscles. 

* Med.  Chir.  Trans,  of  London,  vol.  xlvi. 


SECTION  VII. 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

In  this,  as  in  the  preceding  section,  it  will  be  well  to  introduce  the 
study  of  individual  diseases  by  a short  enumeration  of  the  general  rules 
established  for  the  diagnosis  of  lesions  of  the  Kespiratory  System. 
They  are — 

1.  A friction  murmur  heard  over  the  pulmonary  organs  indicates 
pleuritic  exudation. 

2.  Moist  or  dry  rales,  without  dulness  on  percussion,  or  increased 
vocal  resonance,  indicate  bronchitis,  with  or  without  fluid  in  the  bronchi. 

3.  Dry  rales  accompanying  prolonged  expiration,  with  unusual  reso- 
nance on  percussion  indicate  emphysema. 

4.  A moist  rale  at  the  base  of  the  lung,  with  dulness  on  percussion 
and  increased  vocal  resonance  indicates  pneumonia. 

6.  Harshness  of  the  inspiratory  murmur,  prolonged  expiration,  and 
increased  vocal  resonance  confined  to  the  apex  of  the  lung,  indicate  in- 
cipient phthisis. 

6.  Moist  rales,  with  dulness  on  percussion,  and  increased  vocal  reso- 
nance at  the  apex  of  the  lung,  indicate  either  advanced  phthisis  or  pneu- 
monia. The  latter  lesion  commencing  at  or  confined  to  the  apex  is  rare, 
and  hence  these  signs  are  diagnostic  of  phthisis. 

7.  Circumscribed  bronchophony  or  pectoriloquy,  with  cavernous  dry 
or  moist  rale,  indicates  a cavity.  This  maybe  dependent  on  tubercular 
ulceration,  a gangrenous  abscess,  or  a bronchial  dilatation.  The  first  is 
generally  at  the  apex,  and  the  two  last  about  the  centre  of  the  lung. 

8.  Total  absence  of  respiration  indicates  a collection  of  fluid  or  of 
air  in  the  pleural  cavity.  In  the  former  case  there  is  diffused  dulness, 
and  in  the  latter  diffused  resonance  on  percussion. 

9.  Marked  permanent  dulness,  with  increased  vocal  resonance,  and 
diminution  or  absence  of  respiration,  may  depend  on  chronic  pleurisy, 
on  thoracic  aneurism,  or  on  a cancerous  tumor  of  the  lung.  The  diag- 
nosis between  these  lesions  must  be  determined  by  a careful  consideration 
of  the  concomitant  signs  and  symptoms. 

The  general  diagnostic  indications,  now  noticed  as  being  derivable 
from  physical  signs,  admit  of  several  exceptions,  which,  however,  it 
would  be  difficult  to  systematize,  and  which  can  only  be  known  from  a 
careful  study  of  individual  cases.  It  is  important  also  to  remember  that 


638 


DISEASES  OF  THE  EESPIRATORY  SYSTEM. 


these  signs  should  never  he  relied  on  alone,  hut  he  invariably  comhined 
with  a minute  ohservation  of  all  the  concomitant  symptoms.  Thus  the 
signs  indicative  of  incipient  phthisis  may  he  induced  hy  a chronic  pleurisy 
confined  to  the  apex,  or  hy  retrograde  tubercle.  In  either  case  the  pre- 
vious history,  age,  etc.,  may  enable  you  to  determine  the  nature  of  the 
lesion.  Again,  it  may  be  impossible  at  the  moment  of  examination  to 
distinguish  between  two  diseases.  For  instance  there  may  be  general 
fever,  more  or  less  embarrassment  of  the  respiration,  and  pain  in  the 
side,  accompanied  with  no  dulness  on  percussion,  but  with  a decided  ab- 
nonnal  murmur,  difficult  to  characterise,  as  being  a fine  moist  rattle,  or 
a gentle  friction  sound.  Under  such  circumstances,  the  progress  of  the 
case  also  will  soon  relieve  you  from  any  doubt  as  to  whether  a pleurisy 
or  a pneumonia  be  present.  The  alterations  which  occur  in  the  physical 
signs  during  the  progress  of  the  case  also  will  indicate  to  the  pathologist 
the  changes  which  occur  in  the  physical  conditions  and  morbid  lesions 
of  the  lungs.  Thus  the  fugitive  dry  or  mucous  rales  heard  during  a 
bronchitis,  point  out  the  occasional  constrictions  and  obstructions  in  the 
bronchial  tubes.  The  fine  crepitation  of  incipient  pneumonia,  passing 
into  absence  of  respiration,  and  this  again  into  crepitation,  will  satisfy 
him  as  to  effusion,  solid  coagulation,  and  subsequent  softening  of  the  ex- 
udation. In  the  same  way,  by  an  accurate  appreciation  of  physical  signs, 
and  a thorough  knowledge  of  morbid  anatomy,  the  practised  physician 
can  tell  the  abnormal  conditions  produced  by  phthisis,  pleurisy,  etc.,  and 
judge  from  the  symptoms  the  effect  of  these  upon  the  constitution,  with 
a degree  of  accuracy  that  to  the  tyro  must  appear  to  be  marvellous.  All 
such  knowledge  can  only  be  acquired  by  constant  examination  of  the 
patient  on  the  one  hand,  and  by  a careful  study  of  morbid  anatomy  in 
the  pathological  theatre  on  the  other. 


DISEASES  OF  THE  LAEYNX. 

Case  CXXIX.* — Acute  Laryngitis — Treatso  hj  Topical  Applications — . 

Recovery. 

History. — Alexander  Flint,  aet.  27,  a salesman — admitted  February  17,  1851, 
suffering  from  extensive  lupus  of  the  face,  severe  diarrhoea,  Bright’s  disease,  and  scro- 
fulous caries  of  the  left  knee-joint.  Under  appropriate  treatment  the  diarrhoea  ceased, 
the  lupus  was  cured,  and  the  disease  of  the  kidney  much  alleviated. 

Symptoms  op  the  Attack. — On  the  24th  of  May,  about  three  months  after  admis- 
sion, he  first  complained  of  dry  cough  and  slight  pain  in  the  throat,  with  difficulty  of 
deglutition.  These  symptoms  were  increased  on  the  following  day;  and  on  examina- 
tion the  mouth  and  fauces  were  unusually  red,  with  minute  florid  elevations  scattered 
over  tiie  mucous  surface.  Notwithstanding  the  application  of  leeches,  and  sponging 
the  fauces  with  a solution  of  the  nitrate  of  silver,  the  laryngitis  progressed. 

Progress  of  the  Case. — On  the  14th  of  June  the  pain  and  difficulty  of  deglu- 
tition had  increased,  and  his  voice  had  become  indistinct  and  hoarse.  The  cough 
also  continued,  but  was  now  attended  with  a difficult  expectoration  of  muco-purulent 
matter.  On  the  30th  of  June,  notwithstanding  the  assiduous  use  of  astringent 
gargles,  occasional  sponging  of  the  fauces  with  solution  of  nitrate  of  silver,  and  the 
aiiplication  of  leeches,  he  was  evidently  worse,  and  he  could  only  speak  in  a whisper. 
Jidtj  Uh. — To-day  Dr.  Horace  Green,  of  New  York,  who  went  round  the  wards  with 


* Reported  by  Mr.  W.  M.  Calder,  Clinical  Clerk. 


DISEASES  OF  THE  LARYJS-X. 


639 


Dr.  Bennett,  stated  that  this  was  a remarkably  good  example  of  what  he  had  named 
follicular  disease,  affecting  the  larynx.  He  passed  the  sponge,  saturated  with  a solu- 
tion of  nitrate  of  silver  (3ij  to  | i of  water),  through  the  larynx  into  the  trachea. 
The  patient  could  not  take  a breath  for  some  seconds  afterwards,  and  described  the 
sensation  as  like  that  produced  by  a piece  of  food  “ passing  down  the  wrong  way,  and 
causing  choking.”  The  immediate  effect  of  the  operation  was  decided  improvement 
of  the  voice,  and  more  ease  in  deglutition.  From  this  time  his  symptoms  gradually 
left  him.  On  the  10th,  the  sponge  was  again  passed  into  the  larynx  by  Dr.  Bennett, 
and  produced  the  same  sense  of  temporary  suffocation  ; but  immediately  afterwards  he 
spoke  with  perfect  clearness  of  voice.  The  application  was  made  every  second  day 
until  the  16th,  when  all  the  laryngeal  symptoms  had  disappeared,  the  voice  was  nor- 
mal, and  there  was  no  cough,  expectoration,  pain,  or  difficulty  of  deglutition.  He  now 
left  the  house ; the  disease  in  the  joint  had  made  considerable  progress,  but  the  renal 
disorder  was  much  alleviated. 

Case  CXXX.* — Chronic  La/ryngitis — Topical  Applications — Recovery. 

History. — Helen  Guthrie,  set.  24,  married,  a fisherwoman — admitted  July  4th, 
1851.  Four  months  ago  was  seized  with  a cough,  attended  with  hoarseness  of  the 
voice,  dryness  of  the  throat,  painful  deglutition,  and  pain  in  the  larynx,  which  symp- 
toms have  continued  with  greater  or  less  intensity  up  to  the  period  of  admission.  Lat- 
terly, there  has  been  considerable  expectoration  of  purulent  matter,  often  tinged  with 
blood. 

Symptoms  on  Admission. — On  admission,  she  complains  of  cough  coming  on  in 
paroxysms,  dryness  in  the  throat,  and  pain  in  the  larynx,  voice  cracked  and  occa- 
sionally absent.  There  is  no  difficulty  in  swallowing,  but  copious  expectoration  of 
frothy  mucus.  Can  inspire  without  difficulty.  Percussion  over  chest  elicits  nothing 
abnormal.  On  auscultation,  the  inspiratory  murmur  is  harsh  over  superior  tliird  of 
chest  on  both  sides.  Over  larynx  and  trachea  there  is  heard  a dry  snoring  sound. 
On  examining  the  fauces,  red  patches  were  observable  here  and  there,  with  slight 
erosion  on  the  left  side.  The  fauces  and  epiglottis  were  sponged  with  a solution  oi 
nitrate  of  silver  ( Dj  to  % j of  vvater). 

Progress  of  the  Case. — The  application  was  repeated  on  the  following  day,  and 
the  voice  was  evidently  improved.  On  the  6th,  the  sponge,  saturated  with  the  solu- 
tion, was  passed  into  the  larynx  by  Dr.  Hoi’ace  Green,  of  New  York,  and  produced 
no  feeling  of  suffocation  whatever.  It  was  passed  afterwards  every  day  by  Dr.  Ben- 
nett till  the  14th,  when  she  left  the  house,  all  the  laryngeal  symptoms  having  disap- 
peared, and  the  voice  nearly  restored  to  its  proper  tone. 

Commentary. — The  two  cases  above  recorded  point  out  to  you  in 
a very  marked  manner  the  great  advantage  to  be  derived  from  the 
method  of  local  application  to  the  larynx,  introduced  by  Dr.  Horace 
Green,  of  New  York.  This  practice  consists  in  the  direct  application 
of  a solution  of  nitrate  of  silver  to  the  interior  of  the  larynx  and  trachea, 
by  means  of  a bent  whalebone  probe,  with  a piece  of  sponge  fastened 
to  its  extremity.  Numerous  attempts  had  been  made,  with  more  or  less 
success,  by  Sir  C.  Bell,  Mr.  Vance,  Mr.  Cusack,  and  MM.  Trousseau 
and  Belloc,  to  carry  this  practice  into  effect,  and  the  results  obtained, 
even  by  their  imperfect  efforts,  exhibited  the  great  advantages  which 
were  to  be  derived  from  it  in  the  treatment  of  laryngeal  diseases.  Now, 
thanks  to  Dr.  Green,  we  can  wnth  safety  apply  various  solutions  directly 
to  the  parts  affected,  and  the  two  cases  you  have  observed  must  convince 
you  of  the  benefit  which  patients  so  treated  may  obtain.  In  Case 
CXXIX.  you  have  observed  the  progress  of  a tolerably  acute  case  of 
laryngitis  from  its  commencement  to  its  termination — the  distressing 
symptoms  produced,  and  the  loss  of  voice  occasioned.  You  have  re- 
marked, I trust,  the  gradual  increase  of  the  disorder,  from  its  commence- 

* Reported  by  Mr.  D.  0.  Hoile,  Clinical  Clerk. 


640 


DISEASES  OF  THE  EESPIRATORT  SYSTEM. 


ment  on  tlie  24tli  of  May  until  the  6th  of  July,  when  you  saw  Pr 
Green  himself  pass  the  sponge  into  the  larynx,  and  the  immediate  effect 
it  occasioned.  Lastly,  from  that  moment  you  saw  the  case  get  better, 
and  terminate  in  perfect  cure  eight  days  afterwards.  No  stronger 
evidence  could  be  offered  you  in  any  single  case  of  the  benefit  to  be 
derived  from  a local  application,  especially  when  it  is  considered  that 
the  usual  treatment  had  been  actively  employed,  consisting  of  leeches 
externally,  gargles,  and  the  application  of  a strong  solution  of  nitrate 
of  silver  to  the  fauces,  pharynx,  and  epiglottis  without  any  benefit. 
It  was  only  when  the  application  was  made  directly  to  the  part  affected 
that  good  was  obtained.  The  second  case,  though  more  chronic,  and 
though  she  went  out  before  a perfect  cure  was  obtained,  is  also  calculated 
to  impress  upon  you  the  value  of  this  treatment. 

The  instruments  to  be  employed  are,  first,  a tongue  depressor,  with 
a bent  handle,  such  as  I now  show  you  (Figs.  4 and  5),  by  means  of 
which  the  tongue  can  be  firmly  pressed  down,  so  as  to  expose  the  whole 
of  the  fauces,  and  the  upper  edge  of  the  epiglottis.  In  doing  this,  some 
patients  experience  no  inconvenience,  whilst  in  others  there  is  such 
excessive  irritability,  that  spasmodic  cough  or  even  vomiting  is  occasioned, 
which  prevents  the  possibility  of  seeing  the  epiglottis.  Secondly,  a 
whalebone  probang,  about  ten  inches  long,  having  at  its  extremity  a 
round  piece  of  the  finest  sponge,  about  the  size  o?  a gun  or  pistol  bullet. 
The  probang,  towards  the  extremity,  must  be  bent  in  a curve,  which, 
according  to  Dr.  Green,  ought  to  form  the  arc  of  one  quarter  of  a circle 
whose  diameter  is  four  inches.  Sometimes  the  curve  must  be  altered  to 
suit  particular  cases ; and  when  it  is  thought  necessary  to  pass  it  into 
the  trachea,  the  curve  must  be  considerably  less.  It  is  important  that 
the  sponge  be  fine,  and  capable  of  imbibing  a considerable  quantity  of 
fluid ; that  it  be  8ewn  firmly  to  the  extremity  of  the  whalebone,  and 
that  this  last  should  not  be  cut  in  the  form  of  a bulb,  but  tapered  as 
much  as  consistent  with  firmness. 

The  solutions  of  the  nitrate  of  silver  which  will  be  found  most  use- 
ful are  of  two  strengths.  One  is  formed  of  3ij  and  the  other  3 j of  the 
crystallized  salt  to  an  ounce  of  distilled  water.  On  some  occasions  a solution 
of  the  sulphate  of  copper  has  been  found  beneficial,  and  it  is  very  possible 
that  as  our  experience  of  this  kind  of  treatment  extends,  the  application 
of  other  substances  in  solution  may  be  found  capable  of  meeting  parti- 
cular indications.  Some  have  used  Tr.  of  Iodine,  others  solutions  of 
various  salts,  and  Dr.  Scott  Alison,  in  cases  of  great  irritability,  has  re- 
commended olive  oil. 

The  method  of  introducing  the  sponge  which  I have  found  most 
successful  is  as  follows  : — The  patient  being  seated  in  a chair  and  exposed 
to  a good  light,  you  should  stand  on  his  right  side,  and  depress  the 
tongue  with  the  depressor  held  in  the  left  hand.  Holding  the  probang 
in  the  right  hand,  the  sponge  having  been  saturated  in  the  solution, 
you  pass  it  carefully  over  the  upper  surface  of  the  instrument,  exactly  in 
the  median  plane^  until  it  is  above  or  immediately  behind  the  epiglottis. 
You  now  tell  the  patient  to  inspire,  and  as  he  does  so,  you  drag  the 
tongue  slightly  forwards  with  the  depressor,  and  thrust  the  probang  down- 
wards and  forwards  by  a movement  which  causes  you  to  elevate  the  right 


DISEASES  OF  THE  LAEYXX. 


641 


arm,  and  brings  your  hand  almost  in  contact  with  the  patient’s  face. 
This  operation  requires  more  dexterity  than  may  at  first  be  supposed. 
The  rima  glottidis  is  narrow,  and  unless  the  sponge  come  fairly  down 
upon  it,  it  readily  slips  into  the  oesophagus.  Its  passage  into  the  proper 
channel  may  be  determined  by  the  sensation  of  overcoming  a constric- 
tion, which  you  yourself  experience  when  the  sponge  is  momentarily  em- 
braced by  the  rima,  as  well  as  by  the  momentary  spasm  it  occasions  in 
the  patient,  or  the  harsh  expiration  which  follows, — symptoms  which  are 
more  marked  according  to  the  sensibility  of  the  parts. 

If  the  probang  be  properly  prepared,  and  the  operation  well  per- 
formed, the  actions  which  take  place  are  as  follows  : — 1st,  The  sponge, 
saturated  with  the  solution,  is  rapidly  thrust  through  the  rima  into  the 
larynx,  and  frequently  into  the  trachea ; for  if  the  distance  of  the  pro- 
bang be  measured  from  that  portion  of  it  which  comes  in  contact  with 
the  lips,  the  extent  it  has  been  thrust  downwards  can  be  pretty  accu- 
rately determined.  I am  persuaded  that  on  many  occasions  I have  pass- 
ed it  pretty  deep  into  the  trachea,  not  only  from  the  length  of  the  pro- 
bang which  has  disappeared,  but  also  from  the  sensations  of  the  patient, 
although  this  may  be  thought  hy  some  a fallacious  method  of  determin- 
ing the  point.  In  the  first  part  of  the  operation,  the  rima  glottidis  is, 
as  it  were,  taken  by  surprise,  and  the  sponge  enters,  if  the  right  direc- 
tion be  given  to  it,  without  difficulty.  But  2d,  The  rima  glottidis  im- 
mediately contracts  by  reflex  action,  so  that  on  withdrawing  the  instru- 
ment you  feel  the  constriction.  This  also  squeezes  out  the  solution, 
which  is  diffused  over  the  laryngeal  and  tracheal  mucous  membrane. 
Now,  if  the  sponge  be  a fine  one,  it  will  be  found  capable  of  holding 
about  3 ss  of  fluid,  the  effect  of  which  upon  the  secretions  and  mucous 
surface  almost  always  produces  temporary  relief  to  the  symptoms,  and 
strengthens  the  tone  of  the  voice — results  at  once  apparent  after  the 
momentary  spasm  has  abated.  3d,  The  action  of  the  nitrate  of  silver 
solution  is  not  that  of  a stimulant,  but  rather  that  of  a calmative  or 
sedative.  It  acts  chemically  on  the  mucus,  pus,  or  other  albuminous 
fluids  it  comes  in  contact  with,  throws  down  a copious  white  precipitate, 
in  the  form  of  a molecular  membrane,  which  defends  for  a time  the  ten- 
der mucous  surface  or  irritable  ulcer,  and  leaves  the  passage  free  for  the 
acts  of  respiration.  Hence  arises  the  feeling  of  relief  almost  always 
occasioned,  with  that  diminution  of  irritability  in  the  parts  which  is 
so  favorable  to  cure,  and  why  it  is  that  strong  solutions  of  the  salt 
are  more  efficacious  than  weak  ones.  It  may  be  easily  conceived 
that  such  good  effects  must  be  more  or  less  advantageous  in  almost 
all  the  diseases  that  affect  parts  so  sensitive,  from  whatever  cause 
they  may  arise ; and  that  this  treatment  is  not  only  adapted  to  one  of 
the  diseases  of  the  larynx,  but,  like  all  important  remedies,  meets  a 
general  indication  of  which  the  judicious  practitioner  will  know  how 
to  avail  himself. 

The  mucous  membrane  of  the  larynx  consists  of  ciliated  epithelium 
externally,  a basement  layer  below  this,  and  areolar  tissue  internally, 
richly  supplied  with  blood-vessels.  Scattered  over  its  surface  are 
numerous  follicles,  which  secrete  mucus.  It  is  liable  to  the  same 
structural  alterations  as  all  other  similar  membranes,  which  may  be 
41 


642 


DISEASES  OF  THE  EESPIRATOKY  SYSTEM. 


divided  into — 1st,  Exudation,  into  the  areolar  tissue  between  the  base- 
ment membrane  and  epithelium,  or  upon  the  external  surface  ; 2d, 
Abrasions  or  desquamations  of  the  epithelial  layer  ; 3d,  Ulcerations  ex- 
tending more  or  less  deep  into  the  areolar  tissue  ; and  4th,  Obstruction, 
swelling,  and  subsequent  ulceration  of  the  mucous  follicles,  a lesion 
particularly  described  by  Dr.  Horace  Green,  and  denominated  by  him 
“ follicular  disease  of  the  air  passages.”  These  different  lesions  may  be 
more  or  less  complicated  with  each  other,  and  will  vary  in  intensity"  ac- 
cording to  the  rapidity  of  their  progress,  and  the  extent  to  which  the 
mucous  membrane  is  implicated.  Sometimes  the  exudation  is  thrown 
out  quickly  and  infiltrates  the  textures,  as  in  oedema  glottidis,  or  in 
malignant  angina.  At  other  times  it  is  poured  out  on  the  surface  as  in 
croup.  More  frequently  it  is  partial,  occasioning  subsequent  abrasion 
or  ulceration,  and  the  acute  disease  becomes  chronic.  Perhaps  the  most 
common  form  it  assumes  is  when  it  is  chronic  from  the  commencement, 
sometimes  dependent  on  atmospheric  changes,  at  other  times  on  re- 
peated attacks  of  “cold;”  in  a third  class  dependent  on  too  much 
straining  of  voice,  as  occurs  in  public  speakers,  clergymen,  singers,  etc., 
and  occasionally  it  is  connected  with  a general  constitutional  disorder, 
as  syphilis,  tuberculosis,  or  some  form  of  cancer.  All  these  forms  of 
laryngeal  disease  may  be  further  associated  with  similar  lesions  of  the 
fauces,  tonsils,  uvula,  and  pharynx. 

The  symptoms  will  of  course  vary  according  to  these  different  cir- 
cumstances. The  acute  forms  are  accompanied  with  general  fever,  con- 
siderable local  pain,  more  or  less  obstruction  to  deglutition  and  respira- 
tion, and  loss  or  alteration  in  the  character  of  the  voice.  As  a general 
rule,  it  may  be  said  that  lesions  of  the  fauces,  tonsils,  and  neighboring 
parts,  are  indicated  by  greater  or  less  difficulty  or  uneasiness  in  swallow- 
ing, whilst  the  laryngeal  disorder  is  evinced  by  changes  in  the  character 
or  power  of  sustaining  the  voice.  Then,  as  a general  result  of  the  local 
irritation,  spasmodic  action  is  evinced,  and  we  have  cough,  at  first  dry, 
but  afterwards  attended  with  mucous  or  purulent  expectoration,  and  not 
unfrequently  with  discharge  of  blood.  Elongation  of  the  uvula  may 
produce  these  effects.  It  has  been  lately  supposed  that  hooping-cough 
is  only  an  obscure  form  of  laryngeal  disease.  In  the  more  acute  and  ex- 
tensive cases  of  exudative  laryngitis,  the  spasms  are  more  violent  and 
prolonged,  and  the  greatest  caution  is  necessary  in  watching  persons  so 
affected,  lest,  from  sudden  and  continued  closure  of  the  glottis,  fatal 
asphyxia  be  induced.  The  following  case  is  very  instructive  in  this 
point  of  view. 

Case  CXXXI.'^ — Acute  (Edema  of  the  Glottis — Chronic  Pharyngitis  and 
Laryngitis — Sudden  Death. 

History. — Frances  Nichol,  set.  25,  a shoe-binder,  married — was  admitted  in  the 
evening  of  February  2V,  1851,  complaining  of  sore  throat,  but  breathing  easily,  and 
otherwise  presenting  no  urgent  symptoms.  She  has  suffered  from  cough  upwards  of 
four  years,  had  secondary  syphilis,  and  ulcerations  in  the  throat  for  twelve  months. 

Symptoms  on  Admission. — At  the  visit  I found  her  breathing  to  be  laborious  and 
noisy  ; cough  frequent  ; expectoration  difficult,  with  frothy  sputum  tinged  with  blood  ; 

* Reported  by  Mr.  Henry  Thom,  Clinical  Clerk. 


DISEASES  OF  THE  LARYNX. 


643 


countenance  anxious  ; lips  livid;  pulse  130,  small  and  soft;  cannot  speak,  nor  can 
any  oujc  give  any  account  of  her.  On  examining  the  mouth  and  fauces,  the  mucous 
membrane  was  seen  to  be  covered  with  tenacious  muco-purulent  matter.  The  sott  pa- 
late is  perforated  by  ulcerations  the  size  of  a pea  in  three  places ; there  is  another 
ulcer  the  size  of  a fourpenuy  piece  on  the  roof  of  the  mouth.  The  tonsils  and  mucous 
mnnbrane  surrounding  tlie  glottis  were  somewhat  swollen,  but  not  unusually  red. 
On  percussing  the  chest,  no  dulness  could  anywhere  be  detected.  Respiratory  mur- 
murs over  the  large  air-tubes  loud  and  harsh,  with  occasional  mucous  rale,  but  their 
character  masked  by  the  loud  snoring  noise  in  the  larynx.  To  have  3 ss  of  wine  every 
half-hour  ; an  antispasmodic  mixture  of  sulphuric  ether ^ ammonia^  and  opium  ; the 
ulcers  and  mucous  membrane  of  the  fauces  to  he  sponged  with  a weak  solution  of  nitrate 
of  silver^  and  the  steam  inhaler  to  he  used  assiduously. 

Progress  of  the  Case. — These  remedies  alleviated  all  her  symptoms,  so  that  in 
the  evening  she  gave  a history  of  her  case.  Seeing  that  she  was  so  much  better  at 
the  evening  visit  of  the  house-clerk,  the  intensity  of  the  disease  was  supposed  to  have 
abated,  but  in  the  morning  she  was  found  dead  in  bed. 

Sectio  Cadaveris. — Fifty  hours  after  death. 

Pharynx,  Larynx,  and  Trachea. — The  opening  of  the  fauces  was  considerably 
contracted  ; and  the  mucous  membrane  of  the  tonsils,  soft  palate,  and  from  this  to  the 
root  of  the  tongue,  presented  numerous  ulcerations,  extending  to  the  submucous  tis- 
sue, and  undermining  to  some  extent  the  mucous  membrane.  The  ulcers  were  mostly 
rounded  in  form,  of  exceedingly  various  size,  up  to  a diameter  of  three-eighths  of  an 
inch  ; the  edges  not  at  all  elevated,  and  for  the  most  part  smooth,  as  though  scooped 
out  by  a punch.  The  floors  of  the  ulcers  consiste  1 of  the  submucous  tissue,  perfectly 
clean  and  pale,  without  the  least  trace  of  granulations  or  pus.  The  neighboring  mu- 
cous membrane  was  scarcely  at  any  point  more  vascular  th  in  natural.  The  aryteno- 
epiglottidean  folds  were  hypertrophied, — that  of  the  right  side  being  thickened  and 
cedematous,  that  of  the  left  being  flaccid  and  relaxed.  They  could  be  made  to  lie  in 
apposition,  so  as  almost  to  close  the  opening  of  the  glottic.  The  mucous  membrane 
of  the  entire  larynx  was  somewhat  rose-colored  ; and  the  submucous  tissue  of  the 
epiglottis,  the  chordae  vocales,  and  the  ventricles,  considerably  infiltrated  with  fluid. 
Throughout  the  trachea,  the  membrane  was  of  a rose  color,  becoming  deeper  towards 
the  bronchi,  and  was  everywhere  covered  with  a thick  mucus,  whic’n  lay  in  semi-trans- 
parent drops,  the  size  of  a very  small  pin’s  head,  on  the  opening  of  the  follicles. 

Thorax. — The  tissue  of  the  lungs  was  for  the  most  part  healthy,  but  here  and 
there  a few  small  portions  of  its  substance  were  collapsed.  The  mucous  membrane  of 
the  larger  bronchi  was  congested,  and  the  smaller  ones  on  the  right  side  yielded  drops 
of  purulent  mucus,  on  compressing  the  cut  surface  of  the  lung. 

Abdomen. — There  were  several  small  cancerous  nodules  in  the  liver,  but  all  the 
organs  were  healthy. 

Commentary. — In  this  case  I think  there  can  be  little  doubt  that 
during  the  night  some  obstruction  occurred  to  the  breathing,  dependent 
on  the  local  disease,  which  caused  asphyxia  and  death.  Neither  can  we 
have  any  hesitation  in  thinking,  that  had  tracheotomy  been  performed  in 
time,  life  would  have  been  saved,  inasmuch  as  the  tissue  of  the  lungs 
was  healthy,  and  the  only  lesion  found  in  those  organs  was  a trifling 
bronchitis.  No  doubt  the  amelioration  of  the  symptoms  which  was 
observed  at  the  evening  visit  removed  the  idea  of  urgency,  but  this  is 
just  the  reason  I have  cited  the  case,  as  a lesson  to  all  of  us,  with  regard 
to  the  watchfulness  which  is  necessary  in  the  treatment  of  such  disorders. 
In  another  case,  occurring  in  a man  who  entered  the  clinical  ward  shortly 
afterwards,  laboring  under  symptoms  so  similar  that  I need  not  detail 
them,  I ordered  tracheotomy  to  be  performed  at  once,  and  the  result  was 
the  preservation  of  life  and  restoration  to  health,  although  the  ulceration 
destroyed  the  vocal  chords,  and  the  aphonia  was  complete. 

The  following  case  presents  the  most  rapid  progress  of  acute 
laryngitis  I ever  saw,  and  points  out  strongly  the  necessity  of  great 
watchfulness  in  this  disease. 


C44 


DISEASES  OF  THE  EESPIKATORY  SYSTEM. 


Case  CXXXII.^' — Acute  Laryngitis  supervening  on  Ascites^  and  Cirrhosis 
of  Liver — Sudden  Death  from  Asphyxia. 

History, — William  Corbett,  set.  40,  seaman — admitted  October  4th,  1860  with 
enlarged  liver  and  ascites. 

Symptoms  on  Admission. — The  liver,  on  percussion,  measures  six  inches  vertically, 
and  the  abdomen  is  greatly  distended.  Urine  passed  daily  only  19  oz.  The  treatment 
was  directed,  by  means  of  diuretics,  to  increase  the  flow  of  urine,  and  Tr.  of  Iodine 
was  ordered  to  be  painted  over,  the  liepatic  region. 

Progress  of  the  Case. — Odober  29^/n — Has  been  taking  half-drachm  doses  of  the 
bitartrate  of  potass,  with  the  effect  of  increasing  the  flow  of  urine  to  40  and  45  oz. 
daily.  To-day  complains  of  pain  in  swallowing,  and  says  he  has  had  cough  for  the 
last  two  nights.  The  fauces  on  examination  are  somewhat  congested.  The  throat  to 
he  fomented.,  and  a xmrm  poultice  to  he  applied  at  night.  October  81s^. — Has  experienced 

much  relief  from  the  warm  applications,  and  swallows  without  much  inconvenience. 
He  expectorates,  however,  after  coughing,  a frothy,  slightly  viscous  mucus.  November 
1st. — Cough  very  troublesome  during  the  night.  Expectoiated  about  6 oz.  of  frothy 
mucus  since  yesterday.  Tongue  covered  with  a brown  fur.  Pulse  accelerated,  but  no 
fever.  Abdominal  symptoms  and  signs  unchanged.  Passes  45  oz.  of  urine  daily. 
H Chlor'odyne  3 ss  ; 3Iist.  Carnph.  3 ij.  Half  to  he  taken  at  hed-time,  arid  repeated  in 
the  night  if  the  cough  he  troublesome.  Wai'm  poultices  to  the  throat  to  he  continued. 
November  ‘Id. — Cough  and  expectoration  very  troublesome  last  night,  preventing 
sleep,  notwithstanding  the  anodyne,  Sputum  frothy,  slightly  purulent.  Voice  slightly 
hoarse.  On  examining  throat,  fauces  seem  to  be  very  red,  and  tonsils  swollen. 
Other  symptoms  the  same.  To  use  an  astringent  alum  gargle.  Continue  fomentations 
and  poultices  to  the  throat.  November  Zd. — According  to  the  reports  of  the  night 
nurse,  he  became  restless,  constantly  requiring  attention  about  the  middle  of  the  night, 
with  difficulty  of  breathing.  She  did  not  observe  anything  very  urgent,  however,  un- 
til 6 A.M.  this  morning,  when  she  went  for  the  house  physician.  No  sooner  had  she 
left  his  bedside,  than  he  rose,  fell  down,  and  on  being  raised  by  two  neighboring  pa^ 
tients,  gave  one  gasp  and  expired. 

Sectio  Cadaveris. — Thirty  hours  after  death. 

Considerable  lividity  of  lips,  face,  and  neck. 

Fauces  and  Larynx. — Fauces  everywhere  greatly  congested.  Left  tonsil  much 
swollen,  and  the  circumvallate  vilii  at  the  base  of  the  tongue  numerous,  enlarged,  and 
prominent.  The  epiglottis  thickened,  indurated,  and  erect,  of  deep  purple  color,  con- 
ical form,  with  its  external  edges  curved  inwards.  The  neighboring  mucous  mem- 
brane thickened  and  infiltrated  with  exudation.  On  opening  the  trachea  and  larynx 
from  behind,  the  mucous  membrane  was  seen  to  be  oi  a deep  mahogany  unitbim  color 
from  congestion  ; both  vocal  chords,  true  and  false,  on  each  side  were  infiltrated  with 
exudation.  The  right  ventricle  was  occupied  by,  and  distended  wdth,  a straw-colored 
mass  of  coagulated  exudation  | of  an  inch  long,  and  \ of  an  inch  broad  at  its  widest 
part,  bulging  inwards  tow'ards  the  rima  glottidis.  The  mucous  membrane  surround 
ing  left  ventricle,  oedematous,  indurated,  and  an  oval  mass  of  coagulated  exudation 
4 of  an  ineh  long,  blocking  up  the  left  ventricle,  bulging  inwards  and  obstructing  the 
rima  glottidis. 

Chest. — About  an  ounce  of  serum  in  the  pericardium,  none  in  the  pleural  cavities. 
Heart  healthy,  cavities  empty.  No  congestion  of  right  side  of  heart.  Lungs  of  dark 
mahogany  color  throughout ; bronchial  lining  membrane  also  of  dark  mahogany  color, 
and  towards  bases  of  both  lungs  posteriorly  the  bronchi  contained  a slight  amount  of 
frothy  mucus. 

Abdomen. — Liver  enlarged,  weighing  6 lb.  2 oz.,  of  a pale  fawn  color,  considerably 
indurated,  in  the  second  stage  of  cirrhosis.  Abdomen  contained  two  gallons  and  a 
half  of  amber-colored  serum.  Other  organs  healthy. 

Microscopic  Examination. — The  lymph  filling  up  the  ventricles  of  the  larynx 
was  entirely  composed  of  molecular  fibres,  included  in  a mass  of  coagulated  molecular 
exudation. 

Commentary . — This  man,  while  laboring  under  enlarged  liver  with 
ascites,  was  apparently  seized  with  an  ordinary  sore  throat,  having  caught 
cold,  as  it  was  afterwards  ascertained,  when  visiting  the  water-closet. 


* Recorded  by  Mr.  James  Pettigrew,  Clinical  Clerk. 


DISEASES  OF  THE  LARYXX. 


645 


There  were  no  severe  symptoms,  however,  farther  than  cough,  expectora- 
tion, and  slight  difficulty  of  deglutition,  which  latter  symptom  yielded  to 
warm  fomentations  and  poultices  applied  to  the  throat.  On  the  morning 
before  his  death,  the  voice  was  somewhat  hoarse,  which  was  the  first 
symptom  indicating  that  the  larynx  was  alfected.  Neither  at  the  visit, 


Fig.  448. 

nor  in  the  evening  when  seen  by  the  house  physician,  nor  by  the  nurse, 
were  any  urgent  symptoms  observed,  until  about  the  middle  of  the  night. 
Then  suddenly  respiration  became  affected,  he  was  restless,  and  dyspnoea 
came  on  so  rapidly,  that  before  medical  assistance  could  be  procured,  he 
expired  on  making  the  exertion  of  rising  from  bed.  I have  previously 
pointed  out  how  insidiously  fatal  laryngitis  may  come  on,  and  how  rapid 

Fig.  448.  Appearances  described  in  the  case  of  Corbett — Natural  size. 


646 


DISEASES  OF  THE  EESPIRATORT  SYSTEM. 


its  effects  occasionally  are.  It  is  certain  that  no  acute  symptoms  indi- 
cated danger  at  the  morning  or  evening  visit,  the  man  speaking  on  both 
occasions,  and  that  day  for  the  first  time  somewhat  hoarsely.  There  can 
therefore  be  little  doubt  that  it  was  in  the  middle  of  the  night  that  the 
exudation  must  have  occurred  into  the  ventricles  of  the  larynx,  which,  bv 
closing  the  glottis,  caused  the  fatal  asphyxia.  The  appearances  observed 
were  so  striking  that  they  are  represented  Fig.  448. 

Case  CXXXIII.*- — Chronic  Laryngitis  and  Pharyngitis — 
Tracheotomy — Recovery. 

History. — Hugh  Martin,  set.  36,  laborer — admitted  December  28th,  1849.  Says, 
that  six  years  ago,  he  had  gonorrhoea,  without  any  other  form  of  venereal  affection. 
Twelve  months  since,  he  was  treated  with  calomel  for  some  swellings  below  his  jaw, 
and  shortly  after,  having  caught  cold,  was  affected  with  sore  throat.  Subsequently 
he  was  again  treated  with  mercury  in  the  Glasgow  infirmary,  and  having  again  caught 
cold,  his  throat  became  worse. 

Symptoms  on  Admission. — His  general  appearance  is  cachectic  and  emaciated. 
His  speech  is  almost  inaudible,  and  the  upper  part  of  a large  ulcer  is  seen  deep  down 
in  the  pharynx.  Respiration  is  evidently  impeded  and  accompanied  by  hoarse  tubular 
breathing,  heard  on  placing  a stethoscope  over  the  larynx.  Pulmonary  sounds  feeble, 
and  resonance  good  everywhere  on  percussion  over  the  lungs.  Has  slight  cough  with 
muco-purulent  expectoration,  not  so  copious,  he  says,  as  it  has  been.  Has  pain  in 
deglutition,  which  often  excites  violent  cough.  Pulse  82,  of  natural  strength.  Other 
functions  well  performed.  The  urine  contains  hexagonal  plates  of  cystine,  mingled 
with  crystals  of  uric  acid. 

Progress  of  the  Case. — Pcc€inh(r  ZOfh. — Topical  applications  of  a weak  solution 
of  nitrate  of  silver  internally,  and  warm  fomentations  to  the  throat  externally,  have 
failed  to  cause  relief.  Breathing  still  impeded  and  difficult;  voice  extinct.  Tracheo- 
tomy teas  performed,  a^nd  a hthe  inserted.  January  \lth. — Since  the  operation,  he 
has  breathed  freely  through  the  tube,  and  feels  much  easier.  The  ulcer  in  the  pharynx 
has  been  touched  occasionally  with  nitrate  of  silver,  and  is  now  healed.  Has  con- 
siderable difficulty  in  expectorating  mucus  through  the  tube.  To  have  steak  diet. 
Pec.  20/A. — A solution  of  nitrate  of  silver  (2  gr.  to  of  water)  to  he  applied  to  the 
inside  of  the  trachea  every  other  day,  by  means  of  a sponge  attached  to  a slip  of  bent 
whedebone.  Pec.  28c?. — Has  been  greatly  relieved  by  the  topical  application  to  the 
trachea.  Strength  of  solution  to  he  increased  to  Argent.  Nit.  gr.  v.  to  § j water,  and 
applied  daily.  Pecember  2f)/A. — Strength  of  solution  further  increased  to  gr.  x.  of  the 
salt  /o  3 j of  water.  From  this  time,  the  muco-purulent  expectoration  gradually  subsided. 
B Potass,  loelid.  3 ss  ; Tr.  Gent.  c.  3 j ; Pif.  Gent.  c.  § v.  M.  j to  be  taken  three  times 
a day.  February  10/A. — The  tube  was  removed.  The  voice  returned,  although  it  re- 
mained very  hoarse,  and  there  was  every  reason  to  believe  tfiat  the  ulcer  in  the  larynx, 
if  not  perfectly  cicatrized,  was  nearly  so,  when  he  went  out,  February  20th 

Commentary. — In  this  case  tracheotomy  was  performed,  not  so  much 
with  the  view  of  relieving  urgent  symptoms,  as  to  secure  rest  and 
immobility  to  the  larynx,  so  that  the  ulcerations  might  cicatrize.  This 
object  was  effected,  and  the  man  slowly  got  well.  First,  the  ulcer  in 
the  pharynx  healed,  and  subsequently  that  in  the  larynx,  although,  when 
the  tube  was  removed  from  the  trachea,  it  was  apparent  that  the  vocal 
chords  had  been  partially  destroyed.  At  the  time  this  case  was  treated, 
the  mode  of  application  by  means  of  sponges  to  the  interior  of  the  larynx 
was  unknown.  The  record  shows,  however,  that  in  1849  I applied  a 
nitrate  of  silver  solution  directly  to  the  trachea,  through  the  aperture 
made  for  the  tube,  which  was  from  time  to  time  removed  for  that  pur- 
pose. I then  found  its  use  very  beneficial  in  checking  the  amount  of 
muco-purulent  secretion,  and  increased  the  strength  of  the  solution  from 

* Reported  by  Mr.  Hugh  M.  Balfour,  Clinical  Clerk. 


DISEASES  OF  THE  LARYNX. 


647 


two  to  ten  grains  of  the  salt  to  an  ounce  of  water.  The  man  complained 
of  no  pain  or  inconvenience  of  any  kind  from  these  applications.  He 
had  undergone  two  courses  of  mercury,  and  so  far  as  his  own  statements 
are  to  be  relied  on,  without  any  other  form  of  venereal  disease  than  that 
of  gonorrhoea,  and  swellings  below  the  jaw.  Even  supposing  that  these 
latter  were  originally  venereal,  it  is  certain  that  the  mercury  produced  no 
benefit,  but,  on  the  contrary,  while  the  local  disease  was  making  pro- 
gress, it  so  affected  his  general  health,  as  to  occasion  emaciation  and 
general  cachexia.  We  have  seen  that  the  ulcers  healed  under  a non- 
mercurial treatment,  and  that  his  health  improved  under  tonics  and 
good  diet. 

The  diagnosis  of  laryngitis  is  most  important,  and  must  be  derived — 
1st,  From  the  general  symptoms;  2d,  From  the  results  obtained  by 
careful  examination  of  the  air-tubes  and  lungs  by  auscultation  and  per- 
cussion ; and  3d,  From  an  inspection  of  the  parts.  With  regard  to  the 
general  symptoms,  I have  already  alluded  to  the  relative  value  to  be 
attached  to  difficulties  of  deglutition  and  of  speech.  Concerning  the 
difficulties  of  respiration,  the  nature  of  the  expectoration,  and  the  cough, 
we  cannot  with  certainty  refer  them  to  the  larynx,  without  a careful 
study  of  the  condition  of  the  pulmonary  organs.  Indeed,  the  attention 
which  has  been  lately  directed  to  the  fauces  and  larynx,  in  consequence 
of  the  writings  of  Dr.  Horace  Green,  has  demonstrated  the  important 
fact,  that  many  of  those  disorders  which  have  been  sometimes  called 
“ chronic  bronchitis,”  and  others  which  have  not  unfrequently  been  sup- 
posed to  indicate  in  young  persons  incipient  phthisis,  are  really  a chronic 
form  of  laryngitis,  altogether  local,  and  readily  removed  by  topical  ap- 
plications. The  distinction  between  them,  however,  often  demands  the 
greatest  care  in  examination,  but  when  a good  auscultator  fails  to  detect 
the  signs  characteristic  of  bronchitis  or  phthisis  pulmonalis,  whilst,  on 
the  other  hand,  there  is  unusual  hoarseness  or  shrillness  of  the  laryngeal 
murmur,  dryness  of  the  throat,  and  hacking  cough,  sometimes  accom- 
panied by  muco-purulent  expectoration,  or  even  occasional  spitting  of 
blood,  then  his  suspicions  may  be  directed  to  laryngeal  rather  than 
to  pulmonary  disorder.  It  is  the  more  important  to  notice  this,  because 
a good  authority  has  lately  stated, — “ Expectoration  of  blood  in  persons 
laboring  under  chronic  bronchitis,  with  or  without  emphysema,  but 
without  notable  disease  of  the  heart,  justifies  in  itself  a suspicion  of  the 
existence  of  latent  tubercles.” — (Walshe.)  In  making  this  diagnosis, 
however,  I must  recommend  to  you  the  exercise  of  the  greatest  caution, 
and  especially  not  to  confound  the  natural  hoarseness  heard  in  the 
larynx  of  some  individuals  with  the  coarse  sounds  heard  in  others  only 
when  the  organ  is  diseased. 

The  examination  of  the  throat  and  upper  edge  of  the  epiglottis  will 
do  much  to  remove  any  difficulty  you  may  experience,  because  in  many 
cases  alterations  in  the  mucous  membrane  of  the  larynx  follow  and 
accompany  similar  changes  in  the  mucous  membrane  of  the  fauces  and 
pharynx.  Indeed,  it  may  be  accepted  as  a general  law,  which  admits  of 
but  few  exceptions,  that  morbid  changes  in  the  mucous  membranes  of 
the  pharynx  and  larynx  proceed  from  above  downwards,  as  is  well  ob- 


648 


DISEASES  OF  THE  KESPIEATORY  SYSTEM. 


served  in  scarlatiea.  Lesions  often  attack  the  fauces  or  tonsils  and  spare 
the  larynx;  but  if  long  continued,  the  latter  is  affected  consecutively. 
Hence  why  chronic,  syphilitic,  and  mercurial  ulcerations  of  the  throat, 
have  such  a tendency  to  attack  the  larynx.  Again,  when  the  larynx  is 
first  attacked,  as  occurs  among  clergymen,  and  in  the  ordinary  croup  of 
children,  the  follicular  disease  in  the  one,  and  the  coagulated  exudation 
in  the  other,  tend  to  pass  down  the  trachea,  and  not  upwards  into  the 
fauces.  It  follows,  that  when  hoarseness  of  the  voice,  cough,  and  other 
laryngeal  symptoms  are  accompanied  by  abrasions  or  ulcerations  in  the 
mucous  membrane  of  the  soft  palate  or  uvula,  by  thickening  or  irregu- 
larity in  the  epiglottis,  and  especially  by  the  follicular  disease  formerly 
alluded  to — presenting  elevated  pimples  more  or  less  numerous  scattered 
over  the  parts — there  is  every  reason  to  believe  that  the  larynx  is  simi- 
larly affected.  The  tongue-depressor  previously  alluded  to  will  enable 
you  to  examine  these  parts  with  the  greatest  ease,  and  in  most  cases  the 
upper  edge  of  the  epiglottis  will  with  its  aid  be  brought  into  view.  In 
this  manner  we  receive  exact  information  as  to  the  state  of  the  fauces, 
uvula,  tonsils,  and  back  of  the  pharynx,  but  valuable  as  such  informa- 
niation  is,  we  cannot  determine  by  it  the  condition  of  the  glottis.  Occa- 
sionally, under  such  circumstances,  the  finger  will  assist  us  and  enable 
us  to  feel  swelling,  induration,  or  irregularity  in  the  epiglottis.  But  to 
derive  information  in  this  manner,  tact  and  habit  are  necessary.  The 
introduction  of  the  laryngoscope  has  been  too  recent,  and  the  cases 
which  have  presented  themselves  during  the  limited  period  I have  been 
on  duty,  have  been  too  few,  to  enable  me  to  say  much  as  to  the  advan- 
tage of  the  instrument  as  a means  of  diagnosis.  I consider,  however, 
that  its  employment  should  be  vigorously  prosecuted,  although  in  acute 
cases  I have  found  the  pain  and  irritability  of  the  parts  oppose  an  in- 
vincible obstacle  to  my  bringing  the  organ  into  view.  In  no  case  ought 
you  to  depend  upon  examination  of  the  parts  alone ; it  should  be  con- 
joined with  the  knowledge  derived  from  a careful  study  of  the  symptoms, 
and  of  the  physical  signs  furnished  by  the  air-tubes  and  lungs. 

Two  other  diseases,  by  causing  obstruction  of  the  larynx,  are  justly 
regarded  with  great  apprehension;  these  are  tracheitis  or  croup,  and 
diphtheria.  In  both  these  diseases  an  exudation  is  thrown  out  on  the 
mucous  membrane,  which,  coagulating  and  blocking  up  the  chink  of 
the  glottis,  proves  fatal.  Neither  of  these  diseases  are  common  in  the 
clinical  wards.  Indeed,  I have  only  seen  one  case  of  diphtheria  here, 
and  that  was  in  a man  called  Carrall,  who  died  in  November  1860, 
affected  with  small-pox,  violent  fever,  and  a sore  throat,  which  was 
covered  with  a dirty  grey  exudation.  In  the  foundling  and  chil- 
dren’s hospitals  of  Paris  I have  frequently  seen  it,  where  it  presents  a 
tough,  adherent  membrane,  in  which  vegetable  parasitic  growths  are  abun- 
dant. (See  Fig.  53.)  All  these  various  affections  pass  insensibly  into  one 
another;  so  that,  with  that  natural  exaggeration  so  common  to  anxious 
relatives,  slight  interruption  of  the  respiration,  owing  to  enlarged  tonsils, 
is  frequently  regarded  as  croup,  whilst  almost  every  severe  case  of  sore 
throat  is  now  denominated  diphtheria. 

In  true  cases  of  croup  and  diphtheria,  however,  with  febrile  symp- 
toms and  the  unequivocal  formation  of  a false  membrane  on  the  mucous 


DISEASES  OF  THE  LARYNX. 


649 


membrane  invading  tlie  glottis,  tbe  greatest  danger  is  to  be  apprehended. 
In  croup,  emetics  are  useful;  and  occasionally  a few  leeches  applied  over 
the  sternum,  I have  seen  act  like  a charm.  Observe  that  when  applied, 
they  must  be  placed  carefully  over  the  bone,  so  that  the  hemorrhage 
may  afterwards  be  commanded  by  slight  pressure ; for  if  placed  on  the 
throat  or  soft  parts,  as  has  occasionally  been  done  through  inadvertence, 
the  danger  and  inconvenience  afterwards  is  very  great.  If  suffocation 
be  threatened,  the  sooner  tracheotomy  be  performed  the  better,  for 
although  that  operation  is  far  from  being  always  successful,  and  is 
not  unattended  with  danger,  the  risk  from  the  disease  I hold  to  be 
much  greater.  Dr.  J.  Buchanan  of  Glasgow  has  recently  published  an 
account  of  twenty-one  cases  of  diphtheria,  all  of  which  were  on  the  point  of 
suffocation  when  the  operation  was  performed,  with  the  result  of  causing 
recovery  in  seven. 

In  all  these  cases  I regard  the  mode  of  applying  topical  remedies 
introduced  by  Dr.  Green  as  a most  valuable  addition  to  our  other  means 
of  cure.  The  experience  of  that  physician  indicates,  that  the  earlier  it  is 
applied  the  greater  the  chance  of  success,  especially  in  acute  cases  of 
scarlatina  and  croup.  It  was  first  applied  in  hooping-cough  by  Dr. 
E.  Watson  of  Glasgow,  and  has  subsequently  been  tried  in  laryngismus 
stridulus,  hay  fever,  and  other  diseases  hitherto  considered  spasmodic, 
and  with  such  success,  as  to  lead  to  the  conclusion  that  these  disorders 
are  essentially  connected  with  local  irritations  or  an  obscure  form  of 
catarrh.  In  various  kinds  of  laryngeal  disease  occurring  in  the  adult, 
whether  primary  or  secondary,  I have  employed  it  very  extensively,  in 
many  instances  with  permanent  good  results,  and  in  a large  number 
with  temporary  alleviation.  Indeed,  nothing  is  more  remarkable  than 
the  immediate  effect  it  has  in  clearing  the  throat  and  improving  the  tone 
of  the  voice,  and  hence,  in  many  cases  which  do  not  admit  of  cure,  it 
may  be  employed  as  a palliative.  As  such,  I have  successfully  used  it 
in  old  cases  of  chronic  laryngitis  and  bronchitis,  clergyman’s  sore  throat, 
spasmodic  asthma  with  accumulation  of  mucus  in  the  trachea,  and  so  on. 
In  syphilitic  and  confirmed  tubercular  laryngitis,  though  not  so  bene- 
ficial, it  is  still  in  some  cases  decidedly  useful.  I have,  however,  met 
with  several  instances  where  it  has  been  very  injudiciously  employed, 
and  others  where  the  sponge  had  been  passed  by  unskilful  hands  re- 
peatedly down  the  oesophagus  without  any  good  effect,  the  patient  having 
been  persuaded  for  a considerable  period  that  it  had  been  applied  to  the 
larynx.  Circumstances  of  this  kind  may  bring  the  practice  into  dis- 
repute with  some,  but  I trust  you  will  discriminate,  and  neither  lightly 
abandon  it  from  a few  failures,  nor  be  led  into  the  opposite  error,  of 
supposing,  from  one  or  two  favorable  cases,  that  it  is  capable  of  being 
invariably  successful. 

Case  CXXXIY."* — Pertussis — Violent  Paroxysms — Bronchitis — Collapse 
of  the  Lungs — Recovery. 

History. — William  Campbell,  aet.  4^ — admitted  18th  June  1864.  The  mother  first 
noticed  a cough  in  this  child  two  weeks  ago,  which  was  accompanied  by  a distinct 
whoop.  • About  the  same  time  he  vomited  a good  deal  of  mucus  at  the  close  of  cough- 


* Reported  by  Mr.  H.  S.  Pavson,  Clinical  Clerk. 


650 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


ing,  which  seemed  to  give  him  great  relief.  She  knows  no  cause  for  the  disease,  except 
that,  for  a tew  tine  days  previous  to  the  commencement  of  the  cough,  the  child  played 
out  of  doors  without  shoes. 

Symptoms  on  Admission. — A strong,  vigorous  child.  Respirations  68  per  minute. 
Inspiration  hurried.  Percussion  anteriorly  normal.  Sibilant  and  sonorous  rales  heard 
on  both  sides  of  chest.  Posteriorly  percussion  normal.  Sibilant  and  sonorous  rales 
heard,  with  mucous  rales  over  both  bases  of  lung,  with  inspiration  and  expiration. 
Expectoration  copious,  nummular.  Pulse  144,  regular,  but  feeble.  Tongue  covered 
with  a slight  white  fur — oedematous.  Bowels  regular.  Stools  natural.  Skin  moist. 
Patient  emaciated.  Other  functions  normal. 

Progress  of  the  Case. — June  19/A. — Slept  well  last  night,  but  had  two  or  three 
fits  of  coughing.  Expectorates  large  quantities  of  mucus.  Took  his  breakfast  this 
morning.  Had  several  paroxysms  of  coughing  at  the  visit,  with  the  w^hoop  so  loud  as 
to  be  heard  not  only  over  the  ward,  but  in  the  neighboring  passages.  The  congestion 
and  lividity  of  the  face,  scalp,  and  neck,  were  well  marked.  He  generally  feels  hungry 
after  each  paroxysm,  and  asks  for  something  to  eat.  Dyspnoea  continues.  Pulse  150. 
Skin  hot  and  dry.  Had  three  stools  to-day.  Urine  amber-colored  ; sp.  gr.  1022 ; 
acid  reaction ; otherwise  normal.  Acid.  Nit.  DU.  3 j ; Tr.  Cardam.  Co.  3 ss ; 
Syrupi  3 ivss.  M.  Sig  a dessertspoonful  to  be  given  every  four  hours.  ^Ath. — Has 
continued  the  same,  but  on  examining  the  chest  anteriorly  slight  comparative  dulness 
on  right  side  inferiorly ; breathing  tubular  and  harsh,  with  a few  mucous  rales.  On 
left  side,  loud  vesicular  breathing,  wdth  abundant  mucous  rales.  Posteriorly,  dulness 
on  percussion  in  lower  third  of  right,  and  in  lower  fourth  of  left  back.  Percussion 
otherwise  normal.  At  right  base,  breathing  tubular,  with  clicking  mucous  rales ; 
higher  up,  breathing  feebly  tubular,  mixed  Avith  vesicular  breathing.  On  left  side, 
breath  sounds  normal.  Urine  deposits  lithates.  25/A. — Cough  increased.  Takes  food 
as  usual.  Tongue  clean.  Bowels  regular.  Vomited  after  tea,  in  consequence  of  a tit 
of  coughing.  Pulmonary  signs  as  yesterday.  Sputum  as  on  admission,  only  not 
nummular.  Ordered  a linseed  poultice,  with  mustard  on  it,  to  be  applied  to  the  right 
side  of  the  chest  for  ten  minutes.  Urine  still  loaded  wdth  lithates.  Continues  to  take 
the  acid  mixture.  26/A. — No  change.  The  acid  mixture  has  been  taken  regularly,  but 
appears  to  produce  no  effect  on  the  disease.  Ordered  Linimentum  Terebinthince  Ace- 
ticum  (PA.  P.),  to  be  rubbed  over  back  and  front  of  the  chest  twice  a day^  especially  over 
right  side.  28/A. — Pulse  180,  regular.  Respirations  80  per  minute.  Tongue  clean. 
Bow'els  regular.  Breathing  rather  troublesome.  Skin  warm  and  moist.  T 0 discon- 
tinue Acid  Mixture.,  and  to  have  Sherry  wine  3 ii  daily.  29/A. — Slept  pretty  well 
last  night.  Took  some  bread  and  milk  for  breakfast.  Had  several  paroxysms  of 
cough  during  the  night,  but  did  not  vomit.  Vespere. — Was  asleep  at  visit,  but  had 

a loud  wheezing  noise  in  his  chest.  Respirations  hurried  (68  per  minute).  Took 
some  broth  and  meat  for  dinner.  R Acidi  Hydrocyan.  DU.  TT^xvi ; Syrupi  Simplicis 
3 ss ; Aquee  Menthce  Pip.  3 iiiss.  M.  Fiat  mistura.  A teaspoonful  to  be  taken  every 
second  hour.  He  now  slowly  recovered,  and  was  dismissed  July  29th,  the  w'hoop  and 
severe  paroxysms  of  cough  having  disappeared,  but  with  considerable  w'heezing  in  the 
chest  and  occasional  cough. 

Commentary. — Cases  of  hooping- cougli  vary  considerably  as  to  the 
intensity  of  inflammatory  and  of  spasmodic  symptoms  present,  some- 
times one  and  sometimes  the  other  being  predominant.  In  the  present 
case  both  were  well  marked.  The  bronchitis  was  intense,  while  con- 
densation of  both  lungs,  from  collapse,  was  present  for  a considerable 
time.  The  spasms,  dyspnoea,  constriction  of  the  larynx,  and  attendant 
whoop,  were  also  well  marked.  Having  tried  all  kinds  of  remedies  in  this 
aff’ection,  without  deriving  much  benefit  from  any  of  them,  my  notice 
was  directed  by  the  class  to  the  strong  statements  of  Dr.  Gibb  as  to  the 
value  of  nitric  acid  taken  internally  in  this  disease.  According  to  him, 
it  is  as  effectual  as  quinine  in  intermittent  fever, and  it  was  therefore 
carefully  given,  and  its  use  prolonged  from  the  19th  to  the  28th  of 
June,  but  manifestly  without  the  slightest  benefit.  Good  nourishment, 


See  Dr.  Gibb  on  Hooping  Cough,  p.  335. 


BEONCHITIS. 


651 


and  latterly  a little  wine,  enabled  the  patient  ultimately  to  struggle 
tlirougli  the  disease,  which  was  very  severe. 

I consider  that  hooping-cough  is  one  of  those  disorders  that  runs 
through  a certain  course,  and  is  very  little  affected  by  remedial  measures. 
Our  efforts  should  be  directed  to  keeping  the  surface  warm,  preventing 
exposure  to  cold  winds  and  alternations  of  temperature,  and  supporting  the 
strength  by  good  diet  and  a little  wine.  When  the  disorder  becomes 
chronic,  there  can  be  no  doubt  that  change  of  air  often  acts  in  at  once 
removing  the  disease,  much  in  the  same  way  that  it  is  frequently  seen  to 
relieve  asthma. 

Analogous  to  the  nervous  phenomena  observed  in  hooping-cough  is 
the  laryngismus  stridulus,  or  crowing  inspiration  of  children,  which,  as 
pointed  oat  by  Dr.  Ley,  may  often  depend  upon  enlarged  glands  in  the 
neck,  and  may  originate  in  any  cause  irritating  the  recurrent  nerve,  di- 
rectly or  indirectly,  by  diastaltic  action,  as  ably  pointed  out  by  Dr. 
Marshall  Hall.  It  is  not  an  uncommon  symptom,  for  instance,  in 
aneurismal  swellings  affecting  the  throat  and  root  of  the  neck. 

BRONCHITIS. 

Case  CXXXY.* — Acute  Bronchitis. 

Histoky. — Martin  Conolly,  aet.  25,  a robust  laborer — admitted  May  16th,  1857. 
On  the  7th  of  May,  after  working  some  days  standing  in  water,  he  had  a rigor,  with 
great  heat  of  skin,  followed  by  profuse  perspiration,  but  no  headache.  He  continued 
at  his  work  till  10th  May,  when  he  was  confined  to  bed,  the  pain  having  got  worse. 
Cough  commenced  the  previous  day,  accompanied  with  a thick  yellow  sputum,  and 
these  symptoms,  with  dyspnoea,  have  gradually  increased  in  severity  up  to  his  ad- 
mission. 

Symptoms  on  Admission, — Form  of  chest  unusually  rounded  and  well  developed. 
Anteriorly,  percussion  is  clear  on  both  sides.  On  auscultation,  inspiration  is  short- 
ened ; expiration  prolonged,  and  accompanied  by  long  sibilant  and  sonorous  rales. 
Vocal  resonance  weak,  but  equal  on  both  sides.  Posteriorly  there  is  clear  resonance 
on  percussion  on  both  sides.  On  auscultation,  the  same  sibilant  and  sonorous  rales 
accompany  expiration,  and  are  occasionally  but  rarely  heard  with  inspiration,  which 
at  the  right  base  is  accompanied  by  moist  rales.  Cough  and  dyspnoea  urgent.  Re- 
spirations 36  per  minute.  Expectoration  gelatinous  and  muco-purulent.  Cardiac 
sounds  somewhat  masked,  but  normal.  Pulse  122,  strong,  full,  and  regular.  Skin 
hot,  but  otherwise  normal.  Tongue  moist  and  clean.  Appetite  much  impaired. 
Thirst  great.  Bowels  regular.  Urine  high  colored,  otherwise  normal.  Venesection 
to  14  oz.  was  performed  by  Dr.  Bennett  without  any  immediate  relief,  and  § ss  of  the 
following  mixture  ordered  to  be  taken  every  four  hours.  R . A quae  Acetatis  Ammo- 
nice  3 iss  ; Spirit.  ./Ether.  Nitrici  3 ij  ; Vin.  Antimonial.  3 ij  ; Aquam  ad  § vj. 
In  the  evening,  dyspiima  had  much  diminished.  Respirations  24  per  minute.  Pulse 
108,  still  regular,  full,  and  stroi.g.  Heat  of  skin  less. 

Progress  op  the  Case. — Next  day  improvement  was  found  to  continue.  Pulse 
116,  full,  but  softer  than  yesterday.  Sibilations  no  longer  audible  with  expiration. 
The  moist  sounds  are  fainter  and  less  abundant  than  at  last  examination.  May  \%th. 
— Sibilant  and  cooing  rales  accompany  both  respiratory  acts  posteriorly.  Anteriorly 
these  sounds  are  less  intense,  but  are  accompanied  by  fine  crepitus.  Under  the  left 
nipple,  crepitus  is  mixed  with  a certain  harshness,  both  on  expiration  and  inspiration 
(friction?)  Urine  rendered  turbid  by  the  presence  of  urates.  Pulse  116,  of  the  same 
character  as  yesterday.  May  \2th  (twelfth  day  of  the  disease).  Patient  was  found 
bathed  in  profuse  perspiration.  The  moist  sounds  are  diminishing  in  amount.  Crepi- 


* Reported  by  Mr.  W.  H,  Davies,  Clinical  Clerk. 


652 


DISEASES  OF  THE  EESPIEATOEY  SYSTEM. 


tation  still  audible  under  left  nipple.  Patient  still  complains  of  pain  in  that  region, 
but  there  is  no  friction.  Cough  continues,  but  is  less  severe.  Sputum  still  copious  and 
muco-purulent.  Pulse  102,  soft.  Appetite  improving.  Skin  moist.  Urine  throws 
down  a copious  sediment  of  urates.  May  21s<  (fourteenth  day). — Patient  still  per- 
spires profusely.  Crepitation  with  fine  sibilus  still  heard  anteriorly,  most  distinctly 
under  left  nipple.  Pain  in  left  side  continues,  being  most  severe  on  deep  inspiration. 
Sputum  diminished  in  quantity,  muco-purulent.  Pulse  100,  soft  and  full.  On  the 
26th,  moist  rattle  had  nearly. disappeared.  On  the  29th,  sibilations  were  very  faint,  the 
cough  was  trifling,  and  sputum  nearly  gone.  June  Ath. — He  was  discharged  quite  well. 

Commentary. — This  was  a case  of  violent  acute  bronchitis  of  both 
lungs,  in  a strong  vigorous  man.  On  admission,  so  great  was  his 
dyspnoea,  that  I bled  him  with  a view  of  determining  whether  the  re- 
medy would  relieve  that  symptom.  I satisfied  myself  that  it  had  no  im- 
mediate effect,  and  the  disease  subsequently  ran  its  natural  course,  ter- 
minating in  perfect  recovery  on  the  twenty-first  day. 

Bronchitis,  like  laryngitis,  consists  of  an  exudation  infiltrated  into 
the  various  tissues  forming  the  bronchi,  or  coagulated  upon  their  mucous 
surface.  It  terminates  in  the  transformation  of  this  exudation — accord- 
ing to  laws  previously  explained,  p.  166  et  seq. — into  matters  which  permit 
of  being  either  absorbed  into  the  blood  or  expectorated.  At  first  the 
lesion  causes  increased  dryness,  narrowing,  and  rigidity,  and  subsequent- 
ly moisture,  dilatation,  and  relaxation  of  the  tubes.  Owing  to  these 
changes,  the  vibrating  sounds  caused  by  the  passage  of  air  through  the 
bronchi  undergo  variations,  which  indicate  pretty  clearly  the  dry  or  moist 
nature  of  the  disease,  or,  as  some  term  it,  dry  or  moist  catarrh. 

Acute  bronchitis  may  differ  in  intensity,  from  an  affection  very  tri- 
fling and  scarcely  regarded,  to  one  which  very  nearly  approaches  in  se- 
verity a decided  attack  of  pneumonia.  It  may  be  epidemic,  and  con- 
stitute what  is  called  influenza.  It  may  follow  or  precede  a similar  lesion 
in  the  lining  membrane  of  the  nasal  passages,  that  is,  coryza.  These 
affections  are  so  common  as  to  be  . generally  treated  by  domestic  medi- 
cines only,  or,  it  may  be,  totally  disregarded.  But  there  can  be  no 
doubt  that  a disposition  to  attacks  of  this  kind,  though  they  may  often 
occur  for  a long  time  with  impunity,  frequently  leads  to  the  incurable 
and  distressing  change  of  pulmonary  texture  known  as  emphysema.^  with 
its  fearful  accompaniment  of  spasmodic  asthma  and  consecutive  disease 
of  the  heart.  Bronchitis,  therefore,  is  an  affection  which,  if  not  check- 
ed early,  should  be  carefully  assisted  through  its  natural  progress. 

To  check  the  progress  of  an  incipient  bronchitis  or  coryza,  when 
slight,  Dr.  Christison  recommends  a full  dose  of  morphia  on  the  first,  or 
at  latest  second  night,  on  going  to  bed.  In  the  morning  the  patient 
should  breakfast  in  bed,  and  keep  himself  warm  at  home  during  the  day. 
Should  the  disease  progress,  patience  is  perhaps  the  best  remedy,  as  the 
disease  will  run  its  course.  But  if  the  bronchi  become  clogged,  sudori- 
fics  and  expectorants,  especially  ipecacuanha,  may  be  useful,  and  a sina- 
pism or  blister  will  sometimes  dissipate  any  lingering  trace  of  the  dis- 
ease. The  chief  caution  to  be  given  should  be  to  get  perfectly  rid  of 
the  disorder  before  any  exposure  to  cold  air  be  allowed.  It  is  the  dis- 
regard of  this  point,  and  the  getting  “ cold  upon  cold,”  which  serves  so 
much  to  keep  up  the  affection,  and  at  length  induces  the  chronic  form  of 
the  disease. 


BEONCHITIS. 


653 


Case  CXXXVL"^ — Chronic  Bronchitis — Acute  Peritonitis — Collapse  of 

the  Lung. 

History. — MaryNichol,  aet.  21,  a servant — admittedJuly  8th,  1851.  She  has  suf- 
fered more  or  less  from  cough  for  the  last  two  years.  Occasionally  it  has  been  very 
troublesome,  but  not  accompanied  by  much  expectoration.  Seven  weeks  ago  experi- 
enced severe  pain  in  the  epigastrium,  and  since  then  the  breathing  has  become  short 
and  hurried. 

Symptoms  on  Admission. — Anteriorly  the  lungs  are  everywhere  resonant  on  per- 
cussion. On  auscultation,  the  inspiratory  murmur  is  harsh,  and  towards  its  termina- 
tion fine  sibilant  rales  are  heard.  Posteriorly,  the  right  side  is  more  dull  on  percus- 
sion than  the  left.  This  is  more  marked  towards  the  apex.  At  this  point  there  is 
harsh  inspiration  and  increased  vocal  resonance.  There  are  also,  over  the  whole 
right  back,  sibilant  rales  during  inspiration.  Cough,  with  trilling  mucous  expectora- 
tion ; respirations  short  and  hurried  ; great  tenderness  over  the  epigastrium,  increased 
on  taking  a deep  inspiration ; appetite  tolerably  good ; no  nausea  or  vomiting, 
and,  with  the  exception  of  constipation,  digestive  system  healthy  ; pulse  80,  soft ; 
heart  sounds  natural ; catamenia  regular  ; urine  voided  with  pain,  and  in  small  quan- 
tity, otherwise  healthy. 

Progress  op  the  Case. — The  dry  rales  accompanying  the  inspiration  continued 
for  some  days;  but  on  the  21st  they  became  moist,  and  coarse  crepitation  was  audi- 
ble over  the  inferior  third  of  right  back.  The  cough  became  more  loose  also,  and 
the  expectoration  increased.  On  the  24th,  the  moist  rattles  were  converted  into  deep 
sonorous  murmurs,  and  great  variations  were  heard  from  day  to  day,  evidently  in  con- 
sequence of  the  greater  or  less  amount  of  fiuid  in  the  bronchi.  The  cough  and  ex- 
pectoration also  varied  greatly  in  intensity.  Her  principal  complaint,  however,  was 
the  epigastric  pain,  which,  notwithstanding  the  application  of  leeches,  warm  fomenta- 
tions, opiates,  and  counter-irritants,  continued  to  increase.  On  the  28th  there  was 
diffuse  swelling  of  the  abdomen,  general  tenderness  of  the  surface,  and  all  the  symp- 
toms of  peritonitis  from  intestinal  perforation.  Latterly  there  was  dulness  and  ab- 
sence of  respiration  over  the  lower  thh-d  of  right  lung.  She  died  August  10th,  1851 ; 
but  unfortunately  no  dissection  could  be  procured. 

Gommentanj. — This  girl  labored  under  a chronic  bronchitis  of  some 
standing,  which  presented,  during  the  progress  of  the  case,  most  of  the 
physical  signs  characteristic  of  the  disease.  Her  chief  complaint,  how- 
ever, was  a fixed  pain  in  the  epigastric  region,  which  proved  in  no  way 
amenable  to  treatment,  and  which,  as  the  event  proved,  was  evidently 
connected  with  an  ulcer  either  in  the  stomach  or  neighboring  intestinal 
viscera,  probably  the  former,  considering  the  frequent  occurrence  of 
ulcers  in  that  viscus  among-  servant  girls.  But  in  the  absence  of  the 
facts  which  a dissection  only  could  have  afforded,  all  speculation  on 
such  a point  is  evidently  useless.  The  dulness  on  percussion  at  the  apex 
of  the  right  lung,  the  harsh  inspiration  and  increased  vocal  resonance, 
point  to  the  existence  of  some  condition  of  the  organ  at  that  point, 
giving  it  increased  density.  They  constitute  the  signs  of  incipient  or 
of  cretaceous  tubercle.  But  percussion  over  the  whole  of  right  back 
was  impaired ; and  towards  the  close  of  life,  as  weakness  appeared,  there 
was  dulness  and  absence  of  respiration  over  the  lower  third  of  right 
lung.  These  physical  signs  indicate  collapse  of  the  organ  in  this  situa- 
tion, or  a condition  which  has  been  variously  called  by  pathologists 
“ condensation  ” — infarction  ” — “ hypostatic  pneumonia  ” — “ peri-pneu- 
monie  des  agonisans,”  etc.  etc. 

In  a series  of  observations  on  bronchitis,  by  Br.  W.  T.  Grairdner,f 
he  points  out,  as  one  of  the  most  common  results  of  the  disease,  more 
or  less  collapse  of  the  vesicular  tissue,  dependent  on  obstruction  to  the 
* Reported  by  Mr.  C.  D.  Phillips,  Clinical  Clerk, 
f Papers  in  Monthly  Journal  for  1850. 


654 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


passage  of  air  during  inspiration,  by  glutinous  or  inspissated  mucus. 
This  collapse  is  often  confined  to  individual  lobules,  which  are  condensed, 
comparatively  heavy,  indurated  to  the  feel,  of  dark  color,  and  present 
the  usual  characters  of  the  unexpanded  portions  of  lung  in  the  newly- 
born  infant  iateleciasis).  Doubtless,  also,  such 
collapsed  lobules  have  often  been  mistaken  for 
lobular  pneumonia,  or  pulmonary  apoplexy  in 
children.  Dr.  Gairdner  has  further  recorded 
facts,  which  render  it  highly  probable  that  this 
collapse  becomes  more  diffused  in  chronic  cases  of 
bronchitis,  when  a large  bronchus  is  obstructed, 
as  represented  Fig.  449,  and  when,  from  the  weak- 
ness of  the  individual,  from  abdominal  disease,  or 
want  of  resistance  in  the  thoracic  walls,  the  pa- 
tient is  unable  to  clear  the  air-passages  by  a strong 
expiratory  effort.  Hence  why  this  lesion  is  com- 
mon in  fever,  in  bronchitis  accompanying  perito- 
nitis or  ascites,  and  in  young  children.  The  case 
recorded  is  evidently  one  where,  from  the  physical 
signs  and  other  symptoms,  we  can  have  little  doubt  that  collapse  in  the 
right  lung  occurred  to  a considerable  extent. 

Case  CXXXVII.^ — Chronic  Bronchitis — Emphysema — Acute 
Laryngitis, 

History. — Edward  Jackson,  ast.  22,  a robust  negro,  cook  to  a vessel — admitted 
February  14,  1851.  He  says  that  three  months  ago,  when  at  sea,  he  first  began  to 
suffer  from  cough,  expectoration,  and  shortness  of  breath,  which  symptoms,  notwith- 
standing various  remedies  given  him  by  his  captain,  have  continued  to  increase  up  to 
the  present  time. 

Symptoms  on  Admission. — Anteriorly  the  thorax  is  unusually  arched  from  above 
downwards.  On  percussion,  there  is  everywhere  loud  resonance,  especially  in  front. 
On  auscultation,  the  expiration  is  much  prolonged,  and  accompanied  by  sibilant  and 
sonorous  rales,  louder  and  more  general  on  the  right  side.  There  is  frequent  and  pro- 
longed cough,  accompanied  by  copious  frothy  mucous  expectoration,  gi’cat  dyspnoea 
on  making  an  exertion,  and  occasionally  coming  on  in  paroxysms  without  any  obvious 
cause.  Cardiac  sounds  normal.  Pulse  80,  strong.  Frequently  vomits  after  a severe 
fit  of  coughing ; but  the  digestive  and  other  systems  are  otherwise  healthy. 

Progress  of  the  Case. — In  addition  to  the  dry  rales  heard  when  he  ivas  first  ex- 
amined, it  was  soon  ascertained  that  copious  coarse  moist  rales  appeared  posteriorly 
and  inferiorly,  especially  on  the  right,  but  also  on  the  left  side.  These  rales  were  oc- 
casionally absent,  but  continued  tolerably  constant.  The  dry  rales  also  underwent  from 
time  to  time  several  variations  in  tone,  intensity,  and  situation.  During  February,  May, 
and  June,  he  was  tortured  by  severe  and  prolonged  attacks  of  dyspnoea,  during  which 
he  gasped  for  breath,  and  appeared  on  the  point  of  suffocation.  The  attack  generally 
terminated  by  violent  cough,  expectoration,  and  vomiting,  after  which  he  always  felt 
relieved.  These  attacks  came  on  every  second  or  third  night,  and  were  sometimes 
occasioned  by  an  unusually  full  meal.  In  May  there  was  noticed,  in  addition  to  the 
other  physical  signs,  a coarse  moist  tracheal  rattle,  so  loud  as  to  mask  the  pulmonary 
sounds.  On  one  occasion,  during  this  month,  the  attack  of  dyspnoea  lasted  four 
hours,  producing  partial  asphyxia,  delirium,  and  stupor.  On  the  24th  of  May,  he  was 
attacked  with  sore  throat,  and  difficulty  in  deglutition,  followed  on  the  39th  by  laryn- 
gitis and  partial  aphonia,  which  greatly  aggravated  the  asthmatic  attacks.  During  all 
this  time,  expectorants,  antispasmodics,  anodynes,  counter-irritants,  with  occasional 

* Reported  by  Mr.  W.  M.  Calder,  Clinical  Clerk. 

Fig.  449.  Plug  of  mucus  or  coagulated  blood,  so  placed  that,  while  it  admits  of 
partial  expiration,  it  prevents  inspiration  and  causes  collapse  of  the  pulmonary  tissue, 
to  which  the  smaller  bronchi  are  distributed. — ( Gairdner.) 


BRONCHITIS. 


655 


emetics,  and  cupping,  were  employed,  with  temporary  but  no  permanent  benefit.  In 
April  and  May  the  smoking  of  stramonium  evidently  alTorded  him  considerable  ease. 
He  also  experienced  marked  relief  from  a draught  containing  3 iss  each  of  Tr.  Lobe- 
li£e  and  of  Ether.  Towards  the  end  of  June,  a sponge,  saturated  with  a strong  solu- 
tion of  nitrate  of  silver,  was  passed  into  the  larynx  several  times,  with  marked  bene- 
fit; indeed,  so  much  so,  that,  on  the  11th  of  July,  his  condition  was  greatly  im- 
proved, the  attacks  of  dyspnoea  ceased,  and  the  cough,  expectoration,  and  other 
symptoms,  were  much  abated.  On  the  16th,  he  was  dismissed  at  his  own  recpiest,  to 
resume  his  occupation  as  cook  on  board  ship.  The  sore  throat  and  laryngitis  had 
then  disappeared,  but  the  chest  was  still  unusually  resonant  on  percussion  ; there  was 
loud  tracheal  breathing,  prolonged  expiration,  and  occasional  sibilant  rale.  Kespira- 
tion,  however,  was  comparatively  easy,  and  he  considered  himself,  as  he  certainly  was, 
greatly  relieved. 

Commentary. — This  man  presented  all  the  physical  signs  and  symp- 
toms indicative  of  extensive  emphysema  dependent  on  chronic  bronchitis, 
accompanied  with  the  most  severe  asthmatic  attacks.  These  attacks 
were  of  a spasmodic  character,  referable  to  irritation  of  the  inci- 
dent filaments  of  the  pneumo-gastric  nerve,  and  to  reflex  action  by 
means  of  the  excident  ones,  whereby  the  bronchial  tubes  were  contract- 
ed, the  glottis  clqsed,  and  the  muscles  of  inspiration  rendered  incapable 
of  dilating  the  chest.  Violent  cough  and  vomiting  were  always  induced 
towards  the  close  of  the  attack,  followed  by  relief.  The  dyspnoea  dur- 
ing the  course  of  the  disease  was  alleviated  by  antispasmodics,  and  the 
laryngitis  by  topical  applications,  of  which  I have  previously  spoken.  I 
consider,  however,  that  his  recovery  was  mainly  due  to  the  advance  of 
summer  and  a change  of  temperature — circumstances  whicli  should 
never  be  overlooked  in  estimating  the  effects  of  treatment  in  such  cases. 

Of  all  the  causes  which  excite  asthmatic  paroxysms  in  individuals 
laboring  under  emphysema,  the  effect  of  certain  seasons  and  changes  of 
temperature  is  the  most  unequivocal,  and  yet  the  most  mysterious. 
Thus  some  persons  who  are  martyrs  to  the  disease  in  winter  are  perfect- 
ly well  in  summer,  and  vice  versa.  Some  are  immediately  affected  by 
the  foggy  air  of  Loudon,  and  are  well  in  the  country ; others  arc  at- 
tacked when  the  wind  blows  from  a particular  quarter,  especially  the 
east.  However  difficult  it  may  be  to  explain  such  idiosyncrasies,  there 
can  be  no  doubt  that  a knowledge  of  these  circumstances  will  enable 
those  who  can  change  their  residence,  to  alleviate  their  sufferings  in  no 
small  degree. 

Emphysema  is  characterised  anatomically  by  a permanent  enlarge- 
ment of  the  air-vesicles  of  the  lung.  These  may  frequently  be  seen 
through  the  pleura,  with  an  ordinary  lens,  like  groups  of  minute  pearls. 
Two  or  more  of  them  may  break  into  each  other,  and  produce  others  of 
larger  dimensions,  say  the  size  of  a millet  seed,  and  this  process  may  go 
on,  until,  by  the  breaking  down  of  the  intervening  partitions,  every  size 
of  emphysematous  cavity  may  be  formed,  up  to  that  of  a large  orange. 
The  walls  of  such  cavities  remain  permanently  open,  having  lost  their 
elasticity.  The  tissues  which  form  them  also  are  evidently  atrophied, 
and  their  paleness  proves  that  the  capillaries  have  been  so  compressed  as 
to  be  either  obliterated  or  impervious  to  the  passage  of  blood. 

In  order  to  account  for  emphysema,  numerous  theories  have  been 
advanced,  of  which  I shall  allude  to  only  the  first  and  last.  Laennec 


656 


DISEASES  OF  THE  EESPIEATORY  SYSTEM. 


supposed  that  the  fine  bronchial  tubes  became  rigid  and  more  or  less  im- 
pervious from  swelling  of  their  lining  membranes  or  impaction  of  mucus. 
He  conceived  that  inspiration  was  a more  powerful  action  than  expira- 
tion, so  that  while  air  could  be  drawn  through  the  obstructions,  it  could 
not  be  breathed  out.  In  consequence,  it  accumulated  in  the  ultimate 
pulmonary  vesicles,  became  expanded  by  heat,  and  so  acted  mechanical- 
ly as  a dilator,  distending  them  from  within,  and  causing  them  to  en- 
large more  and  more  according  to  the  duration  of  the  disease,  and  ex- 
tent of  the  respiratory  efforts.  Dr.  Gairdner,  however,  has  pointed  out 
that  expiration  is  a much  more  powerful  act  than  inspiration,  and  that 
there  is  never  any  difiiculty  in  causing  expulsion  of  air.  It  is  the  in- 
spiration which  is  laborious  in  all  bronchitic  cases,  and,  as  has  been 
previously  stated,  when  the  tubes  are  obstructed,  so  far  are  the  air-cells 
beyond  them  from  being  dilated  that  they  are  in  truth  collapsed.  Em- 
physema, then,  does  not  occur  in  the  vesicles  connected  with  obstructed 
tubes,  but  in  those  healthy  ones  which  are  adjacent.  When  the  lungs 
are  in  a normal  state,  the  column  of  air  presses  equally  on  the  tubes  and 
vesicles,  but  when  one  portion  connected  with  any  obstruction  is  col- 
lapsed or  otherwise  diminished  in  bulk,  then  the  neighboring  portion  is 
over-expanded,  so  as  to  occupy  the  space  previously  filled  by  the  former. 
Hence  why  em.physema  occurs  not  only  as  a result  of  bronchitis,  but  of 
chronic  phthisis,  or  any  other  disease  which  causes  contraction  and 
hypertrophy  of  the  pulmonary  fibrous  tissue.  Dr.  Jenner  also  says,* 
“ The  atmospheric  air  moved  by  the  inspiratory  effort  can  exert  com- 
paratively little  pressure  on  the  inner  surface  of  the  air-cells  situated  at 
the  extreme  margin  of  the  base,  the  root  of  the  lower  lobe  {i.  e.,  that 
part  immediately  next  the  spine  and  below  the  primary  bronchus),  or  at 
the  part  of  the  apex  situa  ted  in  the  furrow  posterior  to  the  trachea  on 
the  right  side.  While  violent  expiration,  being  chiefly  performed  or 
greatly  aided  by  the  abdominal  muscles  forcing  upwards  the  liver,  etc., 
drives  the  air  (in  consequence  of  the  highly  arched  form  of  the  dia- 
phragm in  violent  expiration)  from  the  central  part  of  the  lung,  not  only 
through  the  bronchi  towards  the  larynx,  but  also  towards  the  circumfer- 
ence of  the  lungs,  i.  e.,  towards  those  parts  which  are  the  least  com- 
pressed during  expiration.”  This  view  is  confirmed  by  al  Ithat  we  know 
of  the  usual  seat  of  emphysema,  and  by  the  effects  of  expiration  as 
made  visible  under  particular  circumstances.  In  the  case  of  M.  Groux, 
in  whom  the  sternum  was  deficient,  it  could  be  demonstrated  that  it  was 
only  by  a forced  expiration  that  the  lungs  so  expanded,  as  to  protrude 
through  the  aperture.f 

The  treatment  of  chronic  bronchitis  must  be  directed  to  facilitate 
expectoration  by  means  of  various  expectorants,  and  to  allay  the  irrita- 
bility of  the  bronchial  passages  by  means  of  anodynes.  I have  already 
alluded  to  the  circumstance,  that  chronic  pharyngitis,  tonsillitis,  elonga- 
tion of  the  uvula,  and  follicular  disease  of  the  epiglottis,  keep  up  a cough, 
often  mistaken  for  chronic  bronchitis ; and  it  is  in  these  disorders  that 
demulcents,  lozenges  of  various  kinds,  astringent  and  stimulating  gargles, 
etc.,  are  found  temporarily  beneficial.  In  such  cases  the  employment  of 

* Medico-Chir.  Trans,  of  London,  vol.  xl. 

\ Edin.  Med.  Journal,  vol.  iii.,  p.  853.  1868. 


BRONCHITIS. 


657 


the  spon^’e,  saturated  in  a solution  of  nitrate  of  silver,  is,  as  we  have  seen 
in  Case  CXXXVII.,  of  the  greatest  advantage.  Perhaps  there  is  no  disease 
in  which  blisters  and  counter  irritations  are  more  useful  than  in  bronchitis. 

When  chronic  bronchitis  is  associated  with  emphysema,  and  accom- 
panied by  spasmodic  attacks  of  dyspnoea,  the  various  kinds  of  antispas- 
modics  are  most  serviceable.  Sulphuric  and  chloric  ether  often  act  like 
magic  ; and  the  smoking  of  stramonium,  with  or  without  opium,  and 
other  remedies  of  this  class,  though  they  seldom  cure,  produce  great 
relief.  The  idiosyncrasy  of  the  asthma  should  also  be  studied,  and  a 
change  of  temperature  or  locality  advised,  according  to  the  peculiarities 
of  the  case.  In  very  severe  and  chronic  cases  this  may  be  regarded  as 
the  only  curative  procedure. 

Case  CXXXVIII.* — Chronic  Bronchitis — Emphysema — Injection  of 
the  Bronchi  with  a solution  of  the  Nitrate  of  Silver. 

History. — Eliza  Dawson,  set.  24,  a servant — admitted  2Vth  May  1857. — About 
fourteen  months  ago,  after  exposure  to  damp  and  cold,  she  was  seized  vvith  a severe 
pain  in  the  chest  accompanied  by  cough.  The  pain  in  the  chest  disappeared  in  a few 
days,  but  the  cough  persisted,  though  it  was  not  very  troublesome,  till  twelve  months 
ago,  when  again  it  became  very  severe,  the  house  in  which  she  was  living  being 
damp.  The  pain  in  the  chest  at  the  same  time  returned.  In  the  middle  of  last 
January  the  pain  and  cough  increased  in  severity,  and  were  accompanied  by  consider- 
able dyspnoea.  She  derived  no  benefit  from  treatment,  and  was  at  length  compelled 
to  apply  for  admission,  because  her  weakness  was  such  as  to  prevent  her  continuing 
at  work. 

Symptoms. — On  percussion  over  the  chest,  resonance  is  very  loud  both  anteriorly 
and  posteriorly.  On  auscultation,  expiration  is  everywhere  prolonged.  Sibilant  and 
snoring  sounds  accompany  inspiration  and  expiration  on  both  sides,  anteriorly  and 
posteriorly.  Vocal  resonance  everywhere  diminished.  Cough  and  dyspnoea  paroxys- 
mal ; the  respiration  being  labored  even  in  the  intervals.  Expectoration  in  moderate 
quantity,  consisting  of  frothy  fluid  floating  over  tough  gelatinous  mucus.  Apex  of 
heart  cannot  be  felt.  Cardiac  sounds  normal,  but  masked  by  the  pulmonary  sounds. 
Pulse  74,  of  moderate  strength.  Tongue  clean,  but  somewhat  dry.  Appetite  impaired. 
Feels  pain  in  the  epigastrium  after  taking  food.  Dowels  generally  constipated, 
requiring  the  occasional  use  of  aperients.  Other  functions  normal.  Spirit.  JEther. 
Nitric.  I iij ; Spirit.  Ammon.  Aromatic.  3 iv  ; Aquarn  ad  3 vi.  A table-spoonful  to 
he  taken  thrice  a-day.  The  chest  to  he  dry-cupped  anteriorly  and  posteriorly. 

Progress  of  the  Case. — She  has  experienced  great  relief  from  the  treatment,  and 
on  1st  June  the  snoring  sounds  are  reported  to  have  disappeared.  On  that  day,  how- 
ever, the  dyspnoea  again  became  distressing,  and  on  3d  June,  the  sibilant  and  sonor- 
ous rales  had  returned.  Was  ordered  Spirit.  uEther.  Sulphuric.  3 ij. ; Sol.  Mur. 
Morph.  3 iss  ; Decoct.  Senegce  ad  §vi.  A tahle-spoonfd  to  he  taken  thrice  a-day.  A 
blister  (3  by  4)  to  he  applied  over  the  chest.  This  was  followed  by  great  relief;  sibilus 
continued  audible,  but  the  sputum  diminished  in  quantity,  becoming  altogether  mucous. 
On  the  13th,  cough  and  dyspnoea  again  became  severe,  with  pain  in  the  chest.  A 
blister  (3  by  4)  was  again  applied  with  benefit.  27^A  June. — The  dyspnoea  has  re- 
turned during  the  last  few  days,  the  paroxysms  occurring  chiefly  during  the  night. 
During  the  fit  she  sits  up  in  bed;  the  whole  chest  heaves;  the  head  is  thrown  back 
during  inspiration  ; the  face  is  unusually  pale  and  moist  with  perspiration ; lips  pallid ; 
aiticulation  slow  and  measured;  respiration  accelerated  with  prolongation  of  expira- 
tion. A drachm  of  sulphuric  ether.,  and  half  a drachm  of  Sol.  Mur.  Morph,  in  a 
draught.,  gave  immediate  relief.  The  fits  now  became  less  frequent,  diminishing  at 
the  same  time  in  severity  and  duration.  On  13th  July,  after  the  previous  application 
for  a few  days  of  the  sponge  to  the  throat.  Dr.  Bennett  injected,  by  means  of  a 
catheter  introduced  into  the  trachea,  3 ij  of  a solution  containing  half  a drachm  of 
nitrate  of  silver  to  § j of  water.  The  operation  was  repeated  next  day.  There  was 
no  return  of  dyspnoea  till  15th  July,  when  she  had  two  paroxysms,  both  followed 

* Reported  by  Mr.  Stephen  Scott,  Clinical  Clerk. 

42 


658 


DISEASES  OF  THE  EESPIRATOEY  SYSTEM. 


by  vomiting.  She  had  a third  paroxysm  next  morning  at  4 o’clock,  vhich  left 
her  very  weak  ; respiration  at  2 p.m.  being  still  considerably  embarrassed.  On  1 7th 
July,  3 ij  of  the  solution  of  nitrate  of  silver  were  again  injected  into  the  trachea. 
No  difficulty  is  experienced  in  passing  the  tube,  nor  is  any  inconvenience  felt  by  the 
patient.  The  presence  of  the  catheter  in  the  trachea  was  demonstrated  by  tlie  propul- 
sion of  2 01  3 drops  from  the  external  orifice  to  a distance  of  3 feet  during  a forcible 
expiration.  After  the  operation,  she  passed  a much  better  night ; the  cough  and  ex- 
pectoration being  very  much  less,  and  the  respiration  perfectly  easy.  On  22d  July  the 
operation  was  repeated ; she  vomited  in  an  hour  and  a half  after  it,  but  remained  com- 
paratively free  from  cough  and  dyspnoea  till  30th  July,  when  a re-accession  occurred. 
On  1st  August,  3 ij  of  the  solution  were  again  injected,  and  on  4th  August  she  left  the 
Infirmary  to  obtain  change  of  air. 

Commentary. — This  also  was  a case  of  chronic  bronchitis,  with  em- 
physema and  severe  paroxysms  of  asthma,  in  which  various  remedies 
were  tried  with  the  elfect  of  temporarily  alleviating  the  dyspnoea.  Dur- 
ing her  residence  in  the  house,  much  of  the  bronc.hitis  gradually  disap- 
peared, but  the  emphysema  and  asthma  continued  and  underwent  little 
change.  It  appeared  to  me  a favorable  opportunity  for  trying  the  new 
practice  introduced  by  Dr.  Horace  Grreen  of  New  York,  of  bronchial  in- 
jections with  a solution  of  nitrate  of  silver.  We  were  singularly 
favored  in  this  case  by  the  high  position  of  the  epiglottis,  and  the  com- 
parative insensibility  of  the  larynx.  The  sponge  saturated  with  the 
nitrate  of  silver  solution,  apparently  caused  no  irritation  whatever,  and 
on  passing  the  catheter  through  the  rirna  glottidis  little  uneasiness  was 
manifested.  Two  drachms  of  a solution  ( 3 ss  of  the  salt  to  3 j of  water) 
were  injected  into  the  trachea  several  times,  producing  only  a feeling  of 
warmth  in  the  chest,  but,  as  she  frequently  declared,  greatly  diminish- 
ing the  cough  and  expectoration  from  one  to  two  days  afterwards.  This 
woman,  with  the  catheter  deep  in  the  trachea,  closed  her  mouth  round 
the  tube,  respired  through  it,  and  could  blow  so  as  to  render  the  ex- 
pelled air  quite  sensible  to  the  finger.  No  one  could  doubt  that  the 
tube  was  in  the  trachea,  and  that  the  solution  had  passed  into  the  lungs. 
After  her  dismissal,  I continued  to  see  her,  and  subsequently  increased 
both  the  strength  and  quantity  of  the  injection.  Latterly  I have  thrown 
in  3 ss  of  the  strength  of  3ij  of  the  salt  to  3 j of  water.  She  emigrated 
to  Australia,  May  1858. 

On  Injections  into  the  Bronchi  in  Pulmonary  Diseases. 

In  a publication  which  I received  from  Dr.  Horace  Green  of  New 
j'  ork  in  1856,  there  is  a table  of  106  cases  of  pulmonary  disease,  which 
were  treated  by  injections  into  the  bronchi  of  a solution  of  nitrate  of 
silver.  A flexible  catheter  was  introduced  through  the  larynx,  into  the 
right  or  left  division  of  the  trachea,  and,  by  means  of  a glass  syringe, 
the  injection  thrown  into  the  lung.  This  bold  proceeding  was  described 
as  producing  great  benefit  in  cases  of  pulmonary  tuberculosis,  bronchitis, 
and  asthma.  Whilst  tuberculosis  is  at  first  a constitutional  disease,  its 
localization  in  any  part  reacts  more  or  less  on  the  general  health  ; and 
the  opinion  I have  long  entertained,  that  any  means  which  could  enable 
the  physician  to  act  directly  on  the  tissue  of  the  lung  or  inflamed 
bronchi,  would  assist  his  efforts  at  cure — at  once  led  me  to  take  a favor- 
able view  of  this  new  mode  of  treatment.  The  nitrate  of  silver  ought  to 
act  as  beneficially  on  the  mucous  membrane  of  the  trachea  and  bronchi 


BRONCHITIS. 


659 


as  on  that  of  any  other  hollow  viscus,  and  we  have  seen  previously  that 
the-  remedy  may  be  applied  to  the  traclieal  mucous  membrane  by  means 
of  an  artificial  opening  (see  Case  CXXXIII.),  not  only  without  injury 
but  with  decided  benefit.  The  difficulty  was  obviously  to  get  it  there 
through  the  rima  glottidis.  I therefore  wrote  to  Dr.  Green,  requesting 
him  to  send  me  the  instruments  he  employed.  In  a letter  which  I re- 
ceived from  him  in  reply,  dated  New  York,  January  30,  1857,  he  says  : — 
“ 1 would,  with  much  pleasure,  send  you  the  instruments  I employ, 
but  they  are  simple,  and  may  be  obtained  at  any  surgical  instrument 
maker’s  shop.  They  consist  of  an  ordinary  flexible  or  gum  catheter,  and 
a small  silver  or  a glass  syringe.  The  catheter  is  Hutching’s  gum- 
elastic  catheter  (Nos.  11  or  12),  which  is  12|-  inches  in  length;  and  as 
the  distance  from  the  incisor  teeth  to  the  tracheal  bifurcation  is,  ordi- 
narily, in  the  adult,  about  eight  inches,  if  this  instrument  is  introduced 
so  as  to  leave  only  two  inches  of  the  catheter  projecting  from  the  mouth, 
its  lower  extremity  must  of  course  (if  it  enter  the  trachea)  reach  into 
one  or  the  other  of  its  divisions.  I first  prepare  my  patients  by  making 
applications  with  the  sponge-probang,  for  a period  of  one  or  two  weeks, 
to  the  opening  of  the  glottis  and  the  larynx,  until  the  sensibility  of  the 
parts  is  greatly  diminished.  Then,  having  the  tube  slightly  bent,  I dip 
the  instrument  in  cold  water  (which  serves  to  stiffen  it  for  the  moment, 
and  obviates  the  necessity  of  using  a wire),  and  with  the  patient’s  head 
thrown  well  back,  and  the  tongue  depressed,  I place  the  bent  extremity 
of  the  instrument  on  the  laryngeal  face  of  the  epiglottis,  and  gliding  it 
quickly  through  the  rima  glottidis,  carry  it  down  to  or  below  the  bifur- 
cation, as  the  case  may  require.  It  is  necessary  that  the  patient  continue 
to  respire,  and  the  instrument  is  most  readily  passed  during  the  act  of 
inspiration.  The  tube  being  introduced,  the  point  of  the  syringe  is  in- 
serted into  its  opening,  and  the  solution  injected.  This  latter  part  of 
the  operation  must  be  done  as  quickly  as  possible,  or  a spasm  of  the  glottis 
is  likely  to  occur.  Indeed,  if  the  natural  sensibility  of  the  aperture  of 
the  glottis  is  not  well  subdued  by  previous  applications  of  the  nitrate  of 
silver  solution,  or  if  the  tube  in  its  introduction  touches  roughly  the 
border  or  lips  of  the  glottis,  a spasm  of  the  glottis  is  certain  to  follow, 
which  will  arrest  the  further  progress  of  the  operation.  The  epiglottis^ 
which  is  nearly  insensille  (and  this  you  may  prove  on  any  person,  by 
thrusting  two  fingers  over  the  base  of  the  tongue,  and  touching,  or  even 
scratching  with  the  nail,  that  cartilage),  should  be  our  guide  in  perform- 
ing the  operation.  The  strength  of  the  solution  for  injecting  is  from  10 
to  25  grains  to  the  ounce  of  water.  Commencing  with  10  or  15  grains 
to  the  ounce,  its  strength  is  subsequently  increased,  and  the  amount  I 
now  employ  is  from  \ to  1^  drachms  of  this  solution. 

“ In  cases  of  bronchitis,  asthma,  and  in  phthisis,  even  the  employ- 
ment of  the  tube  once  or  twice  a week  diminishes  the  cough  and  expec- 
torations with  great  certainty,  especially  in  the  two  former  diseases ; and 
many  cases  ha'^e  recovered  under  the  local  treatment  after  other  means 
have  failed.  The  applications  of  the  sponge-probang  are  continued  in  the 
intervals  of  the  employment  of  the  tube.” 

My  period  of  attendance  on  the  clinical  wards  having  expired  in 
January,  it  was  not  until  May  1857  that  I had  an  opportunity  of  making 
a series  of  observations  on  this  subject.  I was  then  fortunately  assisted 


660 


DISEASES  OF  THE  EESPIEATORY  STSTESf. 


by  Professor  Barker  of  New  York,  wlio  showed  me  the  kind  of  catheter 
he  had  seen  Dr.  Green  employ,  and  demonstrated  the  manner  in  which 
the  operation  was  performed.  Without  entering  into  minute  particulars, 
I have  only  to  say  that  I have  confirmed  the  statements  made  by  Dr. 
Horace  Green.  I have  now  introduced  the  catheter  publicly  in  the 
clinical  wards  of  the  Boyal  Infirmary,  in  several  patients  affected  with 
phthisis  in  various  stages,  in  laryngitis,  and  in  chronic  bronchitis,  with 
severe  paroxysms  of  asthma.  In  other  cases  in  which  I attempted  to  pass 
the  tube  it  was  found  to  be  impossible ; in  some  because  the  epiglottis 
could  not  be  fairly  exposed,  and  in  others  on  account  of  the  irritability 
of  the  fauces,  and  too  ready  excitation  of  cough  from  pressure  of  the 
spatula.  I have  been  surprised  at  the  circumstance  of  the  injections  not 
being  followed  by  the  slightest  irritation  whatever,  but  rather  by  a 
pleasant  feeling  of  warmth  in  the  chest  (some  have  experienced  a sensa- 
tion of  coolness),  followed  by  ease  to  the  cough,  and  a check  for  a time 
to  all  expectoration. 

In  making  these  injections,  I have  observed  very  great  differences  in 
the  form  of  the  epiglottis,  as  well  as  in  the  irritability  of  the  fauces  and 
root  of  the  tongue  in  different  individuals.  In  some  persons  the  epiglottis 
is  easily  exposed,  and  on  depression  of  the  tongue  may  be  seen  standing 
erect,  quite  inseuvsible  as  stated  by  Dr.  Green,  so  as  easily  to  permit  the 
passage  of  the  catheter.  In  other  cases,  the  top  of  the  epiglottis  can  only 
be  reached  with  the  greatest  difficulty,  and  in  several  is  not  to  be  seen  at 
all.  In  such  cases  I have  not  as  yet  attempted  to  pass  the  catheter. 
Again,  while  some  individuals  can  bear  without  difficulty  forcible  depres- 
sion of  the  tongue,  and  considerable  freedom  in  touching  the  fauces  and 
rima  glottidis,  others  are  thrown  easily  into  violent  spasms,  or  exhibit 
great  irritation  in  the  parts,  from  the  mere  pressure  of  the  spatula.  This 
appears  to  me  to  be  more  constitutional  than  dependent  on  local  disease  ; 
some  persons  being  more  irritable  or  easily  excited  than  others,  and  I 
have  observed  the  same  difference  in  individuals  who  are  in  all  respects 
perfectly  well.  On  one  occasion  I put  the  sponge  through  the  rima,  and 
allowed  it  to  remain  some  seconds,  completely  obstructing  respiration, 
but  without  causing  cough  or  any  other  inconvenience.  In  the  case  of 
Dawson  (Case  CXXXVIIL),  very  trifling  irritation  was  occasioned  by 
the  pressure  of  the  catheter.  Whenever  great  irritability  exists,  the 
operation  ought  not  to  be  performed. 

One  phthisical  gentleman  who,  with  a desire  to  have  the  operation  com- 
pleted, violently  restrained  all  efforts  to  cough  when  I was  in  the  act  of 
injecting  the  solution,  experienced  great  pain  in  the  chest  for  several  days. 

PLEURITIS. 

Case  C XXXIX.* — Acute  Pleurisy — Recovery. 

History. — Mary  Harvey,  set.  21,  a robust  servant  girl,  was  admitted  into  the 
clinical  ward,  July  23,  1851.  She  enjoyed  good  health  until  seven  days  ago,  when, 
after  unusual  exposure  to  cold  and  wet,  whilst  washing  clothes,  she  was  seized  with 
difficulty  of  breathing,  and  a sharp  cutting  pain  in  the  right  side.  She  shortly 
afterwards  experienced  headache,  general  soreness,  and  the  usual  symptoms  of  fever 

* Reported  by  Mr.  C.  D.  F.  Phillips,  Clinical  Clerk. 


PLEURITIS. 


661 


but  does  not  remember  having  had  rigors.  The  dyspnoea  and  local  pain  have  increased 
in  intensity,  although  the  febrile  symptoms  on  admission  had  somewhat  abated. 

• Symptoms  on  Admission. — On  percussing  the  right  lung  anteriorly,  there  is  com- 
plete dulness  over  its  lower  half,  and,  posteriorly,  the  dulness  extends  over  the  two 
lower  thirds  of  the  lung.  On  the  left  side,  the  lung  is  everywhere  resonant  on  per- 
cussion. On  listening  over  the  dull  portion  of  right  side,  there  is  complete  absence 
of  respiration,  with  loud  pealing  vocal  resonance.  In  the  centre  of  lung  posteriorly 
mgophony.  No  friction  or  crepitating  murmur  can  be  distinguished.  On  the  left  side, 
respiration  is  puerile.  Slight  cough,  but  no  expectoration ; dyspnoea,  but  not  urgent ; 
sharp  cutting  pain  in  right  side,  increased  on  taking  a deep  inspiration.  Considerable 
headache  and  general  soreness;  the  skin  of  natural  temperature,  but  dry.  Pulse  100, 
of  natui-al  strengtli ; tongue  furred  ; face  flushed ; no  appetite ; great  thirst ; func- 
tions of  the  body  otherwise  well  performed. 

Progress  op  the  Case. — On  the  following  day  the  dyspnoea  and  pain  had 
diminished.  On  the  morning  of  the  25th  there  was  considerable  sweating,  and  next 
day  a copious  sediment  of  phosphates  and  lithates  appeared  in  the  urine,  and  it  was 
observed  that  the  febrile  symptoms  had  disappeared.  The  pulse  was  84,  soft.  On 
auscultation,  a friction  murmur  could  be  heard  at  the  upper  margin  of  the  dulness  on 
the  right  side.  On  the  3d  of  August  the  pulse  was  72,  and  weak.  The  pain  still  con- 
tinued, and  the  physical  signs  were  the  same.  On  the  6th,  the  extent  of  the  dulness, 
the  aegophony,  and  the  vocal  resonance,  began  to  diminish,  and  the  friction  murmur 
to  increase.  On  the  9th  no  friction  could  be  heard,  and  the  respiratory  murmurs  were 
audible  in  the  primary  dull  portion  of  lung.  On  the  27th,  with  the  exception  of 
slight  dulness,  she  was  quite  well,  and  was  dismissed  by  her  own  desire.  On  admis- 
sion, twelve  leeches  were  applied  to  the  affected  side,  followed  by  warm  fomentations. 
Two  purgative  pills  were  administered,  and  a third  of  a grain  of  tartrate  of  antimony, 
with  3 ss  of  solution  of  muriate  of  morphia,  ordered  to  be  taken  every  four  hours. 
Subsequently  a succession  of  blisters  was  applied  to  the  right  side.  On  the  3d  of 
August  she  was  ordered  a pill  of  calomel  and  opium  three  times  a day.  All  the  six 
prescribed  were  not  taken,  and  no  physiological  action  of  the  drug  resulted. 

Commentary. — This  was  a case  of  uncomplicated  acute  pleuritis,  with 
all  the  characteristic  symptoms  and  signs,  as  described  by  systematic 
authors.  The  fever  terminated  by  crisis  through  the  skin  and  kidneys 
on  the  tenth  day.  The  physical  signs  commenced  to  disappear  on  the 
seventeenth  day,  but  had  not  wholly  vanished  until  the  thirty-fifth  day. 
On  admission,  there  must  have  been  a considerable  amount  of  ex- 
udation, with  serum  subsequently  separated  from  it  compressing  the 
lung,  so  as  to  destroy  the  respiratory  murmurs  inferiorly.  At  the  upper 
margin  of  the  dulness,  however,  aegophony  was  heard,  a sign  as  often 
absent  as  present  in  pleurisy,  and  certainly  not  deserving  the  importance 
which  Laennec  attached  to  it.  The  diminished  action  in  the  compressed 
lung  was  evidently  counterbalanced  by  increased  action  in  other  portions 
of  the  pulmonary  organs,  as  determined  by  the  puerile  respiration  on 
the  opposite  side.  Lastly,  it  was  very  instructive  to  observe  how,  as  the 
fluid  became  absorbed,  and  the  pleural  surfaces  were  thereby  allowed  to 
come  into  contact,  friction  sounds  were  developed,  and  then  ultimately 
disappeared,  when  union  between  these  surfaces  may  be  supposed  to  have 
taken  place.  The  treatment  slightly  diminished  the  pain  in  the  side, 
but  in  other  respects  evidently  had  no  effect  whatever  on  the  progress  of 
the  disease. 

Case  CXL.^ — Acute  Pleurisy  loithout  Functional  Symptoms — Rapid 

Recovery. 

History. — Peter  M‘Guire,  aged  21,  laborer — admitted  September  12th,  1866. 
(States  that  in  June  last  he  was  seized  with  pain  in  right  side,  hot  skin,  and  slight 

* Reported  by  Mr.  A.  Turnbull,  Clinical  Clerk. 


662 


DISEASES  OF  THE  RESPIEATOEY  STSTEil. 


fever,  for  which  he  was  bled,  blistered,  and  confined  to  bed  for  a fortnight.  He  per- 
fectly recovered,  but  for  the  last  five  weeks  he  had  been  unable  to  carry  on  his  usual 
employment,  in  consequence  of  pains  in  his  right  shoulder,  arm,  and  side.  On  Tues- 
day last  (tlie  9th),  these  pains  were  unusually  severe,  accompanied,  as  he  says,  by 
dyspnoea,  thirst,  and  heat  of  skin.  On  the  following  day  (10th),  although  not  confined 
to  bed,  he  could  not  go  to  his  work ; and  finding  no  improvement  take  place,  he  came 
to  the  hospital. 

Symptoms  on  Admission. — Percussion  note  over  whole  of  the  left  side  of  thorax 
is  resonant.  Respiration  is  somewhat  puerile.  On  the  right  side  the  lung  is  every- 
where resonant  on  percussion,  except  posteriorly,  where  there  is  slight  dulness  below 
the  level  of  the  angle  of  the  scapula,  and  laterally,  below  the  level  of  the  sixth  rib.  On 
auscultation  over  the  dull  portion,  respiration  is  faint,  but  there  is  no  friction  or  crepi- 
tation to  be  heard.  At  the  apex  the  respiration  is  harsh,  and  the  vocal  resonance  is 
louder  than  on  the  other  side.  At  the  base  near  the  spine  there  is  an  approach  to 
mgophony.  Cough  slight,  attended  by  little  pain.  Expectoration  scanty  and  frothy. 
No  pain  in  right  side,  nor  uneasiness  in  taking  a deep  inspiration.  Circulatory  system 
normal,  with  the  exception  of  the  pulse,  which  is  96,  full.  Bowels  constipated.  Ap- 
petite bad.  Considerable  thirst.  Urine  clear;  does  not  coagulate  on  being  heated, 
nor  on  the  addition  of  nitric  acid.  Chlorides  abundant.  R Pulv.  Ipecac.  Co.  gr.  xii 
to  be  taken  at  bed-time. 

Proorkss  of  the  Case. — September  l-ith. — Has  not  perspired  much  during  the 
night.  Complains  of  slight  palpitation,  but  has  no  pain  of  any  kind.  Heart’s 
sounds  normal.  On  percussion  over  the  right  side  of  chest,  the  line  of  dulness,  which 
in  the  recumbent  position  is  at  the  fifth  intercostal  space,  rises  as  high  as  the  third 
when  he  sits  up  in  bed.  lUh. — Line  of  dulness  now  extends  up  to  the  second  rib 

anteriorly,  and  is  the  same  in  all  positions.  Vocal  resonance  above  the  right  nip- 
ple is  loud,  but  breathing  faint.  At  the  apex,  the  expiration  harsh  and  very  much 
prolonged.  Was  ordered  one-twelfth  of  a grain  of  antimony  every  four  hours.  Had 
a blister  applied  last  nighty  which  has  risen  well.  Sept.  ikth. — ^No  pain  in  the  side 
even  on  a deep  inspiration.  Has  no  fever ; appetite  good  ; expresses  himself  as  much 
better.  Pulse  100,  small  and  weak.  Dulness  has  become  universal  over  the  right 
side  posteriorly,  and  anteriorly  ascends  to  the  second  rib,  above  which  a cracked- 
pot  sound  is  audible.  There  is  now  no  difference  on  percussion,  when  in  the  upright 
and  when  in  the  recumbent  position.  Respiratory  murmurs  posteriorly  are  feeble  and 
distant,  not  healthy ; aegophony  well  marked.  On  the  left  side  posteriorly,  expiration 
is  puerile.  Anteriorly  on  right  side,  respiration  exaggerated  superiorly,  feeble  in- 
feriorly,  and  vocal  resonance  increased.  No  friction  murmur  anywhere  audible.  Sept. 
ISth. — Dulness  has  extended  higher.  Cracked-pot  sound  more  limited,  but  increased 
in  intensity  under  the  clavicle.  Posteriorly  an  occasional  fr  iction  sound  was  detected  ; 
ordered  to  have  this  part  painted  with  iodine.  Sept.  \9th. — Dulness  now  clearly 
limited  by  a line,  the  convexity  of  which  is  downwards,  its  greatest  distance  being 
from  the  clavicle  one  and  a quarter  inch,  and  its  smallest  distance  one  quarter  of  an 
inch.  Sej)t.  IsiJ. — Cracked-pot  sound — now  limited  to  a spot  below  the  sterno- 
clavicular articulation — is  not  so  audible.  Complains  of  dyspnoea  when  walking. 
Sept.  ^ad. — Cracked-pot  sound  replaced  by  a somewhat  metallic  sound.  Patient 
feels  so  much  better,  that  he  is  anxious  to  leave  the  hospital  to  resume  his  labors. 
23(/. — Very  little  expansion  of  right  side  of  chest  even  on  deep  inspiration.  A warm 
poultice  to  be  applied  over  the  whole  right  side  of  chest.  26^/i. — Patient  complains 
that  after  walking  quickly  he  experienced  dyspnoea.  Hot  spongio-piline  to  be  ap- 
plied to  foment  the  whole  side.  Patient  takes  three  ounces  of  wine  daily.  21th. — 
The  convex  line  of  dulness  anteriorly,  which  has  for  seven  days  been  stationary  at 
the  line  mentioned  on  the  19th,  has  now  become  lower,  and  not  so  clearly  defined. 
No  cough  nor  expectoration.  Pulse  80  per  minute,  rather  feeble.  Appetite  pretty 
good.  Fomentations  and  wine  continued.  October  2d. — Resonance  in  front,  and 
internal  to  the  nipple,  extends  as  far  down  as  sixth  intercostal  space.  Dulness  to 
the  right  of  the  nipple  still  remains.  The  resonant  portion  at  the  anterior  and 
upper  part  of  right  side  may  be  bounded  by  a line  drawn  from  the  upper  part  of 
the  axillary  region  to  the  nipple.  Pulse  gradually  gaining  strength.  4th. — The  an- 
terior portion  of  right  side  has  almost  entirely  regained  its  normal  resonance. 
Lateral  region  of  same  side  is  also  more  clear  on  percussion.  Anteriorly  and  laterally 
over  fourth  and  fifth  ribs,  and  posteriorly  to  a lesser  degree,  there  is  heard  friction  de 
retour.  The  palpitation  has  again  returned,  and  on  auscultation,  a very  soft  murmur 
is  heard  with  the  first  sound.  13^/t. — Percussion  perfect  over  the  whole  of  anterior 


PLETJRITIS. 


663 


surface  of  right  side  of  thorax  ; still  a little  clulness  posteriorly.  Friction  d(.  retour  is 
only  slightly  marked  during  ordinary  respiration,  \%th. — Both  sides  of  chest  expand 
equally  on  deep  inspiration.  Anteriorly  over  both  sides  of  chest,  resonance  equal. 
Laterally,  external  to  nipple  of  right  side,  there  is  marked  sense  of  resistance  and 
slight  diminution  of  tone  on  percussion  when  compared  with  opposite  side.  Poste^ 
riorly  over  whole  of  right  side,  percussion  duller  than  over  left,  but  still  resonance  is 
greatly  increased  to  what  previously  existed.  On  auscultation  posteriorly,  respiratory 
murmurs  equal  on  both  sides ; no  friction  anywhere  but  on  right  side  ; vocal  reso- 
nance increased,  especially  laterally  below  the  axilla.  His  general  health  has  long 
been  quite  good,  and  he  insisted  on  going  out.  Dismissed. 

Commentary. — Od  the  admission  of  this  man,  it  was  supposed,  and 
I still  think  correctly,  that  the  comparative  dulness  which  existed  on 
percussion  over  the  right  back  depended  on  the  pleurisy  he  had  had  in 
the  previous  June,  and  that  the  wandering  pains  and  slight  fever  were 
owing  to  rheumatism.  Two  days  afterwards,  fresh  exudation  was  evi- 
dently poured  into  the  right  pleural  cavity,  and  it  is  a remarkable  fact 
that  it  continued  to  increase  until  the  whole  of  that  cavity  was  occupied, 
and  this  without  fever,  pain  in  the  side,  or  any  of  those  symptoms  which 
are  thought  the  usual  indications  of  acute  pleurisy.  In  this  state  the 
exudation  remained  stationary  for  seven  days,  then  began  to  be  absorbed, 
and  gradually  disappeared.  In  short,  we  had  the  most  distinct  evidence 
from  physical  signs  of  the  commencement,  onward  progress,  and  decline 
of  an  acute  pleurisy,  without  any  functional  symptoms  whatever,  the  man 
all  the  time  maintaining  he  was  in  perfect  health,  and  being  with  great 
difficulty  retained  in  the  house  for  the  sake  of  observation.  In  this 
respect,  the  case  proves  that  an  acute  pleurisy,  like  an  acute  pericarditis 
(Case  C.),  may  be  altogether  latent,  and  at  no  period  of  its  progress  give 
rise  to  those  symptoms  with  which  systematic  writers  have  made  us  so 
familiar.  For  another  remarkable  example  of  this  fact,  see  Case 
CXXVII.  It  is  unnecessary  to  comment  in  this  place  on  the  importance 
of  such  cases  in  reference  to  treatment,  and  to  former  views  as  to  the 
good  effects  of  blood-letting  and  antiphlogistic  remedies.  In  the  case 
of  Stanbroke  (Case  XCVII.),  we  saw  that  a pericarditis  required  no  such 
remedies  to  enable  it  to  pass  through  its  natural  progress,  and  we  have 
here  another  illustration  of  the  same  fact  in  reference  to  pleuritis.  Local 
pain  appears  to  be  an  accidental  occurrence,  and  in  no  way  essential  to  a 
true  inflammation. 

Case  CXLI.'^ — Chronic  Pleurisy  on  both  sides — Bronchitis. 

History. — John  O’Neill,  set.  40,  a writer — admitted  into  the  clinical  ward 
November  28th,  1850.  Three  weeks  before  admission,  he  was  suddenly  seized  with  a 
severe  pain  in  his  left  side,  which  impeded  breathing.  Three  days  afterwards  feeling 
better,  he  returned  to  his  employment,  but  in  the  evening  he  experienced  distinct 
rigors,  and  the  pain  returned.  Strong  febrile  symptoms  followed,  with  cough  and 
expectoration.  He  has  been  under  medical  treatment  since  then,  and  now,  on  admis- 
sion, is  considerably  better. 

Symptoms  on  Admission. — On  percussion,  there  is  complete  dulness  over  the 
whole  of  left  side,  anteriorly  and  posteriorly,  with  the  exception  of  the  infraclavicular 
region,  where  the  dulness  is  incomplete.  Over  the  whole  of  right  side  there  is  unusual 
resonance.  The  expansion  of  the  chest  is  greatly  diminished  on  the  left  side  with 
absence  of  vocal  fremitus.  On  auscultation,  the  respiratory  murmurs  are  inaudible 
over  left  side,  except  at  the  apex,  where  there  is  prolonged  expiration  accompanied 
with  sibilant  rale.  On  the  right  side  anteriorly,  loud  sibilant  rales,  both  with  inspira- 
tion and  expiration.  Posteriorly  the  respiratory  murmurs  are  puerile.  Increased 
vocal  resonance,  amounting  to  bronchophony,  heard  over  whole  of  left  side,  assuming 


* Keported  by  Messrs.  Cunningham  and  Calder,  Clinical  Clerks. 


664 


DISEASES  OF  THE  KESPIRATOET  SYSTEM. 


an  00gophonic  character  over  scapular  region.  On  right  side  vocal  resonaace  normal. 
Frequent  and  severe  cough,  followed  by  copious  expectoration  of  frothy  mucus.  No 
pain  in  chest  on  taking  a deep  inspiration,  but  occasional  “stitches  ” in  left  side.  No 
dyspnoea.  The  apex  of  heart  beats  in  the  epigastrium,  immediately  below  ensiform 
cartilage,  and  its  sounds  (which  are  healthy  in  character)  are  heard  most  distinctly  on 
right  side  of  sternum  interiorly.  Pulse  68,  small.  Urine  turbid,  with  deposit  of 
lithates.  Appetite  good.  Other  symptoms  normal. 

Progress  op  the  Case. — On  the  ^th  of  December  a.  frietion  sound  was  heard  below 
the  left  clavicle,  and  the  resonance  on  percussion  was  more  diffused.  On  the  26^A,  loud 
friction  sounds  had  extended  from  above  on  the  left  side  down  to  an  inch  below  the 
nipple,  and  dulness  on  percussion  was  confined  to  the  two  lower  thirds  of  the  lung. 
The  bronchitis,  also,  was  diminished,  and  on  the  l^th  of  January  the  cough  and  ex- 
pectoration had  ceased,  and  the  bronchitic  rales  had  disappeared.  On  the  23(i  of 
February  a eareful  examination  showed  that  there  was  complete  dulness  over  left  lung, 
from  the  nipple  downwards,  and  that  on  auscultation  there  were  loud  double-frietion 
sounds  with  absence  of  respiration.  He  now  complained  of  dull  pain  on  the  right  side 
of  chest  inferiorly,  and  on  the  following  day  there  was  heard  in  that  situation  a double- 
friction sound,  which,  however,  disappeared  on  the  ^th  of  March.  It  returned  every 
now  and  then,  accompanied  by  “ stitches  ” more  or  less  severe.  On  the  of  April 
there  was  dulness  over  both  sides  of  chest,  anteriorly  from  the  nipple  downwards,  to- 
gether with  double-friction  sounds  on  both  sides.  The  expansion  of  both  sides  of  chest 
is  now  equal — that  on  the  left  side  having  greatly  inereased,  and  the  respiration  being 
audible  over  its  two  superior  thirds.  During  the  whole  of  April  the  physical  signs 
underwent  no  change,  and  he  suffered  considerably  from  dyspnoea.  In  May  the  dul- 
ness was  more  circumscribed  on  the  left,  and  more  extended  on  the  right  side.  The 
dyspnoea,  however,  was  diminished,  and  his  general  health  so  improved  that  he  was 
enabled  to  take  walks  in  the  green.  During  the  months  of  June  and*  July  he  continued 
to  improve,  but  complained  of  occasional  pain  in  the  chest,  and  cough,  Avith  slight  ex- 
pectoration, originating  apparently  from  imprudent  exposure  to  cold.  The  respiration, 
however,  insensibly  extemled  itself  inferiorly  on  the  left  side,  and  towards  the  end  of 
July  tlie  dulness  was  greatly  diminished  on  the  right  side  also.  At  this  time  he  was  so 
well  that  he  was  dismissed,  August  4.  The  treatment  consisted  at  first  of  expectorants 
and  anodynes  to  mitigate  the  bronchitis,  together  with  a course  of  the  iodide  of  potassium, 
and  frequent  blisters  applied  to  the  pleuritic  side.  In  February.^  pills  of  calomel  and 
opium  were  ordered,  which  caused  slight  salivation  for  a period  of  ten  days.  On  the 
appearance  of  pleurisy  on  the  right  side,  it  was  combated  by  frequent  applications  of 
leeches,  followed  by  counter- irritation.  The  latter  remedy  was  continued  from  time  to 
time  during  his  subsequent  residence  in  the  house,  together  with  occasional  expectorants, 
anodynes,  anti-spasmodics,  and  purgatives,  according  as  his  symptoms  required  them. 

Commentary. — In  this  case  the  disease  ran  a more  chronic  course, 
beginning  on  the  left  side,  and  subsequently  attacking  the  right.  As  the 
one  declined,  the  other  increased,  and  in  both  the  physical  signs  deter- 
mined with  great  exactitude  the  extent  of  the  fluid  exudation,  its  subse- 
quent absorption,  the  rubbing  of  the  diseased  surfaces  against  each  other, 
and,  lastly,  their  subsequent  adhesion.  These  changes  occupied  a period 
of  upwards  of  eight  months.  Seeing  the  slow  progress  of  the  case,  and 
the  indisposition  of  the  exudation  exhibited  to  be  absorbed,  mercury  was 
tried,  and  salivation  maintained  for  ten  days.  At  this  time,  such  was 
the  state  of  discomfort  it  produced,  so  thoroughly  did  it  destroy  the 
appetite  and  thereby  diminish  the  vital  powers,  that  it  was  discontinued. 
So  far  from  causing  absorption,  the  action  of  the  drug  not  only  failed  to 
do  so,  but  pleurisy  on  the  opposite  side  actually  developed  itself  while 
the  system  was  under  its  influence.  Surely  facts  of  this  kind  ought  to 
disabuse  medical  men  of  the  notion,  still  very  prevalent,  of  the  power  of 
this  drug  in  causing  absorption  of  an  exudation.  (See  Pericarditis.) 

Pathology.,  Diagnosis,  and  Treatment  of  Pleuritis. 

The  physical  signs  of  pleurisy  can  scarcely  be  understood  without  an 
accurate  acquaintance  with  the  appearances  which  the  exudation  assumes 


PLEURTTIS. 


665 


on  the  pleural  surface.  This  is  essentially  the  same  as  has  been  previ- 
ously described  in  the  case  of  Pericarditis,  pp.  .174  and  175. 

In  very  acute  cases  of  pleuritis,  which  have  proved  rapidly  fatal,  I 
have  repeatedly  observed  the  following  appearances ; — On  elevating  the 
sternum,  care  having  been  taken  not  to  disturb  the  body  for  some  hours, 
the  pleural  cavity  on  the  side  affected  has  been  found  full  of  an  appar- 
ently clear  fluid  of  a yellowish  or  greenish  tint.  On  removing  this  by 
means  of  a small  shallow  cup,  the  first  portions  seem  perfectly  clear  and 
transparent.  On  continuing  to  empty  out  the  fluid,  it  has  been  ob- 
served that  the  deeper  we  descend  the  more  turbid  it  becomes,  until  at 
length  nothing  but  a semifluid  mass  is  removed.  It  will  frequently  be 
found  that  large  portions  of  this  mass,  although  tolerably  consistent,  are 
semi-transparent,  resembling  a light-colored  calf’s-foot  jelly,  whilst  other 
portions  present  the  usual  opaque  appearance.  Sometimes,  when  the 
body  has  been  undisturbed  for  twenty-four  hours,  the  whole  exudation 
is  separated  into  two  distinct  portions, — the  upper,  fluid  and  perfectly 
transparent,  whilst  the  lower  is  composed  of  a pultaceous  mass,  re- 
sembling a bread-and-water  or  oatmeal  poultice.  In  all  such  cases,  the 
fibrinous  portions,  from  their  superior  specific  gravity,  have  sunk  to 
the  bottom,  whilst  the  supernatant  serum  remains  clear.  The  semi- 
transparent lymph  is  the  portion  most  recently  exuded,  in  which  very 
few  of  the  plastic  corpuscles  formerly  described,  p.  165  have  been 
developed. 

When  the  progress  of  the  exudation  is  less  rapid,  the  coagulated 
fibrin  or  lymph  assumes  a more  consistent  appearance,  and  forms,  over 
the  part  inflamed,  flocculi  of  different  sizes,  or  a distinct  lining,  varying 
in  thickness  from  half  a line  to  an  inch.  This  is  always  villous,  but 
sometimes  it  presents  a honey-combed  appearance,  or  hangs  in  the  serum 
in  loose  flakes  of  a dendritic  character.  A serous  membrane,  when  in- 
flamed, resembles  a mucous  surface,  and,  in  point  of  fact,  performs  the 
functions  of  or.e  for  a time,  and  is  very  active  in  absorbing  the  serum. 
Occasionally  also  it  assumes  a lamellar  arrangement,  attributable  prob- 
ably to  repeated  exudations  of  blood-plasma  at  different  times.  This 
may  be  frequently  observed  on  the  pleura,  and  layer  after  layer  may  be 
readily  dissected  off.  Sometimes  there  is  more  or  less  blood  extravasated 
with  exudation,  causing  it  to  assume  various  tints  of  red,  mahogany, 
purple,  etc.,  according  to  the  amount  thrown  out,  and  the  period  which 
has  elapsed  before  examination. 

When  the  inflammation  has  been  less  acute,  or  is  of  longer  standing, 
we  find,  after  death,  that  the  coagulated  blood-plasma  or  lymph  has 
become  more  consistent.  It  assumes  a more  distinctly  fibrous  appear- 
ance, often  extending  between  opposed  serous  surfaces  in  the  form  of 
bands,  which  have  considerable  tenacity  and  strength.  These  bands 
have  a great  disposition  to  contract,  and  ultimately  become  shorter  and 
shorter,  and  assist  in  forming  a dense  substance,  which  at  length  firmly 
unites  together  the  serous  surfaces.  This  uniting  substance  becomes 
more  and  more  dense,  and  not  unfrequently  resembles  ligament  in 
toughness  and  general  aspect.  In  this  form  it  may  frequently  be  seen 
in  phthisical  cases,  uniting  together  the  lobes  of  the  lung  and  pleura] 
surfaces.  Occasionally  it  assumes  even  a cartilaginous  hardness,  resem 


666 


DISEASES  OF  THE  KESPIKATOET  SYSTEM. 


bling  the  fibro-cartilage  of  the  intervertebral  substance.  In  this  state  it 
may  frequently  be  observed  on  the  pleurae,  and  I have  seen  it  thus  half 
an  inch  thick,  intimately  uniting  the  lungs  to  the  ribs.  When  it  has 
been  very  slowly  developed,  it  produces  white  indurated  patches,  of  a 
glistening  cartilaginous  appearance,  varying  in  extent,  the  surface  of 

which  has  assumed  the  character  of 
a serous  membrane,  and  in  no  way 
interferes  with  the  movements  of 
neighboring  organs.  Such  patches 
are  exceedingly  common  on  the  sur- 
face of  parenchymatous  organs,  as 
the  lungs,  heart,  liver,  spleen,  and 
kidneys.  Occasionally  encysted  ab- 
scesses of  the  pleura  are  resolved, 
and  their  walls  contracting  assume 
a cartilaginous  hardness.  Dr,  Mark- 
ham has  recorded  a remarkable  ex- 
ample where  the  pyogenic  walls  in 
this  manner  formed  a tube  sur- 
rounded by  puckering  of  the  pleura 
pulrnonalis,  the  lung  itself  being 
quite  healthy.*  (Fig.  450).  The 
hardish  gritty  particles  scraped 
from  its  roughened  inner  surface 
consisted  chiefly  of  cholesterine  and 
granular  matter.  Lastly,  false  mem- 
branes on  the  pleural  surfaces,  but 
Fig.  450.  especially  on  the  costal  one,  may 

assume  a stony  hardness,  from  the  deposition  of  calcareous  matter ; and 
patches  of  this  character  may  be  scattered  over  the  serous  membrane,  or 
may  exist  in  disseminated  points. 

The  minute  structure  ot  the  coagulated  exudation,  composed  of  plas- 
tic or  pyoid  corpuscles  and  molecular  fibres,  has  been  previously  de- 
scribed and  figured,  p.  165.  These  fibres  are  more  and  more  aggregated 
together  the  more  dense  the  lymph  becomes,  and,  in  cases  of  calcareous 
deposition,  are  associated  with  molecules  and  irregular  masses  of  earthy 
salts,  mingled  with  crystals  of  cholesterine,  and,  it  may  be,  numerous 
fatty  molecules  and  granules. 

It  results  from  our  knowledge  of  the  morbid  anatomy  of  pleuritis, 
conjoined  with  careful  observation  at  the  bedside,  that,  if  a large  quantity 
of  fluid  be  interposed  between  the  pleurae,  the  respiratory  murmurs  will 
be  lost,  while  the  vocal  resonance  is  diminished.  If  the  amount  of  fluid 
be  small,  the  murmurs  are  obscure,  and  the  vocal  resonance  assumes  a 
peculiar  vibrating  character,  said  to  resemble  the  bleating  of  a goat. 
This  is  cegophony.  If  strings  or  bands  of  chronic  lymph  exist,  which  are 
stretched  during  the  movements  of  the  chest,  then  the  rubbing  sound 
will  assume  a leathery  or  creaking  character ; and  if  there  be  calcareous 
deposition,  a filing  or  grating  noise  may  be  produced,  although  this  is 

^ Patholog.  Soc.  Trans.,  vol.  ix.  p.  61. 


Fig.  450.  Remains  of  a pleural  abscess. — {Markham), 


PLEUEITIS. 


6G7 


very  rarely  heard  over  the  pleurae.  Not  unfrequently  dense  adhesions, 
with  thickening  of  the  fibrous  tissues  uniting  the  pleurae,  may  occasion 
partial  dulness,  and  increase  of  the  vocal  resonance,  a result  not  uncom- 
mon at  the  apices  of  the  lung,  but  which  must  be  carefully  distinguished 
from  the  condensation  from  tubercle. 

With  regard  to  the  treatment,  it  is  essentially  the  same  as  that  of 
other  acute  infiammations.  It  is  rare  that  a case  enters  an  hospital  in 
its  incipient  stage,  that  is,  when  the  serous  membrane  is  unusually  dry, 
and  before  much  exudation  has  occurred.  But  in  private  practice  such 
cases  are  more  common,  and  occasionally  they  may  come  on  in  the  ward 
of  an  hospital.  At  this  early  period,  a general  bleeding  was  formerly 
recommended,  with  a view  of  cutting  short  the  inflammation,  the 
possibility  of  which  we  have  discussed  at  p.  306.  When,  however, 
exudation  has  been  poured  out  to  any  extent,  and  has  coagulated, 
bleeding  is  injurious,  and  we  must  endeavor  to  favor  the  development, 
absorption,  and  excretion  of  the  exudation,  by  means  of  warm,  topical 
applications,  sudorifics,  and  diuretics.  The  urine  especially  should  be 
carefull}"  watched,  as  the  sediments  it  contains  will  serve  as  an  index 
to  the  amount  of  exuded  matter  excreted.  Care  should  also  be  taken, 
at  this  period,  not  to  allow  the  general  strength  to  sink,  for  it  is  only 
by  keeping  up  the  nutritive  functions  that  we  can  assist  the  vital 
powers  in  making  those  transformations  which  are  essential  in  procuring 
the  disappearance  of  the  fluid,  and  adhesion  of  the  solid  exudation. 
By  some,  calomel  is  considered  to  be  directly  indicated  as  a means  of 
favoring  absorption  from  the  serous  cavity.  It  was  fairly  tried  in  Case 
CXLI.,  but  was  more  productive  of  harm  than  of  good;  and  although  I 
have  frequently  seen  the  drug  employed  for  this  purpose,  I have  not 
met  with  a single  instance  where  its  good  effects  have  been  unequivocal. 
If  there  be  much  local  pain,  warm  applications  at  first,  and  subsequently 
blisters,  tend  to  remove  it. 

On  some  occasions,  when  the  exudation  has  been  very  abundant  in 
the  pleural  cavity,  and  the  vital  powers  of  the  economy  are  constitution- 
ally low,  and  have  been  depressed  by  injudicious  antiphlogistic  treatment 
or  want  of  rest,  the  changes  described  do  not  occur.  The  exudation,  in 
such  cases,  passes  into  pus,  although  some  of  the  fibrous  element  attaches 
itself  to  and  lines  the  membrane.  This  termination  of  pleuritis  is 
denominated  empyema. 

Case  CXLII."^' — Empyema.,  with  Fistulous  Openings  between  the  Lung 

and  Pleural  Cavity.,  and  between  the  Pleural  Cavity  and  External 

Surface. 

History. — George  Fair,  set.  30,  a ploughman — admitted  December  10th,  1850,  in 
a very  exhausted  state.  Fourteen  months  ago  had  acute  pleuritis,  on  account  of 
which  he  was  confined  to  bed  for  eight  weeks,  and  was  bled  several  times.  Three 
months  afterwards  he  still  felt  occasional  pain  in  the  right  side,  which  gradually 
became  more  constant  and  severe,  and  at  length  was  accompanied  by  cough  and  ex- 
pectoration. He  now  perceived  a small  swelling  below  the  right  nipple,  which,  at  the 
end  of  last  July,  was  the  size  of  a hen’s  egg.  It  was  then  opened  by  incision,  and  a 
quart  of  purulent  matter  extracted.  About  the  end  of  August,  two  other  apertures 
formed  spontaneously  in  the  neighborhood  of  the  previous  one.  As  soon  as  matter 

^ Keported  by  Mr.  J.  M.  Cunningham,  Clinical  Clerk. 


6G8 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


was  discharged  from  the  external  opening,  the  amount  of  expectoration  was  di 
minished. 

Sympi'Oms  on  Admission. — Thoracic  walls  much  depressed  under  right  clavicle  ; 
right  side  of  chest  motionless  on  taking  a full  inspiration  ; three  apertures  still  exist 
in  the  thoracic  walls  ; the  upper  one  (that  made  by  the  incision)  is  between  the  sixth 
and  seventh  ribs,  immediately  below  the  right  nipple,  the  two  others  a little  lower 
down,  and  somewhat  smaller ; from  all  three  there  is  a copious  purulent  discharge. 
Circumfereuce  of  the  thorax,  on  a level  with  the  right  nipple,  measures  thirty-five 
inches  ; from  the  spinous  processes  of  the  vertebrae  to  the  sternum,  on  the  right  side, 
measures  sixteen  and  a half  inches,  and  on  the  left,  nineteen  inches.  On  percussion, 
the  left  side  is  resonant  throughout  ; on  the  right  side  there  is  a dulness  everywhere, 
but  most  marked  in  the  inferior  two-thirds  ; posteriorly,  the  dulness  is  not  so  marked 
as  in  front.  On  auscultation,  the  respiratory  murmurs  on  the  left  side  are  puerile ; 
under  the  right  clavicle  the  respiratory  murmurs  are  harsh,  and  the  vocal  resonance 
increased ; a little  lower  down  the  respiratory  murmurs  become  more  feeble,  and 
there  is  crepitation  with  the  inspiration  ; in  the  remaining  lower  two-thirds  of  the 
right  front,  the  respiratory  sounds  are  inaudible ; over  the  whole  right  back,  the 
respiratory  murmurs  are  feeble  ; the  vocal  resonance  increased  and  segophonic ; in  the 
lower  third  crepitation  is  audible.  Pain  over  the  sternum  and  under  right . clavicle  ; 
cough  neither  frequent  nor  severe  ; expectoration  scanty,  partly  white  and  frothy, 
partly  tenacious  and  muco-purulent.  Apex  of  heart  beats  feebly  half  an  inch  to  the 
left  of  its  natural  position.  Pulse  92,  slightly  jerking,  but  compressible  ; general 
strength  much  reduced. 

Progress  of  the  Case. — In  the  beginning  of  January,  he  was  attacked  with 
vomiting  and  diarrhoea,  accompanied  with  febrile  symptoms,  which  greatly  diminished 
his  strength  ; his  countenance  assumed  a hectic  appearance,  and  the  opening  in  the 
thorax  became  painful  and  larger,  their  margins  were  inflamed  and  ulcei-ating,  and  the 
discharge  continued.  On  the  l^ih,  it  was  ascertained,  by  means  of  the  probe,  that  of 
the  three  openings  the  middle  one  alone  enters  directly  into  the  pleural  cavity,  and  ad- 
mits with  ease  a No.  8 catheter  ; the  other  two  communicate  with  the  central  one 
underneath  the  integument.  On  the  29^/i,  diarrhoea  and  purulent  discharge  from  the 
chest  had  diminished,  his  appetite  and  general  health  were  also  improved,  but  he  was 
removed  from  the  house  by  his  friends.  The  treatment  consisted  at  first  of  good  diet 
and  tonics  ; and  when  the  vomiting  and  diarrhoea  appeared,  various  remedies  to  check 
these  symptoms.  On  the  18/A  of  January,  a small  canulaand  No.  8 catheter  were  in- 
troduced side  by  side  into  the  opening  into  the  pleura.  By  means  of  a Bead’s 
syringe  attached  to  the  former,  about  a pint  and  a half  of  distilled  water,  at  the 
temperature  of  90°,  was  injected  into  the  pleural  cavity.  The  fluid  escaped  through 
the  flexible  catheter,  but  did  not  equal  in  amount  what  was  thrown  in,  and  was  at 
length  discharged  clear  and  unmixed  with  pus.  During  the  half  hour  immediately 
following  the  operation,  a quantity  of  clear  water  oozed  from  the  wound. 

Commentary. — When  this  man  entered  the  house,  his  general 
strength  was  much  reduced  ; and  it  was  apparent,  from  a careful  study 
of  the  physical  signs  and  symptoms,  that  a communication  existed  be- 
tween the  lungs  and  pleural  cavity,  in  addition  to  the  external  fistulous 
opening  into  the  latter.  The  pleuro-pulmonary  fistula  had  evidently 
formed  before  the  opening  through  the  thorax  was  made  artificially,  as 
evinced  by  the  marked  diminution  of  expectoration  on  the  evacuation  of 
pus  externally.  That  it  continued  to  exist,  I was  satisfied,  by  observing 
that  the  sputum  was  increased  when  the  external  discharge  diminished, 
and  vice  versa.  Two  errors  had  been  made  in  the  previous  treatment. 
These  consisted, — 1st,  In  the  “ frequent  bleedings,”  which  had  so  dimin- 
ished the  general  powers  of  the  system,  as  to  have  checked  those  changes 
in  the  exudation  necessary  for  recovery  ; 2d,  In  making  a free  incision, 
instead  of  a small  puncture,  to  draw  olf  the  purulent  matter.  Of  these 
two  errors,  the  first,  however,  was  the  greatest ; indeed  it  was  irremedi- 
able. The  second  was  probably  undertaken  with  the  idea  formerly  so 
prevalent,  that  pus  is  injurious  to  the  economy,  and  wlien  known  to 
exist  should  be  let  out  as  soon  and  as  freely  as  possible.  We  now  know 


PLEURITIS, 


669 


^hat  there  is  nothing  to  be  feared  from  the  mere  presence  of  piis,  either 
in  the  lung  or  pleural  cavity  ; and  that  the  most  natural  method  for  its 
disappearance  is  by  absorption  and  elimination.  Still,  when  large  in 
amount,  and  either  pointing  externally,  or  displacing  the  heart  internally, 
no  danger  can  arise  from  making  a puncture  with  a small  canula,  and 
allowing  the  matter  to  flow  out,  while  we  prevent  air  from  passing  in. 
Indeed  there  is  every  chance  of  producing  benefit,  for  we  thereby  save 
the  vital  powers  a considerable  amount  of  unnecessary  work,  and  so 
facilitate  the  disappearance  of  the  exudation  and  return  of  expansion  in 
the  compressed  lung.  With  regard  to  the  operation  of  paracentesis 
thoracis,  and  the  good  effects  attending  it,  I refer  you  to  some  excel- 
lent papers  by  Dr.  Hughes,*  and  a lecture  by  Dr.  Alison.f  (See  also 
p.  675.) 

In  the  case  before  us,  the  difficulty  experienced  was  to  rally  the 
general  strength,  especially  after  it  had  been  so  much  reduced  by 
diarrhoea,  and  this  was  to  some  extent  accomplished.  My  attention  was 
then  directed  to  the  cure  of  the  thoracic  disease  ; and  it  occurred  to 
me  that  if  the  pus  could  be  replaced  by  water,  there  would  be  less  labor 
thrown  upon  the  weakened  absorbing  surfaces.  The  pleural  cavity, 
therefore,  was  washed  out  with  distilled  water,  heated  to  90°  as  di- 
rected ; and  this  would  have  been  repeated  at  intervals,  had  he  not  left 
the  house,  and  thus  put  an  end  to  every  effort  undertaken  for  his 
benefit. 

Case  CXLIII.lj; — Chronic  Pleuritis  and  Pneumo-Thorax^  without  Symp- 
toms— Articular  Rheumatism — Pericarditis — Recovery. 

History. — William  Dow,  get.  33,  boot, -maker — admitted  26th  of  January,  1857. 
States  that  he  has  always  been  a temperate  man  up  to  his  present  illness,  and  has 
had  pretty  good  health.  On  the  12th  of  last  December,  after  exposure  to  cold  and 
damp  during  the  day,  he  was  seized  with  articular  pains,  which  affected  most  of  the 
joints,  and  have  continued  to  wander  from  one  to  the  other  up  to  the  present  time. 
On  the  evening  of  the  7th  of  January,  independent  of  any  exertion,  the  patient  was 
suddenly  seized  with  acute  pain  in  the  umbilical  region,  attended  with  difficulty  of 
breathing ; these  symptoms  were  at  once  removed  on  taking  a powder,  which  caused 
the  expulsion  of  much  wind.  He  denies  ever  having  had  cough,  pain  in  the  side,  or 
any  pulmonary  symptoms  whatever. 

Symptoms  on  Admission. — On  inspection  of  the  chest,  there  is  less  expansion  on 
the  right  than  on  the  left  side  anteriorly  ; posteriorly,  the  right  side  bulges  consider- 
ably below  the  level  of  the  third  rib  ; the  measurement  of  th  e corresponding  sides 
is  slightly  different ; the  girth  of  the  left  side  being  fifteen  and  a half,  that  of  the 
right  sixteen  inches.  The  movement  of  inspiration  on  the  right  side  is  very  slight  ; 
on  the  left  the  girth  is  increased  half  an  inch  on  a full  inspiration.  Percussion 
note  ever  the  right  side,  anteriorly,  is  tympanitic  from  apex  to  base,  being  flatter  at 
the  apex.  It  likewise  extends  on  a level  with  the  nipple  over  the  left  side  to  about 
half  an  inch  beyond  the  sternum.  On  auscultation,  there  is  a slight  harshness  of  re- 
spiratory murmurs  at  the  apex  of  left  lung,  the  sounds  of  which  are  otherwise  nor- 
mal. On  the  right  side,  the  vesicular  murmur  is  supplanted  by  loud  amphoric 
breathing,  more  distinct  towards  the  base.  Expiration  is  much  prolonged.  In  the 
recumbent  posture,  both  inspiration  and  expiration  are  accompanied  by  a clear  pro- 
longed metallic  note,  exactly  like  the  distant  blast  of  a trumpet,  somewhat  louder 
with  expiration.  Vocal  resonance  over  the  middle  third  is  of  a loud  brazen  metallic 
character.  Posteriorly  on  this  side,  percussion  superiorly  is  tympanitic,  but  below 
second  dorsal  spine,  dulness  commences,  becoming  more  intense  as  it  extends  to  the 


* Guy’s  Hospital  Reports,  vol.  ii.  Second  Series,  f Monthly  Journal,  August  1860 
\ Reported  by  Mr.  T.  J.  Walker,  Clinical  Clerk. 


670 


DISEASES  OF  THE  RESPIRATOEY  SYSTEM. 


base  of  the  lung.  Laterally  its  extent  is  bounded  by  a line  drawn  vertically  fron. 
the  posterior  fold  of  the  axilla.  At  the  apex,  inspiration  is  blowing,  with  prolonged 
expiration,  and  at  the  close  of  inspiration  a moist  click  is  heard.  Towards  the  bass, 
the  respiratory  sounds  are  scarcely  audible,  and  inspiration  is  accompanied  with  an 
obscure  crepitation  (?).  Vocal  resonance  at  apex  and  base  is  aegophonic,  but  over 
the  middle  third  it  is  normal.  No  cough,  expectoration,  dyspnoea,  pain,  or  other  pul- 
monary symptoms.  Impulse  of  heart’s  apex  felt  in  the  usual  position.  Transverse 
dulness  and  sounds  normal.  Pulse  108,  feeble.  Patient  is  somewhat  deaf ; has  still 
pain  in  both  knee  and  ankle  joints,  and  in  the  right  shoulder  and  carpo-phalangeal 
joints.  Tongue  dry  and  furred,  otherwise  normal.  Copious  deposit  of  lithatesin  the 
urine.  He  is  much  emaciated,  and  for  the  last  seven  weeks  has  perspired  very  freely. 
Habeat  Pulv.  Doveri  gr.  xij.  hord  somni  snmenda. 

Progress  of  the  Case. — January  28^7i. — Pain  in  the  joints  is  now  so  much  re- 
lieved, that  he  can  move  the  limbs  with  comparative  freedom.  He  slept  well  last 
night.  Potass.  Nitrat.  ; Potass.  Bicarb,  ail  3 ij  : Aquam  ad  § vj.  31.  Capiat  § ss 
ter  indies.  Jan.  297/i. — On  examining  the  patient  to-day.  Dr.  Bennett  found  that,  while 
lying  on  his  left  side,  percussion  note  was  duller  over  the  sternum  than  when  he  lay 
on  his  back,  and  the  slightly  dull  tone  over  the  right  lateral  region  became  clear. 
When  also  the  patient  is  placed  in  a sitting  or  recumbent  posture,  dulness  extends 
from  the  back  forwards  to  the  centre  of  the  right  lateral  region,  and  upon  being  laid 
on  his  left  side,  the  posterior  part  of  the  lateral  region  becomes  resonant.  Jan.  31s7. 
— Physical  signs  over  right  side  of  chest  continue  as  before.  Apex  of  cardiac  organ 
beats  with  a visible  impulse  somewhat  to  the  inner  side  of  a line,  vertical  from  the 
nipple  between  the  fifth  and  sixth  ribs.  At  the  margin  of  sternum  a double  rumbling 
sound  is  audible,  not  qnite  synchronous  with  the  systolic  or  diastolic  movements. 
Transverse  dulness  of  heart  on  percussion  still  two  inches.  Pulse  100,  small,  rather 
hard.  Respirations  twenty-two.  Feb.  2(7. — Friction  murmurs  at  the  base  of  the  car- 
diac organ  more  audible  ; the  patient  has  no  pain  over  pericardium,  nor  uneasiness, 
except  after  cough,  over  the  chest  generally ; feels  very  slight  tenderness  on  percus- 
sion over  the  sternum  at  the  level  of  fifth  and  sixth  ribs.  To  have  spongio-piline^  sa- 
turated with  warm  water.,  applied  over  the  prcecordial  region.  Feb.  ^th. — Patient  so 
well  as  to  get  up  in  the  morning,  and  from  this  time  he  rapidly  regained  his  strength. 
The  pulmonary  signs  have  undergone  no  change.  The  friction  murmurs  over  the 
heart  gradually  diminished,  and  disappeared  on  the  12th,  while  a blowing  murmur 
was  gradually  established,  heard  loudest  with  the  first  sound  over  the  apex.  He  was 
dismissed  March  11th. 

June  22(7. — He  was  re-admitted  to-day,  having  in  the  interval  again  lost  strength 
in  consequence  of  his  work  being  too  fatiguing,  and  his  appetite  having  failed  him. 
The  amphoric  respiration,  metallic  notes,  and  brazen  resonance  of  voice,  have  now 
disappeared  from  the  right  side,  which  is  didl  on  percussion,  immovable  during  inspi- 
ration, with  slight  trace  of  respiratory  murmur,  and  great  increase  in  the  vocal  reson- 
ance. Left  lung  healthy,  with  puerile  respiration.  Still  a blowing  murmur  with  the 
first  sound  of  the  heart,  loudest  at  the  apex.  To  have  nutrients.,  with  § iv  of  wine 
daily.  July  2.%th. — Since  last  report  his  general  health  has  been  iirproving,  and  he 
now  looks  fat  and  well  nourished,  and  says  he  is  much  stronger.  Has  no  pain,  cough, 
dyspinna,  or  inconvenience  of  any  kind.  There  is  now  decided  flattening  anteriorly 
over  the  upper  third  of  the  right  chest.  On  deep  inspiration  it  expands  much  more 
than  formerly.  It  is  still  everywhere  dull  on  percussion,  with  great  increase  of  vocal 
resonance  amounting  to  bronchophony  anteriorly,  and  pectoriloquy  posteriorly  and 
superiorly.  Resjiiratory  murmurs  are  absent  over  upper  third  of  lung,  but  inferiorly 
and  anteriorly  inspiration  is  audible  but  feeble,  and  posteriorly  is  much  stronger. 
Discharged. 

Commentary. — It  is  no  uncommon  thing  for  men  who  have  pre^ 
viously  had  pleurisy,  to  be  seen  walking  about  the  streets  with  one  side 
of  the  chest  more  or  less  dull  on  percussion  and  incapable  of  action, 
although  complaining  of  nothing.  But  this,  so  far  as  I am  aware,  is  the 
only  instance  on  record  where  a pleurisy  has  come  on  and  proceeded  to 
the  formation  of  extensive  pneumo-thorax,  not  only  without  symptoms, 
but  without  the  cognizance  of  the  patient.  Yet  such  is  the  case  before 
•as.  For  when  I demonstrated  to  the  clinical  class  at  the  bed-side  the 


PLEUEITIS. 


en 


tympanitic  sound  over  the  right  chest  on  percussion,  the  absence  of 
healthy  respiration,  the  metallic  notes  with  the  respiratory  murmurs,  and 
the-brazen  amphoric  vocal  resonance,  he  himself  denied  that  there  was 
anything  wrong  with  his  chest,  and  smiled  at  the  trouble  we  gave  our- 
selves in  examining  it.  In  his  case,  as  in  Case  CXL.,  after  the  acute 
rheumatism  subsided,  we  had  the  greatest  difficulty  in  keeping  him  in 
the  house  for  the  purpose  of  observation.  On  his  going  out,  however,  he 
himself  at  length  became  satisfied  that  his  breathing  was  not  so  good  as 
it  ought  to  be,  and  on  his  re-admission  subsequently  we  had  the  pleasure, 
under  the  influence  of  nutrients,  to  see  the  morbid  murmurs  disappear, 
the  chest  gradually  contract,  and  his  general  health  re-establish  itself. 
V>'"hat  might  have  been  the  consequences,  if  by  means  of  physical  signs 
we  had  not  detected  this  morbid  condition,  but  had  dismissed  him  from 
the  house  as  soon  as  ho  had  recovered  from  his  rheumatism,  cannot 
positively  be  said ; but  judging  from  what  followed,  I have  myself  no 
doubt  that  he  would  rapidly  have  sunk  exhausted.  I saw  him  several 
times  after  his  first  dismissal,  and  he  was  only  supported  by  the  most 
energetic  use  of  nutrients  and  wine. 

Case  CXLIV.^ — Empyema^  following  Chronic  Phthisis — Paracentesis 
Thoracis — Pneumo-Thorax — Singular  mode  of  Death  from  Enor- 
mous Distention  of  the  Stomach  and  Emphysema  of  its  Coats — 
Tubercular  Pleuritis — Adherent  P ericardium — Waxy  Spleen — 
Tubercle  in  the  Kidneys. 

History. — Allan  Brown,- aet.  2-6,  a gilder — admitted  November  26,  1856.  States 
that  about  twelve  months  ago,  he  suddenly  at  night,  experienced  pains  about  the 
heart  in  drawing  breath,  together  with  shivering  and  febrile  symptoms.  For  three 
days  the  pain  was  acute  ; it  then  disappeared,  to  come  back  however  at  different  times, 
lasting  for  a day  or  two,  and  then  disappearing  again.  During  the  six  months  pre- 
ceding this  attack,  he  had  had  a short,  and,  for  the  most  part,  a dry  cough,  with 
frothy,  white,  and  gelatinous  sputum.  This  has  continued  ever  since  ; and  on  one 
occasion,  eight  months  since,  he  spat  up  blood.  Six  months  ago  he  noticed  the  left 
side  enlarging  ; two  months  afterwards  he  became  unfit  for  work,  and  also  unable  to  lie 
in  bed  on  the  right  side.  About  this  period  he  was  subject  to  profuse  sweatings,  which 
have  since  gradually  declined.  His  appetite,  at  no  time  great,  has  become  yet  more  defec- 
tive, especially  during  the  last  few  months.  His  thirst  has  always  been  considerable. 

Symptoms  on  Admission. — There  is  marked  depression  of  the  right  chest  under 
the  clavicle.  On  the  left  side,  there  is  a bulging  in  the  mammary  region  outwards 
and  forwards.  Posteriorly  there  is  a general  protrusion  of  the  left  side  of  chest  infe- 
riorly,  and  fulness  of  the  intercostal  spaces,  but  to  no  great  extent,  except  at  the 
extreme  base  and  over  the  lumbar  region,  where  there  is  fluctuation  and  extreme  ten- 
derness on  pressure,  with  redness  and  increase  of  temperature.  The  chest  measures — 


This  examination  was  conducted  throughout  while  the  patient  was  in  the  sitting 
posture.  During  respiration  there  is  an  expansive  motion  on  the  right  side,  espe- 
cially under  the  clavicle  and  in  the  infra  axillary  region,  but  on  the  left  side  there  is 
no  corresponding  motion.  There  is  also  slight  vocal  fremitus  on  the  right  side,  but 
none  on  the  left.  On  percussion  there  is  absolute  dulness  on  the  left  side  anteriorly, 
laterally,  and  posteriorly.  On  the  right  side  anteriorly  there  is  comparative  reson- 
ance, but  not  loud  nor  clear,  down  to  the  level  of  the  third  rib.  Below  that  level, 
over  a region  in  which  the  cardiac  pulsation  may  be  felt,  there  is  dulness.  Laterally 
and  posteriorly  the  percussion  is  good.  On  auscultation  on  the  right  side  anteriorly 
down  to  the  level  of  the  third  rib,  also  laterally  and  posteriorly,  the  respiratory  mur- 


Level  of  Pour  inches 


Left  side 
Eight  side 


Nipple.  lower. 

18  17 

18i  16i 


* Reported  by  Mr.  H.  N.  Maclaurin,  Clinical  Clerk. 


672 


DISEASES  OF  THE  KESPIRATORY  SYSTEM. 


murs  are  dry  and  somewhat  blowing  in  character  and  intensified  in  tone.  On  thg 
left  side  ao  respiration  is  audible,  except  near  the  sternal  end  of  the  clavicle  ante- 
riorly, and  near  the  inferior  angle  of  the  scapula  posteriorly.  In  these  regions  the 
respiratory  murmur  is  heard  faintly.  Vocal  resonance  is  greater  over  right  apex,  and 
posteriorly  over  the  whole  side,  then  over  the  corresponding  left.  There  is  great 
dyspnoea,  so  that  the  patient  frequently  cannot  answer  questions  until  he  recovers 
breath.  The  cough  is  short,  shallow  and  gasping,  and  when  excited  continues  for  a 
considerable  time,  the  patient’s  face  becoming  flushed.  Sputum  is  scanty,  and 
expectorated  with  difficulty.  The  cardiac  impulse  is  between  the  fifth  and  sixth  ribs 
on  the  right  side,  an  inch  and  a half  below  and  to  the  outside  of  the  right  nipple. 
Cardiac  sounds  healthy.  Pulse  130,  small  and  weak.  At  this  stage  of  the  exami- 
nation the  patient  became  much  troubled  with  spasmodic  cough,  so  that  further  inter- 
rogation was  considered  unadvisable.  To  have  ^ iij  of  wine,  steak  diet,  extra  milk  and 
an  ecig  for  breakfast. 

Progress  of  the  Case. — On  the  %th  and  dth  November  he  was  troubled  with 
slight  diarrhoea.  On  the  10th  he  had  slight  rigors.  At  evening  visit  the  following 
facts  were  elicited ; — At  the  base  of  the  right  lateral  region,  strong  fremitus  corre- 
sponding to  the  respiratory  rhythm  may  be  felt  on  applying  the  hand.  No  particular 
pain  exists  on  this  spot  except  on  pressure,  and  no  dulness  can  be  made  out.  Fric- 
tion may  be  heard  with  inspiration  and  expiration  as  high  as  the  lower  third  of  the 
scapula  posteriorly,  laterally  as  high  as  the  eighth  rib,  and  anteriorly  only  at  the 
base.  Vocal  fremitus  unimpaired.  Pulse  120;  small,  weak  and  somewhat  hard. 
Nov.  Will. — Fi’iction  was  still  audible;  the  pulse  was  112,  soft;  the  skin  was  cool; 
the  diarrhoea  stopped,  or  nearly  so ; the  urine  gave  a large  precipitate  of  lithates,  and 
contained  abundant  chlorides.  Nov.  \Wi.  The  operation  of  paracentesis  thoracis 
was  performed  by  Mr.  Sjaiie  in  the  following  manner : A free  incision  was  made  in 
the  lower  part  of  the  left  back  at  the  spot  where  the  tumor  was  pointing,  A con- 
siderable thickness  of  muscle  had  to  be  cut  through,  and  the  wound  enlarged  by 
means  of  the  finger  before  any  matter  escaped.  After  this,  about  sixty  ounces  of 
dirty-yellow  sanious  pus  were  withdrawn,  passing  with  force  at  each  expiration.  In 
the  evening,  forty  ounces  more  of  pus  escaped.  Breathing  was  easier  than  before 
the  operation ; cough  not  so  readily  excited  ; patient  lies  more  on  the  back  than  before. 
Pulse  96,  weak  and  soft.  Nov.  \%th. — Percussion  is  now  tympanitic  over  the  left 
side  anteriorly ; laterally  and  posteriorly,  where  the  integument  is  oedematous,  ppT- 
cussion  gives  great  sense  of  resistance,  with  deep  amphoric  resonance.  Vocal  reson- 
ance posteriorly  and  anteriorly  on  the  same  side  is  amphoric,  with  whispering  pecto- 
riloquy. With  inspiration  under  left  clavicle,  friction  sound  is  audible ; anteriorly, 
respiration  is  exceedingly  faint ; posteriorly  there  is  tubular  breathing,  less  distinct 
towards  the  base  ; close  to  the  spine  over  upper  two-thirds  of  the  lung,  respiratory 
murmur  is  audible,  but  faint  in  comparison  with  the  right  side.  On  the  right  side, 
harsh  inspiration  pnd  prolonged  expiration  continue  to  be  heard,  and  vocal  reson- 
ance is  loud  ; friction  murmui  s have  disappeared  from  the  anterior  and  lateral  regions. 
Cardiac  apex  beats  two  inches  to  the  left  and  one  inch  below  the  right  nipple.  Pulse 
108,  soft  and  feeble.  Tongue  dry  and  bright  red ; appetite  defective ; occasional 
thirst  ; bowels  regular.  Great  weakness,  and  considerable  general  uneasiness,  but  no 
local  pain ; occasional  rigors.  Nov.  \Mh. — At  the  left  apex,  and  over  left  infra- 
mammary  region,  metallic  tinkling  was  heard  at  the  close  of  inspiration,  and  vocal 
resonance  was  loudly  metallic  in  character.  Nov.  l%th. — The  following  measurements 
were  taken  at  the  same  levels  as  those  mentioned  when  he  was  admitted : — 


At  this  time  the  pulse  varied  from  120  to  130 ; it  was  small  and  feeble.  The  patient 
complained  much  of  the  heat  and  foetor  of  the  discharge.  Small  granulations  were 
seen  on  the  edges  of  the  W'ound.  Nov.  2Qth. — The  following  report  was  made  : — 
Three  and  a half  inches  below  right  nipple,  rough  friction  sound  with  inspiration 
and  expiration  ; five  inches  below,  and  two  and  a half  inches  to  the  outer  side  of 
right  nipple,  a rumbling  friction  with  expiration  ; inspiration  harsh  and  short,  but 
otherwise  free.  One  inch  below,  and  four  inches  to  the  outer  side  of  the  same  point, 
a finer  friction  sound  with  expiration  alone.  An  inch  and  a half  above  same  nipple 
respiratory  murmurs  are  heard,  intense  in  tone,  accompanied  during  close  of  inspira- 
tion with  a sound  superficial,  and  rough,  resembling  coarse  crepitation.  Two  and 


Level  of  Four  inchco 
Ripple.  lower. 


Left  side 
Eight  side 


15|  15i 

Hi  17 


PLEURITIS. 


673 


a half  inches  above  the  same  nipple,  a mucous  rale  of  the  same  character,  coarse  and 
dragging,  accompanies  inspiration  only.  Above  this  point,  over  the  upper  two  ribs, 
the  I'espiratory  murmurs  are  harsh  and  loud.  These  observations  were  made  while 
patient  lay  on  his  left  side  : his  weakness  precluded  an  examination  of  the  back. 
His  eyes  were  sunk  ; there  is  a cold  clammy  sweat  on  the  face  ; occasional  feeling  of 
chilliness,  JS^ov.  2,Mh. — No  change  since  last  report.  To-day  his  appetite  has  im- 
proved to  such  ail  extent  that  he  was  able  to  take  two  eggs  for  breakfast.  Loud 
metallic  tinkling  still  audible  over  the  left  chest.  Nov.  ZOth. — Metallic  tinkling  is 
now  no  longer  audible.  Dec.  4:th. — The  following  measurements  w^ere  taken  : — ■ 

Level  of  Four  inches. 

Nipple.  lower. 

Left  side  .......  15  15 

Right  side 16  15^ 

The  second  level  was  that  of  the  ensiform  cartilage.  Dec.  Zth. — A sore  of  the  size  of 
a fourpenny  piece  was  observed  over  the  sacrum,  which  caused  the  patient  consider- 
able pain.  He  continued  to  improve  up  to  the  12th.  His  appetite  increased  ; he 
slept  well ; no  more  rigors  occurred,  and  his  pulse  fell  to  96.  Dec.  lZtJt. — Last  night 
about  eleven  o’clock  he  was  seized  with  severe  pain  in  the  upper  part  of  the  abdomen, 
which  prevented  him  from  sleeping.  This  morning  the  pain  still  continues ; it  is 
increased  by  firm  pressure,  but  he  can  easily  bear  slight  pressure.  Respiration  is 
abdominal  as  well  as  thoracic.  Appetite  gone  ; bowels  opened  freely  a few  hours  ago  ; 
dejections  natural.  Pulse  108,  small,  but  not  hard  or  strong.  Skin  hot ; the  look  is 
not  particularly  anxious.  Dec.  lf>th. — Three  discolored  spots  were  found  over  the 
sacrum,  with  a very  small  ulcer,  which,  however,  had  a healthy  granulating  appearance. 
Continues  to  complain  of  abdominal  pain.  Yesterday,  four  loose  stools  were  passed, 
which  produced  considerable  uneasiness.  To-day  he  has  had  but  one  stool ; there  is 
considerable  tenderness  on  pressure,  and  distention  from  tympanitis  over  the  whole 
left  flank.  Pulse  96,  feeble,  soft.  Dec.  \%th. — He  was  greatly  relieved,  and  he  con- 
tinued in  a comfortable  condition  till  the  18th.  On  the  evening  of  that  day  he  was 
attacked  by  vomiting  and  a sensation  of  fulness  in  the  abdomen,  both  of  which  he 
believed  to  be  due  to  his  having  taken  a quantity  of  lemonade.  The  vomiting  continued 
till  eleven  p.m.,  when  it  ceased  ; the  matters  vomited  were  partly  fluid  and  partly  solid, 
and  evidently  consisted  of  alimentary  substances.  Tenderness  on  pressure  in  the  region 
of  the  recti  muscles  ; bowels  opened  this  morning  ; dejections  natural.  Respirations 
30,  somewhat  labored.  Pulse  120,  small,  somewhat  hard,  but  quite  compressible; 
consciousness  perfect;  skin  hot  and  dry;  cheek  flushed.  Dec.  19<A. — A remission 
of  the  symptoms  took  place.  On  the  20th,  vomiting  recurred,  together  with  abdominal 
pain  and  tenderness,  as  described  in  the  I’eport  of  the  18th.  These  continued  to  become 
severe  till  the  morning  of  the  2 2d,  wlien  he  sunk,  with  all  the  marks  of  great  depres- 
sion of  the  entire  system.  He  died  at  2 a.m.  on  the  22d. 

From  the  moment  of  the  patient’s  entering  the  hospital,  every  effort  was  made  to 
sustain  his  strength  by  means  of  the  most  nourishing  diet,  together  with  wine. 
Diarrhoea  was  put  a stop  to  by  the  use  of  cretaceous  mixtures,  and  the  rigors  were 
Successfully  treated  with  quinine.  The  vomiting  was  diminished  by  bismuth  and  aro- 
matic powder,  and  towards  the  end  of  the  case  he  was  greatly  relieved  by  the  use  of 
brandy,  and  ice  internally.  Effervescing  lemonade  was  allowed  latterly  to  allay  the 
patient’s  thirst. 

Sectio  Cadaveris. — Twenty-eight  hours  after  death. 

Body  considerably  emaciated.  On  reflecting  the  integuments,  and  removing  t.he 
sternum  and  ribs  anteriorly,  so  as  to  expose  the  thoracic  and  abdominal  cavities,  the 
contained  viscera  were  observed  to  be  displaced  as  follows  : — The  left  thoracic  cavity 
presented  an  empty  space,  in  consequence  of  the  lung  being  compressed  and  tightly 
bound  down  to  the  spinal  column  (Fig.  451,  h).  The  heart  was  in  the  centre  of  the 
body,  passing  somewhat  to  the  right  side.  The  stomach  was  enormously  dilated, 
extending  to  the  pubes,  and  concea  ing  all  the  abdominal  viscera,  except  a portion  of 
the  right  lobe  of  the  liver  and  colon  (Fig.  451,  e). 

Thorax. — On  opening  the  thorax,  there  was  an  escape  of  foetid  air  from  the  left 
side.  The  pericardium  was  everywhere  strongly  adherent.  The  heart  and  its  vaives 
healthy,  weighing,  with  pericardium,  8|  oz.  The  left  pleural  cavity  contained  about 
6 oz.  of  dirty  foetid  purulent  fluid.  The  surfaces  of  the  pi  curse,  parietal  and  visceral, 
were  covered  with  a layer  of  chronic  lymph,  having  scattered  throughout  its  substance 
43 


674 


DISEASES  OF  THE  BESPIEATORT  SYSTEM. 


opaque  yelloTT  spots  of  the  size  of  millet  seeds,  resembling  tubercle.  This  layer  of 
lymph  could  readily  be  scraped  off,  and  was  seen  to  be  about  one-eighth  of  an  inch  in 
thickness,  having  a soft  pulpy  layer  internally,  and  where  attached  externally,  to  be 
highly  vascular.  The  lung  was  bound  down  to  the  spinal  column  by  firm  and  dense 
adhesions.  Its  tissue  was  compressed  and  carnified,  and  its  size  reduced  to  a spindle- 
shaped  body  about  five  inches  long,  and  two  inches  in  its  greatest  diameter  (Fig. 
451,  b).  On  insufflation  it  expanded  very  imperfectly.  At  the  apex  there  was  a 

cavity  the  size  of  a walnut,  having  a distinct 
lining  membrane,  and  filled  with  soft,  cheesy, 
tubercular  matter,  evidently  of  old  standing. 
Scattered  through  the  substance  of  the  lung 
were  numerous  small  masses  of  tubercles,  but 
no  other  cavities.  The  right  lung  was  univer- 
sally adherent  by  dense  chronic  adhesions.  It 
was  moderately  voluminous,  and  at  the  apex 
were  numerous  stellate  puckerings,  correspond- 
ing to  dense  fibrous  cicatrices  in  the  substance  of 
the  pulmonary  tissue,  but  without  concretions. 

Abdomen. — The  stomach  was  enormously  di- 
lated, as  formerly  described  (Fig.  451,  e).  On 
opening  it,  it  was  found  to  be  distended  with 
air,  and  somewhat  twisted  round  on  itself  at  the 
junction  of  the  cardia  and  oesophagus.  All  the 
coats  were  very  thin,  apparently  from  the  dis- 
tention. The  mucous  coat  was  healthy,  and  no 
abrasions  could  be  discovered  in  it.  But  be- 
tween the  serous  and  muscular,  as  well  as  the 
muscular  and  mucous  coats,  numerous  bullae  of 
air  were  visible,  which  could  be  moved  about  by 
pressure  of  the  fingers,  evidently  dependent  on 
the  existence  of  some  gas  in  the  texture,  which 
was  in  no  way  putrid,  nor  was  the  gas  itself  of 
foetid  odor.  In  the  caecum  and  ascending 
colon  were  numerous  small  depressions  in  the 
mucous  coat,  the  cicatrices  of  former  ulcers. 
There  was  nowhere  any  trace  of  recent  intes- 
tinal ulcerations.  The  spleen  weighed  8 oz.  ; 
sp.  gr.  1063.  Its  pulp  was  healthy,  but  the 
malpighinn  bodies  were  enlarged  throughout, 
and  resembled  grains  of  boiled  sago.  The 
kidneys  were  pale,  and  had  two  or  three  small 
masses  of  tubercle  imbedded  in  the  cortical  substance.  Liver  and  other  organs  healthy. 

Commentary. — The  mode  of  death  in  this  case  was  very  remarkable, 
and  indeed,  so  far  as  I am  aware,  unique.  The  man  to  relieve  his  thirst 
was  allowed  two  or  three  bottles  of  effervescing  lemonade  as  drink  during 
the  day.  It  would  appear,  that  on  the  15th  of  December,  he  complained 
of  fulness  of  the  stomach  and  tympanitic  distention  of  the  abdomen, 
which  symptoms,  however,  excited  no  great  attention,  although  they  may 
have  originated  in  the  same  cause,  which  apparently  produced  the  more 
violent  complaints  that  came  on  subsequently.  On  the  evening  of  the 
18th  he  was  seized  suddenly  with  all  the  symptoms  of  perforation  of  the 
bowel,  and  on  examining  him  next  day,  such  was  what  I believed  to  have 
occurred.  There  was  great  abdominal  tympanitic  swelling,  excessive 
pain,  vomiting,  etc.  But  on  the  dissection  we  found  that  these  symptoms 
depended  on  great  distention  of  the  stomach,  with  emphysema  of  its 
coats,  the  latter  a lesion,  which  I believe  was  then  observed  for  the  first 

Fig.  451.  Relative  position  of  the  thoracic  and  abdominal  viscera,  on  reflecting 
the  integaments  in  Allan  Brown’s  case,  n,  Empty  Icit  thoracic  cavity  ; 6,  left  lung  5 
c,  right  lung  ; c7,  heart ; e,  enormously  distended  stomach  ; /,  liver ; g,  colon. 


Fig.  451. 


PLEUEITIS. 


675 


time.  It  was  not  caused  by  putrefaction  ; and  the  question  arose,  How 
was  it  produced  ? It  turned  out  on  inquiry  from  the  nurse  and  neigh- 
boring patients,  that  the  man  had  kept  his  bottles  of  etfervescing 
lemonade  till  the  evening,  and  drank  at  least  the  contents  of  two  of  them 
in  quick  succession.  It  is  probable,  therefore,  that  the  extrication  of 
gas  had  distended  the  stomach,  and  caused  it  to  twist  round  partly  on 
itself  at  the  cardia,  so  as  to  prevent  its  escape.  Hence  the  distention 
and  pain,  and  why  probably  the  contained  air,  not  finding  a ready  exit 
through  either  the  cardia  or  pylorus,  had  forced  its  way  between  the 
coats  of  the  organ  itself. 

With  regard  to  the  other  facts  of  this  case,  they  present  in  a well- 
marked  form  all  the  characteristic  phenomena,  first  of  empyema  of  the 
left  side,  and  secondly,  of  pueumo-thorax.  A disquisition  on  these  two 
thoracic  diseases,  their  diagnosis  and  treatment,  would  lead  me  too  far. 
There  is  only  one  point  to  which  I think  it  necessary  to  refer,  namely, 
the  cause  of  metallic  tinkling  ; and  I do  so  merely  to  say  that  notwith- 
standing the  ingenious  theories  which  have  been  advanced  to  account  for 
it,  they  all  appear  to  me  faulty.  I have  satisfied  myself  that  the  break' 
ing  of  bubbles  of  air  on  the  surface  of  fluid,  or  the  splashing  of  water 
in  a cavity  containing  air,  will  not  always  explain  the  occurrence.  On 
one  occasion  I heard  metallic  tinkling  most  distinct  over  the  lung  in  a 
man  dying  of  phthisis.  After  death  I commenced  the  examination  by 
making  an  opening  between  the  ribs  cautiously,  over  the  centre  of  the 
tympanitic  space,  thinking  that  air  would  escape.  But  the  pleurae  were 
universally  adherent.  There  was  no  cavity  whatever,  but  simply  hard 
nodules  of  tubercle,  scattered  throughout  a highly  emphysematous  lung. 

The  place  for  making  an  opening  into  the  thoracic  cavity  in  empyema 
should  always  be  chosen  with  the  greatest  care.  The  general  rule  is, 
that  if  the  pus  causes  a prominent  tumor,  to  puncture  there,  but  if  not, 
then  one  of  the  intercostal  spaces  between  the  fifth  and  seventh  ribs 
should  be  chosen,  but  so  as  to  avoid  the  heart  and  diaphragm.  In  the 
above  case,  with  bulging  of  the  thoracic  walls  inferiorly  and  posteriorly, 
the  opening  was  made  at  the  most  prominent  part  by  a large  incision, 
and  the  offensive  matter  it  contained  replaced  by  air.  This  proceeding, 
which  converts  an  empyema  at  once  into  pueumo-thorax,  it  is  argued, 
can  have  no  ill  effect,  so  long  as  the  aperture  remains  free,  and  the  air 
thereby  prevented  from  becoming  foetid.  The  operation  was  had  recourse 
to  more  as  a palliative  than  as  a curative  proceeding  in  the  present  case, 
the  phthisical  complication  rendering  ultimate  recovery  very  improbable. 
I have  no  doubt,  however,  that,  as  a general  rule,  a small  puncture, 
avoiding  admission  of  air  as  much  as  possible,  holds  out  the  best  pros- 
pect of  success. 

Dr.  Henry  Bowditch,  from  1850  to  December  1861,  has  performed 
the  operation  of  thoracentesis  150  times  on  75  persons,  by  means  of  an 
exploring  trochar  and  suction-pump,  as  originally  suggested  by  Dr. 
Wyman.  This  instrument  permits  the  entrance  of  no  air  into  the 
chest,  but  sucks  out  the  fluid,  and  enables  it  to  be  discharged  by  means 
of  a stop-cock  and  cross-tube  at  the  base  of  the  nozzle.  In  this  manner. 
Dr.  Bowditch  declares  that  the  operation  is  absolutely  innocuous,  says 
that  it  relieves  orthopnoea  when  present,  and  cites  one  instance  where 
it  was  performed  eight  times  in  six  weeks  as  a palliative.  The  results 


676 


DISEASES  OF  THE  EESPIEATOEY  SYSTEM. 


of  liis  experience  are  so  valuable,  however,  that  I transcribe  them  at 
length.* 


“ Twenty-nine  out  of  the  seventy-five  patients  got  wholly  well,  apparently  in  con* 
sequence,  chiefly,  of  the  operation.  The  operation  was  performed  generally  when 
severe  symptoms  were  manifest,  and  I was  called  in  consultation.  In  a few,  a great 
quantity  of  fluid  was  recognised  by  the  physical  signs  alone,  the  rational  having  been 
slight ; but  as  the  disease  was  chronic  an  operation  was  deemed  necessary.  In  all 
these  cases,  the  operations  seemed  the  first  step  towards  a cure.  In  26  out  of  the  75 
serum  was  found  ; and  21  )f  these  patients  got  Avholly  well.  If  after  the  first  opera- 
tion the  fluid  becomes  pin  dent,  an  almost  certain  fatal  prognosis  should  be  made.  I 
have  seen  six  such  cases,  Four  of  the  patients  died,  two  were  lost  sight  of,  but 
when  last  seen  -were  failin  Fus  w’as  found  at  the  first  operation  in  twenty-four 
cases.  Once,  it  was  of  th  : consistence  of  honey,  but  I easily  drew  it  through  the 
exploring  tube.  Seven  of  these  patients  recovered  wholly;  seven  died;  nine  were 
relieved  one  or  many  tinjes ; but  they  had  either  a long  and  tedious  illness,  ter- 
minating usually  in  phthias,  or  a fistulous  opening,  or  a still  doubtful  result.  A 
sanguinolent  fiuid  at  the  first  puncture  (and  by  that  I mean  a dark  red  thin  fluid, 
evidently  stained  with  blood,  thougli  not  coagulating)  I consider  almost  certainly 
fatal,  and  a consequence  of  some  malignant  disease  of  the  lung  or  pleura.  There 
were  seven  of  such  cases.  In  six  the  patients  died.  In  one  there  was  a doubtful 
result,  but  apparently  fatal  • tendencies  were  commencing.  If  the  fluid  is  found 
sanguinolent  at  the  second  fcr  any  subsequent  puncture,  I deem  it  of  comparatively 
little  importance  towards  tha  prognosis.  A mixture  of  bloodi/  purulent  fiuid  at  the 
first  operation  is  usually  fataL  Three  cases,  all  fatal,  occurred.  A fetid  gangrenous 
fluid  is  very  rare,  only  one  case  having  occurred,  and  that  fatal ; but  in  this  case 
infinite  relief  from  horrible  orthopnoea  was  obtained,  and  it  never  returned,  though 
the  patient  sunk  and  died  id  a few  days.  Gangrenous  pleura  was  found.  I have 
operated  once  in  pneumodiyd^pthorax  with  temporary  relief  and  comparative  ease  for 
several  days.  Many  theoretical  objections  may  be  urged  against  the  operation  in 
such  a’ case.-  . Xq  such  objectipns  I have  simply  to  answer  that,  as  the  operation  can 
do  no  harm  and  IhUy-giy^e  much  relief,  I shall  operate  again  in  any  case  where  the 
dyspnoea  may  be  so  great  as  ^i^^require  it.  Finally,  in  seven  cases  I got  no  fluid. 
These  cases  occurred  usually  inuie'  eaiiier  operations,  and  the  failure  was  often 
owing,  I have  no  doubt,  to  th^  cautious  and^owjnanner  with  which  I plunged  the 
trocar  between  the  ribs,  carrying  thus  the  false  membrane-oCthe  pleura  costalis  before 
the  instrument  instead  of  piercing  it ; so  that  a valve  was  really  Termed  over  the  end 
of  the  canula.  At  other  times  I have  little  doubt  that  an  error  of  diagnosis  w'as  made, 
and  that  instead  of  a fluid  thei-(|was  simply  <m  unexpanded  lung  and  thick  false  mem- 
branes on  the  pleura,  causing  ck  much  dulness  on  percussion  and  absence  of  respira- 
tion as  a fluid  would  have  donel  The  differential  diagnosis  of  the  two  w^as  not,  at  first, 
quite  so  easy  as  it  is  now.  Inspection  usudly  is  the  test  between  the  two  conditions  ; 
the  intercostals  being  distinct,  and  depressed  when  a membrane  exists ; but  very  in- 
distinct and  level  with  the  ribs,  or,  possibly  prominent,  when  a fluid  occupies  the  chest. 
Once  an  immense  tumor  occupied  and  uniformly  distended  one  pleural  cavity,  and  in 


its  course  presented  all  the  phenomena,  natural  and  physical,  of  simple  pleurisy.  I tapped 
three  times — viz.,  at  the  back,  side,  and  front,  at  the  same  visit.  No  evil  followed.” 

“ OF  25  cases,  14  were  of  the’ right  side,  11  of  the  left.  Of  the  14  of  the  right  side, 
only  one  person  is  mentioned  as  having  tubercles,  and  in  that  the  pleurisy  was  cured 
and  the  pulmonary  symptoms  mitigated.  Of  the  14  persons  tapped  in  right  side^ 
28*o7  per  cent  died;  64-28  per  cent  were  cured,  and  7‘14  per  cent  remained  doubt- 
ful. Whereas,  of  the  11  cases  of  the  left  side,  45-45  per  cent  died,  36-36  got  w-ell, 
18-18  were  doubtful.  In  other  words,  twice  as  many  have  got  well  from  tapping  the 
right  as  the  left ; and  only  half  as  many  have  had  doubtful  results  from  operations 
on  the  right,  as  in  those  where  the  left  side  has  been  tapped.  Hereafter,  if  my  cases 
are  any  criterion  wherefrom  to  judge,  I shall  regard  an  operation  on  the  right  side  as 
much  more  favorable  than  one  on  the  left ; which  I can  hardly  think  w'ould  be  the 
case  were  all  right  side  pleurisies  tuberculous.  Experience  teaches  me  to  operate  in 
every  case,  how-ever  recent  or  chronic  may  be  the  attack,  provided  there  is  per- 
manent or  occasional  dyspnoea  of  a severe  character,  evidently  due  to  the  fluid.  I 
have,  of  course,  more  hope  of  doing  good  where  the  disease  has  not  been  of  too  long 
duration,  is  uncomplicated  w-ith  phthisis,  or  any  other  disease,  and  where,  moreover, 


* American  Journal  of  the  Medical  Sciences,  January  1863. 


PLEURITIS. 


GYV 


the  amount  of  fluid  seems  directly  the  cause  of  the  trouble.  I also  deem  it  best  to 
operate  in  any,  even  latent  cases,  where  the  pleural  cavity  gets  full  of  fluid ; and  if, 
aftet  a reasonable  amount  of  treatment,  the  fluid  does  not  diminish.  The  point 
originally  chosen  by  Dr.  Wyman  and  myself — viz.,  in  a line  let  fall  from  the  lower 
angle  of  the  scapula,  and  between  the  ninth  and  tenth  ribs — I deem  the  most 
appropriate  point  at  which  to  make  a puncture.  I have,  however,  tapped  under  the 
axilla,  or  in  the  breast,  where  the  case  sCemed  to  require  it.  In  selecting  the  precise 
intercostal  space,  on  the  back,  I usually  choose  one  about  an  inch  and  a half  higher 
than  the  line,  on  a level  with  the  lowest  point  at  which  respiratory  murmur  can 
be  heard  in  the  healthy  lung  of  the  other  pleural  cavity.  I never  wait  until  pointing 
commences  ; for  then  I am  sure  that  pus  will  be  found.  If  pointing  wdthout  opening 
has  commenced,  I do  not  necessarily  tap  in  that  place,  as  recommended  by  the  older 
surgeons,  but  seek  the  most  depending  point  in  the  chest.  While  thus  desiring  to 
operate  before  a local  distention  shows  itself,  I dislike  or  refuse  to  tap  where  there 
is  contraction  of  the  intercostal  muscles ; and  I am  certain  of  getting  fluid  only 
where  there  is  distention  or  flattening  of  the  same.” 

As  to  any  objection  whatever  to  this  operation,  he  admits  of  none. 

It  so  happened,  that  in  the  winter  session  1862-63,  two  cases  of 
chronic  pleurisy  of  the  left  side  entered  my  wards,  in  both  of  which  the 
heart  was  forced  over  into  the  right  chest.  The  whole  question  as  to 
thoracentesis  was  then  carefully  discussed  ; and  as  the  result  was  curious, 
I give  these  cases  shortly,  with  the  commentary  they  elicited  : — 

Two  cases  of  Chronic  Pleurisy^  with  fluid  in  the  left  chesty  forcing  the 
heart  into  the  right  thoracic  cavitg.  Pecoverg  of  the  first  ; no 
change  in  the  second. 

Case  CXLV.*-— William  M‘Gregor,  aet.  25,  a malster — admitted  December  22d, 
1862. — Two  months  ago  he  experienced  stitching  pains  in  the  chest,  but  continued 
to  work  until  fourteen  days  ago,  when  the  breatliing  became  so  difficult  he  was 
obliged  to  desist.  With  the  exception  of  slight  cough,  has  had  no  other  symptom — 
no  pain,  no  fever.  On  admission  the  left  chest  bulges  more  than  the  right,  and 
measures  three-quarters  of  an  inch  more  from  sternum  to  spine.  It  is  completely 
dull  ou  percussion  from  the  apex  to  the  base,  with  absence  of  respiration  everywhere, 
and  pealing  resonance  of  the  voice  posteriorly  over  lower  angle  of  scapula.  Right 
chest  resonant  on  percussion ; breathing  puerile,  but  otherwise  healthy.  The  heart’s 
impulse  is  felt  between  fourth  and  fifth  I’ibs,  ou  right  side,  two  inches  from  the 
sternum.  Its  area  of  dulness  extends  across  two  inches  to  the  right  of  that  bone ; 
sounds  normal.  Pulse  58,  regular,  and  of  good  strength.  Other  functions  healthy. 
Ordered  a mixture  of  Sulphunc  Ether,  Chlorodyne,  and  Squill  mixture,  which  was 
discontinued  in  a few  days,  when  all  cough,  as  well  as  his  other  symptoms,  had  dis- 
appeared. Steak  diet,  with  3 iv  of  wine  daily.  January  Zd. — A clear  note  is  elicited 
on  percussion  below  the  left  clavicle,  extending  down  to  the  fourth  rib,  and  in  this 
clear  space  the  breath-sound  is  audible.  This  clear  space  gradually  extended,  so  that 
on  the  lAth  of  January  \t  had  extended  a little  below  the  nipple;  and  the  apex  of 
the  heart  was  felt  beating  immediately  to  the  left  of  the  sternum.  Jan.  ‘i.Cith. — He 
insisted  on  leaving  the  Infirmary,  considering  himself  quite  well.  His  strength  and 
healthy  appearance  have  returned.  The  left  lung  is  evidently  expanding  daily,  and 
the  heart  returning  to  its  normal  position. 

C.1SK  CXLVI.f — William  Dunlop,  jet.  20,  a confectioner — admitted  December  12th, 
1862. — Caught  severe  cold,  with  pain  in  his  left  chest,  nineteen  months  ago,  on  board 
ship,  when  returning  from  the  East  Indies.  He  had  great  difficulty  of  breathing, 
and  was  confined  to  bed  for  a fortnight.  Six  months  afterwards,  on  arriving  iu 
Greenock,  entered  the  Infirmary  there,  and,  in  addition  to  other  treatment,  had  3^ 
pints  of  clear  fluid  drawn  off  from  his  chest,  which  produced  temporary  relief. 
Dyspnoea,  however,  soon  returned,  and  has  continued  up  to  his  admission.  He  now 
complains  of  constant  palpitation.  The  apex  of  the  heart  beats  between  the  fifth 
and  sixth  ribs  on  the  right  side,  1|  inches  to  the  inside  of  the  nipple.  There  is  com- 
plete dulness  on  percussion  over  the  whole  of  the  left  chest,  while  on  the  right  side 
Ihe  tone  is  normal.  On  left  side  also  there  are  no  breath-sounds,  nor  vocal  resonance 


* Reported  by  Mr.  Michael  Beverley,  Clinical  Clerk, 
f Reported  by  Mr.  T.  Clark  Wilson,  Clinical  Clerk. 


678 


DISEASES  OF  THE  EESPIEATORY  SYSTEM. 


audible,  except  over  root  of  left  lung  posteriorly,  where  there  is  loud  bronchophony 
Respiration  on  right  side  exaggerated,  but  otherwise  normal.  Has  difficulty  of 
breathing  on  taking  any  exertion,  and  a slight  cough.  Left  chest  measures  a quarter 
of  an  inch  more  than  the  right  from  sternum  to  spine  ; other  systems  normal.  To 
have  steak  diet,  and  § ii  of  wine  daily ; Haheat  Potassee  Bitartratis  3 ss  ter  indies. 
The  treatment  was  continued  until  27th  December,  when  diarrhoea  supervening,  the 
Pot.  Bitart.  was  stopped.  Feeling  his  symptoms  then  somewhat  relieved,  he  wished 
to  go  out,  and  did  so  on  7th  January ; his  physical  signs,  dyspnoea  and  palpitation 
on  exertion,  having  in  fact  been  in  no  way  improved. 

Commentary. — It  is  seldom  that  two  such  cases  are  to  be  found  in 
a clinical  ward  at  the  same  time.  Neither  of  them  presented  any 
urgent  symptoms  calling  for  thoracentesis ; and  in  discussing  the  treat- 
ment, it  was  strongly  urged  upon  me  by  the  examining  class  to  try  the 
effects  of  diuretics,  whic-h  at  the  time  were  stated  to  have  been  highly 
successful  in  some  other  wards  of  the  hospital.  I consented  to  the 
proposal ; and  as  the  two  cases  appeared  to  be  very  much  alike,  it  was 
agreed  to  treat  one  by  diet  alone,  and  the  other,  in  addition  to  diet,  by 
3 ss  doses  of  the  supertartrate  of  potass.  The  result  was  that  the  one 
treated  by  diet  alone  recovered,  the  fluid  disappeared  from  the  chest, 
and  the  heart  returned  to  the  left  side,  while  the  other,  who,  in  addition 
to  diet,  took  diuretics,  underwent  no  improvement.  Of  course  such 
result  was  altogether  accidental,  but  there  is  this  caution  to  be  derived 
from  it.  Let  us  suppose  the  treatment  had  been  reversed  in  the  two 
cases,  we  should  scarcely  then  have  freed  ourselves  from  the  conclusion 
that  the  diuretics  had  produced  the  marked  recovery  which  occurred. 
Again,  if  thoracentesis  had  been  performed  on  the  first  case,  we  should 
have  thought  it  was  the  cause  of  recovery.  Such,  among  many  others, 
are  the  difficulties  which  present  themselves  to  just  conclusions  in 
therapeutics ; and  indicate  strongly  how  necessary  it  is  that  such  con- 
clusions should  be  based  upon  a large  number  of  well-observed  facts. 

Several  other  cases  of  chronic  pleurisy  of  great  interest  have  entered 
the  clinical  wards.  That  of  Garvie  * will  be  remembered  with  interest 
by  the  summer  clinical  students  of  1862,  in  whom,  suddenly  after 
coughing,  there  was  elicited  a remarkable  metallic  echo  and  resonance, 
like  that  of  striking  a gong;  and  that  of  James  Robertson,f  admitted  in 
May  1864,  where  a circumscribed  cavity  in  the  right  chest,  sometimes 
filled  with  pus  and  at  others  with  air,  was  carefully  diagnosed,  and  all 
the  views  regarding  it  derived  from  physical  examination  were  con- 
firmed by  the  examination  after  death. 

PNEUMONIA. 

Case  CXLYII.;|; — Pneumonia  on  Right  Side  and  slight  Plevritis — 

Recovery. 

History. — Roderick  M‘Farlane,  8Dt.  20,  a gardener  of  healthy  and  robust  constitu- 
tion— admitted  December  17th,  1856.  On  the  12th  instant  felt  unwell,  with  a sensa- 
tion of  cold  in  the  back.  On  the  13th  had  pain  in  the  right  infra-axillary  region, 
increased  on  deep  inspiration,  with  hot  skin,  headache,  thirst,  and  loss  of  appetite, 
symptoms  which  have  continued  ever  since.  On  the  14th,  cough  appeared  with  scanty 
expectoration.  Has  taken  a dose  of  castor-oil  and  some  pills. 

Symptoms  on  Admission. — Expansion  on  both  sides  of  chest  equal.  Respirations 
twenty-four  in  the  minute,  not  labored.  Can  lie  on  either  side,  but  prefers  lying 

* Reported  by  Mr.  B.  B.  Thurgar,  Clinical  Clerk, 
f Reported  by  Mr.  G.  F.  Fulcher,  Clinical  Clerk, 
j Reported  by  Dr.  J.  Glen,  Resident  Clinical  Physician. 


PNEUMOXIA. 


679 


an  the  back.  Pain  during  deep  inspiration  over  right  infra-axillary  region ; slight 
cough  ; scanty  expectoration — frothy  and  mucous.  On  percussion,  cracked-pot  re- 
sonance extends  from  clavicle  to  fifth  rib  on  the  right  side.  Below  this  level  percussion 
is  dull.  There  is  aiso  decided  dulness  posteriorly  from  spine  of  scapula  to  base.  Else- 
where percussion  natural.  On  auscultation,  puerile  respiration  over  left  front ; over 
right  front  superiorly  respiration  is  harsh,  without  rale  ; below  fifth  rib,  it  is  suppressed. 
Posterioi’ly  over  two  lower  thirds,  double  friction  is  audible,  with  fine  crepitation  at  the 
close  of  inspiration ; on  left  side  occasional  sibilus,  with  a few  moist  rattles  at  close  of 
inspiration  over  lower  third.  The  vocal  resonance  is  increased  and  sharp  on  right  side 
anteriorly,  but  greatly  increased  and  segophonic  posteriorly  over  area  of  dulness.  Pulse 
104,  incompressible  and  full.  Skin  hot  and  dry.  Tongue  in  centre  brown,  dry,  and 
cracked ; edges  moist  and  clean.  No  appetite  ; great  thirst ; bowels  always  regular, 
but  have  been  opened  by  laxatives.  Urine  natural.  Other  functions  normal. 

Sol,  Antim.  Tart.  § ss  ; Aquae.  Ammon.  Acet.  ; Aquae  § viss.  M.  Habeat  sextam 
partem  quartd  qudque  hard. 

Progress  of  the  Case. — December  18. — Grazing  friction  audible  over  the  right 
infra-mammary  region.  Crepitation  distinct  over  right  back  inferiorly.  Pulse  120, 
soft.  Sputum  scanty,  consisting  of  orange-colored  gelatinous  masses.  Otherwise  the 
same.  20th. — Crepitations  very  coarse  over  right  back.  Fever  abated.  Tongue 

moist  and  clean.  Pulse  72,  of  good  strength.  Temperature  of  skin  natural.  Omitt. 
mist.  Dec.  22d — Crepitation  and  friction  disappeared  from  right  back.  Abundant 
sediment  of  lithates  in  the  urine.  U ^P-  -^ther.  Nit.  3 iij  ; Vin.  Sem.  Colchici  3 j. 
Aquam  ad  ? v.  M.  Txeo  table- spoon ftds  to  he  taken  every  four  hours.  Dec.  1\.fh. — 
Dulness  over  right  back  and  cracked-pot  sound  anteriorly  greatly  diminished.  For  the 
last  three  days  has  had  profuse  diaphoresis.  Urine  again  natural.  Omitt.  mist.  To 
have  steak  diet.  Dec.  26^/g — No  dulness  anywhere  ; respirations  natural.  Is  quite  re- 
covered ; but  as  the  weather  was  severe,  and  he  had  to  work  immediately  in  the  open 
air,  if  dismissed,  he  was  not  discharged  until  January  2d. 

Commentary . — This  young  man  was  first  seized  with  illness  on  the 
12th  of  December,  and  was  admitted  on  the  17th,  when  hepatization 
of  the  lung  was  found  to  have  occurred  in  the  lower  two-thirds  of  the 
organ  on  the  right  side,  combined  with  slight  pleuritis.  Fever  was 
well  marked,  the  pulse  full  and  incompressible.  On  the  22d,  the 
exudation  was  thoroughly  softened  and  passing  off  from  the  economy 
principally  by  the  urine,  but  partly  by  the  skin.  On  the  26th,  all 
trace  of  the  disease  had  disappeared.  The  treatment  consisted  at  first 
of  slight  salines  and  rest,  then  of  a diuretic  mixture  to  favor  excretion 
of  the  effete  products  by  the  urine,  and  lastly  of  steak  diet.  From 
the  first  commencement  to  the  complete  disappearance  of  the  disease 
was  fourteen  days ; and  to  the  abatement  of  fever  and  commencing 
resolution,  eight  days.  The  febrile  phenomena  in  this  case  were  un- 
usually well  pronounced.  The  pulse  was  full  and  incompressible — in 
fact,  hard;  the  skin  hot  and  dry.  Tongue  furred  and  dry  ; no  appetite; 
great  thirst,  etc.  In  short,  this  young  vigorous  lad  presented  all  those 
symptoms  in  which  we  are  instructed  by  most  writers  to  bleed,  and  in 
which  it  has  been  argued,  that  without  bleeding  a fatal  suppuration  was 
likely  to  occur.  I need  scarcely  add,  that  the  propriety  of  such  prac- 
tice, as  well  as  the  probable  fatality,  were  alike  negatived  by  the  result. 

Case  CXLVIIT.* — Double  Pneumonia.^  with  urgent  Symptoms.^  and  full^ 
strong  Pulse — Pleuritis  on  Left  Side — Recovery  in  Nine  Days. 

History. — John  M‘Farlane,  set.  30,  a railway  laborer— admitted  Nov.  12,  1858 
Has  been  subject  to  a slight  cough  and  expectoration,  sometimes  tinged  with  blood, 
for  the  last  ten  winters  ; otherwise  he  has  enjoyed  good  health.  On  Nov.  9th,  whilst 
working  on  a railway  bank,  which  was  much  exposed  to  wind  and  cold,  he  was  sud- 
denly seized  with  great  pain  in  his  lower  extremities ; he,  however,  continued  at  his 
work,  till  the  evening,  when  he  experienced  a sharp  pain  in  his  left  side,  with  diffi- 

* Reported  by  Mr.  Arthur  Garrington,  Clinical  Clerk. 


680 


DISEASES  OP  THE  EESPIEATORT  SYSTEM. 


culty  of  breathing,  and  general  febrile  symptoms.  He  went  to  bed  ; and  on  the  10th, 
feeling  no  better,  he  sent  for  a medical  man,  who  ordered  a blister  to  be  applied  to  the 
left  side  ; he  also  gave  him  a powder,  and  a mixture  which  made  him  very  sick.  The 
pain  was  slightly  relieved  after  the  application  ot  the  blister,  and  he  felt  much  easier 
on  the  11th,  but  on  the  12th  the  pain  increased,  while  the  difficulty  of  breathing  and 
of  expectorating  became  so  bad  that  he  was  brought  into  the  Infirmary. 

Symptoms  on  Admission. — His  face  was  much  flushed  ; skin  hot  and  dry  ; tongue 
moist,  and  with  a white  fur  ; great  thirst ; pulse  95,  full  and  regular  ; urine  orange- 
colored,  with  a copious  sediment  of  urates,  only  a slight  trace  of  chlorides,  and  a trace 
of  albumen.  His  respirations  were  quick  and  labored  Expectoration  very  tenacious, 
with  numerous  rusty-colored  masses  in  it.  Cough  frequent  and  painful.  On  the  left 
side  anteriorly  percussion  was  good,  but  crepitation  was  heard  all  over  the  front,  with 
the  exception  of  a space  2^  inches  below  the  clavicle,  where  the  respiratory  sounds  were 
very  harsh.  Posterioi’ly  on  this  side  there  was  marked  dulness  from  the  spine  of  the 
scapula  to  the  base  of  the  lung,  over  which  space  loud  crepitation  was  heard,  and  peal- 
ing vocal  resonance,  more  especially  about  the  centre  of  the  lung.  On  the  right  side 
anteriorly  there  was  slight  comparative  dulness  over  a space  extending  from  the  clavicle 
two  inches  downwards.  Posteriorly  on  this  side  there  was  slight  comparative  dulness 
at  apex,  where  expiration  was  prolonged,  and  the  inspiratory  murmur  harsh.  Pulv, 
Doveri  gr.  x,  to  be  taken  immediately.  Sol.  Antim.  §j;  Potass.  Acet.  | ss ; 
Aqua7n  ad  5 viij  ; Ft.  mist.  Two  table-spoonfuls  every  four  hours. 

Pp>,ogress  of  the  Case. — Nov.  l?>tk. — Passed  a sleepless  night.  Cough  incessant, 
and  dyspnoea  urgent ; face  livid.  Pulse  112,  full  and  strong;  sputum  very  copious, 
rusty  and  gelatinous.  In  addition  to  physical  signs  formerly  reported,  there  was  faint 
crepitation  all  over  right  back  posteriorly  (most  distinct  at  apex),  but  no  great  increase 
of  vocal  resonance  ; friction  over  left  side  anteriorly  below  nipple,  both  with  expiration 
and  inspiration,  but  loudest  with  former,  and  posteriorly  marked  dulness  over  inferioi 
two-thirds,  with  loud  crepitation  and  bronchophony.  Ordered  to  be  cupped  to  over 
region  of  pain  on  left  side.,  and  to  take  only  one  table-spoonful  of  the  mixture.,  to  which 
is  to  be  added  Sp.  .^th.  Nitr.  3 ij.  To  have  strong  beef -tea  and  milk.  Nov.  \4:th. — 
Patient  says  he  felt  relieved  by  the  cupping  for  3 or  4 hours,  but  the  pain  returned  af- 
terwards as  bad  as  before.  There  is  still  great  dyspnoea  and  lividity  of  face  ; expec- 
torates about  18  oz.  of  purulent,  gelatinous,  frothy  matter,  tinged  with  rusty-colored 
blood,  during  the  24  hours.  Pulse  98,  soft  and  irregular.  To  have  a table-spoon fxd 
of  wine  every  hour.  Omit  mixture.  Nov.  \bth. — Dyspnoea  and  pain  in  side  much  di- 
minished. Sputum  less  rusty.  Pulse  100,  strong  and  regular.  Very  coarse  crepita- 
tion (amounting  to  mucous  rattles)  heard  over  left  side  anteriorly.  Respiratory  mur- 
murs harsh  and  dry  over  right  side  anteriorly.  There  is  still  marked  comparative  dul- 
ness over  left  back,  and  also  in  upper  third  of  right  back.  Tubular  breathing  over  up- 
per fourth  of  right  back,  harsh  interiorly.  Crepitation  over  left  back,  but  more  feeble 
than  before.  Vocal  resonance  the  same.  Urine  quite  clear,  and  no  deposit.  Chlo- 
rides have  been  increasing  since  the  13th,  but  are  not  yet  in  normal  proportion.  Still 
thirsty  and  feverish.  B Sp.  jNth.  Nitr.  3 iij  ; Potass.  Acet.  §ss.  Aquarn  ad  ^vj  ; Ft. 
mist.  To  be  taken  as  before.  To  continue  the  milk.,  wine.,  etc..,  and  to  have  6 oz.  of 
beef-steak.  Nov.  \%th. — Patient  says  he  feels  very  much  better.  All  crepitation  gone, 
but  there  is  slightly  increased  vocal  resonance  on  left  side.  Urine  loaded  with  urates. 
Convalescent,  but  steak  to  be  increased  to  8 oz.,  and  wine  to  he  diminished  to  | iv  daily. 
Nov.  2Uh. — Has  been  gradually  getting  stronger  since  last  report.  Yesterday  he  got 
up  for  some  time,  walked  about  the  ward,  and  exposed  himself  to  draughts  in  the  pas- 
sages. This  led  to  an  attack  of  acute  rheumatism,  for  which  he  was  again  confined  to 
bed,  and  ordered  Potass.  Bicarb.  3j  three  times  a day.  He  gradually  got  better,  and 
was  quite  free  from  muscular  pains  on  Dec.  4th ; he  got  up  on  the  'I'th,  and  with  the 
exception  of  slight  weakness,  felt  quite  well.  2 oz.  extra  beef-steak  were  ordered  on 
the  11th,  and  he  left  the  Infirmary  on  the  13th  in  perfect  health. 

Commentary. — This  is  what  some  former  writers  would  have  called 
an  “ ex(]^uisite  ” case  of  pneumonia,  occurring  in  a man  who,  with  some 
emphysema,  was  accustomed  to  have  attacks  of  bronchitis  and  bloody 
expectoration  every  winter.  It  presented  all  the  symptoms  of  the 
disease,  including  pain  in  the  side,  great  dyspnoea,  lividity  of  the  face, 
strong  and  full  pulse,  with  copious  rusty  sputa.  Physical  signs  also 
proved  it  to  consist  of  hepatization  of  the  two  inferior  thirds  of  tho 


PNEUMONIA. 


681 


left  lung,  and  of  the  superior  half  of  the  right  lung.  Occurring  in  the 
year  1858,  it  disposes  of  two  theoretical  statements  which  have  of  late 
been  much  discussed,  viz. — 1st,  TJiat  such  cases  are  now  not  to  be  met 
with ; and,  2d,  that  if  they  should  occur,  bleeding  would  again  be  re- 
quired for  their  treatment.  In  this  respect  the  case  resembles  that  of 
Koderick  M^Farlane,  Case  CXLVII. ; and  in  severity  that  of  Peter 
Robertson,  Case  CXLIX.  In  consequence  of  the  dyspnoea  and  evident 
engorgement  of  the  right  side  of  the  heart,  he  was  cupped,  and  3 v of 
blood  extracted,  with  the  effect  of  relieving  his  symptoms,  but  for  a time 
only,  as  they  returned  with  equal  intensity  in  a few  hours.  This  is 
the  result  which  usually  followed  large  venesections,  and  which  misled 
practitioners  as  to  its  utility.  I have  no  doubt  that  a large  bleeding  in 
this  case,  if  it  had  not  proved  fatal,  would  have  seriously  prolonged  his 
recovery,  which  took  place  under  an  opposite  treatment  on  the  ninth 
day.  The  case  inculcates  another  caution — viz.,  the  necessity  of  avoid- 
ing exposure  to  cold  during  convalescence,  as  in  the  debilitated  condition 
which  then  exists  there  is  very  likely  to  be  a relapse,  or  some  other 
form  of  febrile  disease,  again  proving  that  these  are  the  results  of  weak- 
ness  rather  than  of  strength. 

Case  CXLIX.* — Bouhle  Pneumonia — Great  Pyspnoea — No  Heeding — 
Local  warmth  and  Stimidants — Rapid  Recovery. 

History. — Peter  Kobertson,  set.  51,  a tolerably  robust  man,  house-painter — admit- 
ted May  11,  1857.  On  Tuesday  last,  the  5th  instant,  when  washing  the  outside  of  a 
house,  he  got  wet  through  from  the  dripping  of  water.  In  the  evening  had  a rigor, 
which  continued  more  or  less  all  night.  On  the  following  morning  had  a short  cough, 
and  a thick  yellow  sputum.  These  symptoms  continued  the  two  following  days,  with 
pain  in  the  left  breast  anteriorly ; but  he  continued  at  his  work,  although  feeling 
very  weak.  On  the  9th  he  was  obliged  to  go  to  bed,  and  observed  his  sputum  to  be 
tinged  with  blood.  Yesterday  again  had  rigors,  with  cramps  in  the  arms  and  elbows. 

Symptoms  op  Admission. — On  percussion  there  is  marked  dulness  over  the  lower 
two-thirds  of  the  left  lung  posteriorly,  with  tubular  breathing  and  coarse  mucous  rale  on 
inspiration.  The  vocal  resonance  is  aegophonic  inferiorly,  and  bronchophonic  over  the 
middle  third.  Right  side  and  anterior  surfaces  normal.  Sputum  copious  and  viscid, 
mixed  with  dark  blood.  Pulse  100,  small  and  weak.  Respirations  36  per  minnte. 
Skin  moist.  Other  functions  normal.  R Liq.  Ammon.  Acet.  yEther.  Nitric. 

I ss  ; Vhi.  Antim.  §jss:  Aquam  ad  § vj.  M.  One  table- spoonf id  to  be  taken  every 
three  hours. 

Progress  op  the  Case. — May  W.h. — Dulness  on  percussion  over  lower  third  of 
right  back,  in  addition  to  that  on  the  left,  with  tubular  breathing  and  increased  vocal 
resonance.  Physical  signs  otherwise  the  same.  Respirations  are  40  in  the  minute, 
laborious  and  catching.  Sputum  gelatinous  and  rusty.  Pulse  120,  weak.  Face 
livid,  and  expressive  of  great  anxiety.  Urine  high  colored,  scanty,  and  deficient  in 
chlorides.  Warm  fomentations  to  be  applied  over  left  side.,  and  to  have  § iv  wine. 
May  \2>th. — Much  better.  Respiration  easy.  No  lividity  or  anxiety  of  countenance. 
Cough  diminished.  Pulse  80,  soft,  but  of  good  strength.  Omitt.  mist.  May  lAth. — 
Less  dulness  and  crepitation  on  left  side  ; on  right  side  crepitation  fully  established. 
Chlorides  present  to  a slight  degree  in  urine,  and  urates  abundant.  Pulse  74,  regular. 
Appetite  returning.  Tongue  clean.  May  \<6th. — Is  now  convalescent.  Urine  natural. 
Percussion  resonant  over  both  backs  ; inspiratory  murmurs  heard,  but  no  moist  rales. 
Cough  painless.  Still  gelatinous  sputum  without  blood.  Has  been’  out  of  bed,  and 
feels  tolerably  strong.  Steak  diet.  ALay  l^th. — Has  been  up  all  day,  and  says  he  is 
quite  well.  May  ^Oth. — Dismissed. 

Commentary. — This  was  a severe  case  of  double  pneumonia,  with 
great  dyspnoea,  impending  suffocation,  and  great  weakness  on  the  seventli 

* Reported  by  Mr.  W.  H.  Davies,  Clinical  Clerk. 


682 


DISEASES  OF  THE  EESPIEATOEY  SYSTElf. 


day,  when  wine  was  liberally  administered.  On  the  following  day  he 
was  better,  and  continued  to  improve,  so  that  on  the  fifth  day  after  admis- 
sion he  was  fully  convalescent,  and  on  the  ninth  was  quite  well,  and  re- 
turned to  his  work.  I never  saw  a case  in  which  the  symptoms  were 
more  urgent  than  in  this  man  the  day  after  his  admission,  and  in  which 
the  livid  and  anxious  countenance,  the  intense  dyspnoea,  the  bloody 
sputum  and  feeble  pulse,  gave  stronger  evidence  of  impending  dissolution. 
A question  arises  whether,  if  this  man  had  been  bled,  he  would  have 
been  relieved.  I think  this  is  very  probable.  But  it  appeared  to  me  at 
the  time,  that  the  practice  would  have  been  fatal.  Certain  it  is,  that  by 
following  an  opposite  treatment  of  warm  fomentations  locally,  and  wine 
internally,  these  symptoms  quickly  subsided,  and  next  day  he  was  found 
breathing  easily,  and  from  that  moment,  though  both  lungs  were  alfected, 
speedily  recovered.  In  a similar  case,  recently  published  by  Dr.  Mark- 
ham, a bleeding  of  3 xvj  caused  marked  and  immediate  relief,  and  on  this 
ground  the  practice  of  bleeding  is  again  inculcated.  Now,  everything 
in  such  a case  depends  upon  the  character  of  the  pulse  and  amount  of 
exhaustion — two  points  not  referred  to  by  Dr.  Markham.  It  is  to  be 
observed,  however,  that  whilst  the  above  case,  with  the  same  impending 
dissolution  from  asphyxia  and  double  pneumonia,  was  convalescent  in 
five  days  after  entering  the  house,  and  left  the  hospital  quite  well  on 
the  ninth  day.  Dr.  Markham’s  case,  though  relieved  by  bleeding,  had  a 
long  convalescence,  with  pericarditis  and  pleuritic  abscess.* 

Case  CL.f — Pneumonia  on  the  Right  Side — Early  Bleeding — Slow 

Recovery. 

History. — James  M‘Quair,  tailor,  aet.  29 — admitted  June  4th,  1855.  This  man 
has  been  of  intemperate  habits  during  the  last  five  years.  On  the  28th  of  May,  after 
severe  drinking  and  exertion,  followed  by  exposure  to  the  night  air,  he  was  attacked 
early  in  the  morning  with  rigor,  chilliness,  a feeling  of  weight  over  his  whole  body, 
and  a dull  heavy  pain  in  the  right  chest.  He  drank  several  glasses  of  whisky  and 
water  to  allay  his  thirst,  and  kept  his  bed,  occasionally  vomiting,  and  going  out  of 
doors  to  stool,  until  the  30th.  He  now  felt  very  feverish,  weak,  and  unwell,  and  a 
soup-})lateful  of  blood  was  extracted  from  the  arm  ( 3 xxiv).  Venesection  to  the  same 
amount  was  made  on  the  following  day  ; but  the  pains  in  the  side,  with  sanguineous 
cough  and  expectoration  continuing,  he  came  to  the  Infirmary. 

Symptoms  on  Admission. — On  admission,  the  patient  has  an  anxious  and  flushed 
appearance,  and  feels  very  weak.  The  respiration  is  hurried,  42  in  a minute,  and  the 
lower  part  of  the  right  lung  expands  little.  Cough  is  short,  frequent,  and  suppressed ; 
the  expectoration  scanty,  consisting  of  gelatinous  mucus,  slightly  tinged  Avith  blood. 
Oil  percussion,  there  is  marked  comparative  dulness  over  the  inferior  half  of  the  right 
lung,  but  the  upper  half  anteriorly,  especially  at  the  apex,  though  flat  in  tone,  gives 
out  a tympanitic  and  somewhat  intestinal  note.  On  auscultation,  crepitation  is  audible 
all  over  the  right  lung,  both  anteriorly  and  posteriorly,  and  the  vocal  resonance  is 
much  increased  over  the  dull  portion.  The  left  lung  is  normal.  The  pulse  is  100, 
hard  and  incompressible.  Heart  normal.  Tongue  dry,  and  covered  with  a dark 
brown  fur,  and  the  teeth  surrounded  by  sordes.  Appetite  gone;  great  thirst;  the 
vomiting,  which  existed  at  the  commencement  of  the  attack,  has  noiv  ceased.  Abdo- 
mina'  viscera  normal ; bowels  regular.  Skin  dry  and  hot  to  the  feel.  Urine  high- 
colored  and  diminished  in  quantity,  clear  and  without  sediment.  No  trace  of  chlo- 
rides; no  albumen.  Nervous  system  normal.  Antim.  Tart.  gr.  iij  ; Aquae  § vj ; 
8olv^  One  ounce  to  he  taken  every  three  hours. 

Pko^res.s  of  the  Case. — June  bth. — Says  he  feels  better ; pulse  90,  full  and 


* British  Med.  Journal,  Feb.  4,  1865. 
f Reported  by  Mr.  Robert  Byers,  Clinical  Clerk. 


PNEUMONIA. 


683 


compressible,  but  in  the  evening  it  fell  to  80,  and  became  soft.  June  Uh. — Pulse  78, 
soft,  breathing  more  easy.  On  percussion,  the  lower  half  of  right  lung  is  dull,  but 
the  upper  half  is  resonant,  with  distinct  cracked-pot  sound.  Fine  crepitation  audible 
over  the  whole  of  right  chest.  June  Sth. — The  whole  of  the  right  lung  in  front  has 
become  resonant  on  percussion  ; otherwise  the  same.  Faint  trace  of  chlorides  in  the 
urine.  Jmie  ^th. — Chlorides  abundant  in  the  urine.  June  10th. — Percussion  re- 
sonant and  equal  over  both  sides  of  chest  anteriorly.  Under  right  clavicle,  cracked- 
pot  sound  still  audible.  Crepitation  much  less  inferiorly,  but  continues  at  the 
apex,  with  increase  of  vocal  resonance.  Posteriorly,  percussion  over  right  lung  dull 
inferiorly,  with  loud  crepitation,  and  segophonic  resonance  of  voice.  The  patient 
feels  much  better,  though  weak.  Respiration  free.  Pulse  72,  soft  and  regular.  Con- 
siderable diaphoresis.  Urine  deposits  on  cooling  a large  amount  of  lithates.  R An- 
tim.  Tart.  gr.  ij  ; Tinct.  Camph.  co.  3 ij  ; Decoct.  Serpent.  § xij.  M.  ^ j.  to  he  taken 
every  three  hours.  June  lAth. — Physical  signs  of  right  lung,  with  the  exception  of 
cracked-pot  sound,  much  diminished.  lias  been  taking,  during  the  last  three  days, 
good  diet,  with  § ivof  wine.  From  this  time  he  improved  slowly,  the  crepitation  and 
dulness  posteriorly  gradually  disappeared,  but  the  cracked-pot  sound  continued  with 
great  intensity  up  to  the  29th  of  June,  His  strength  was  not  sufficient  to  admit  of 
his  discharge  until  the  3d  of  July. 

Commeyitartj . — This  was  a case  io  which  nearly  the  whole  of  the 
right  lung  became  pneumonic,  and  where  we  had  an  opportunity  of 
convincing  ourselves  that  full  and  repeated  bleeding,  although  practised 
so  early  as  the  second  and  third  days,  had  no  beneficial  influence  on 
the  progress  of  the  disease.  It  should  also  be  remarked,  that  these 
bleedings  were  practised  in  accordance  with  the  rules  laid  down  in 
systematic  writings,  that  is  to  say,  not  only  early,  but  when  the  pulse 
was  accelerated,  hard  and  incompressible,  with  all  the  characteristic 
symptoms  of  the  disease.  Surely,  if  bleeding  could  cut  short  or 
diminish  the  duration  of  a pneumonia,  it  might  have  been  expected  in 
this  case.  Yet  so  far  from  proving  beneficial,  they  appear  to  me  to 
have  assisted  in  prolonging  the  case,  and  preventing  resolution  and 
recovery.  For  although  the  critical  diaphoresis,  and  discharge  of 
lithates  by  urine,  occurred  on  the  fourteenth  day,  the  subsequent  weak- 
ness was  considerable. 

On  his  admission  into  the  house,  the  Sth  day  of  the  disease,  the 
chlorides  were  observed  to  be  absent  from  the  urine.  This  fluid  was 
tested  daily  for  these  salts,  which  returned  in  small  quantity  on  the 
twelfth,  and  were  abundani  on  the  thirteenth  day  of  the  disease.  If, 
as  we  shall  subsequently  see,  it  is  probable  their  reappearance  indicates 
a cessation  of  fresh  exudation,  then  it  was  observable  that  on  the  day 
following,  excretion  of  the  morbid  products  commenced  by  the  skin  and 
kidneys.  The  interval  between  the  return  of  chlorides  to  the  urine  and 
the  critical  period,  varies  considerably  in  different  cases ; but  the  careful 
estimate  of  these  facts  in  future  will,  I think,  furnish  us  with  valuable 
hints  as  to  the  vital  pow^  of  the  exudation.  If,  for  instance,  it  should 
ultimately  be  shown  that  the  return  of  chlorides  indicates  stoppage  of 
exudation,  and  the  presence  of  lithates  or  other  critical  discharge,  the 
commencement  of  excretion  of  the  exudation,  then  we  shall  possess 
evidence  not  previously  discovered,  as  to  when  the  pathological  lesion  is 
checked,  and  when  the  reparative  changes  in  the  economy  commence. 

Another  fact,  which  excited  considerable  attention  in  this  case,  was 
the  characteristic  cracked-pot  sound  under  the  right  clavicle.  The 
physical  signs  sufficiently  proved  that  the  pneumonic  condensation  com- 
menced at  the  base  of  the  lung,  and  proceeded  upwards,  where,  poste- 


684 


DISEASES  OF  THE  RESPIRATORY  SA'STEM. 


riorly  and  anteriorly,  a considerable  amount  of  air  was  retained  in  the 
air  vesicles,  so  that  percussion  was  never  dull,  although  crepitation  and 
increased  vocal  resonance  existed.  This  presence  of  condensed  lung 
covered  with  or  surrounded  by  air,  or  of  a cavity  containing  air,  sur- 
rounded by  condensed  tissue,  seems  to  constitute  the  condition  under 
which  this  peculiar  noise  is  elicited  when  the  mouth  is  open.  Hence 
the  occurrence  of  the  cracked-pot  sound  {Iruit  de  pot  feU)  is  common  in 
pneumonia,  and  in  a variety  of  diseases  which  present  similar  physical 
conditions.^ 

Case  CLT.f — Double  Pneumonia — Treatment  by  Mercury^  which  caused 
Profuse  Salivation  before  Admission — Prolonged  Recovery. 

History, — Robert  Jude,  set.  36,  a bricklayer — admitted  10th  December,  1855.  On 
the  1st  instant,  while  engaged  building  bricks  round  a boiler,  the  weather  being  very 
cold  and  windy,  he  suddenly  felt  a pain  in  the  chest,  deep-seated,  half  way  between 
the  ensiform  cartilage  and  umbilicus.  The  pain  rapidly  grew  worse,  and  caused 
nausea,  but  he  could  not  vomit.  He  immediately  went  home,  took  some  gruel,  and 
went  to  bed.  On  the  4th,  a medical  man  gave  him  some  pills,  one  of  which  he  took 
every  third  hour.  On  the  Gth  his  teeth  were  loose,  the  gums  very  tender,  and  the 
tongue  swollen  to  twice  its  natural  size,  so  that  he  could  not  spit  out  the  excessive 
amount  of  saliva  that  was  secreted,  and  which  consequently  flowed  from  his  mouth. 
He  also  had  pain  in  the  loins. 

Symptoms  on  Admission. — On  admission,  the  excessive  salivation  has  much  di- 
mini.shed,  but  there  is  still  tenderness  and  redness  of  the  gums,  with  'considerable  dis- 
charge from  the  mouth.  The  breath  foetid,  the  tongue  covered  with  a dense,  dirty 
white  coating.  Tlie  bowels,  while  taking  the  pills,  were  open  from  six  to  seven  times 
a day ; they  are  now  regular.  His  diet  has  been  confined  to  farinaceous  articles.  On 
percussing  the  chest  anteriorly,  it  is  everywhere  resonant,  but  posteriorly  it  is  dull  on 
both  sides,  most  so  on  left  side.  On  auscultation  anteriorly  nothing  abnormal,  but  pos- 
teriorly respiratory  murmurs  are  harsh  and  shrill,  with  occasional  sibilation.  At  the 
base  on  rigid  side,  there  is  crepitation  on  inspiration;  on  the  left  side  respiration  is 
tubular.  Vocal  resonance  equal  superiorly  and  anteriorly,  but  posteriorly  everywhere 
increased,  on  the  left  side  amounting  to  bronchophony.  Pulse,  96,  weak  ; heai-t  sounds 
normal ; skin  hot,  moderately  dry,  but  there  has  been  profuse  perspiration  ; there  is 
dull  pain  in  lumbar  regions ; urine  opaque  from  the  existence  of  a reddish  cloud ; sp. 
gr.  1024,  not  coagulable,  but  clears  on  the  addition  of  heat ; chlorides  diminished  in 
quantity.  1^  Sp.  uEther.  Nit.  3 iij  ; Potass.  Acet.  3 ij  ; Aquam  ad  §yj.  M.  One 
table-spoonful  to  he  taken  every  four  hours.  R Liquor.  Sodae.  Chlor  | j ; Sp.  Vini 
Gallic.  § ss  ; Inf  us.  Rosar.  c.  ad  § yj.  M.  Ft.  garyarisma. 

Progress  of  the  Case. — December  \lth. — Crepitation  more  diffused  over  right 
back.  On  left  side  respirations  still  dry  and  harsh.  Cldorides  absent  from  urine. 
Dec.  12<A. — Crepitation  now  audible  over  left  back.  Lithates  in  urine  more  abundant. 
Discharge  of  saliva  still  copious,  but  greatly  diminished  in  amount.  Pulse  80,  weak. 
JIabeat  Vini  ^ iij  per  diem.  DCc  \Wi. — Chlorides  in  urine  again  perceptible.  Dec. 
\Ath. — Chlorides  in  urine  abundant.  Crepitation  posteriorly  diminishing,  sputum  still 
copious,  frothy,  and  somewhat  gelatinous.  Breath  continues  to  give  off  the  mercurial 
foetor.  Dec.  \Mh,. — Last  night  had  copious  diaphoresis,  followed  by  great  relief 
ill  his  breathing.  Still  a few  crepitations  posteriorly,  increased  vocal  resonance, 
more  marked  on  left  than  on  right  side.  Urates  very  abundant  in  urine.  From 
this  time  he  gradually  improved.  On  the  21st  all  moist  rale  had  disappeared, 
but  respiratory  murmurs  harsh  posteriorly,  and  vocal  resonance  still  increased.  Dec. 
26^A. — Still  a coppery  taste  in  the  mouth.  Yesterday  felt  hungry  for  the  first  time, 
and  was  ordered  an  egg  for  breakfast  and  steak  for  dinner.  From  this  time  he  rapidly 
recovered,  and  he  was  dismissed  January  2,  1856. 

Commentary. — In  this  decided  case  of  pneumonia,  with  absence  of 
chlorides  from  the  urine,  we  had  an  opportunity  of  observing  the  elfects 

* See  the  Author’s  clinical  investigation  into  the  diagnostic  value  of  the  cracked 
pot  sound — Edin.  Med.  Journal,  vol,  i.,  p.  789.  1856. 

f Reported  by  Mr.  John  Glen,  Clinical  Clerk. 


PNEUMONIA. 


685 


of  mercurial  salivation  on  the  progress  of  the  disease.  If  it  he  con- 
trasted with  many  other  cases  of  the  same  kind  previously  recorded,  it 
will'  be  seen  that  the  disease  itself  was  in  no  way  shortened  by  the 
exhibition  of  mercury.  Resolution  commenced  on  the  fourteenth,  but 
was  not  completed  till  the  twenty-first  day.  On  the  other  hand,  the 
unpleasant  effects  produced  by  the  mercury,  the  severe  swelling  of  the 
tongue,  soreness  of  the  gums  and  profuse  salivation,  must  not  only  be 
regarded  as  so  many  increased  evils  and  unnecessary  symptoms  super- 
added  to  the  original  disease,  but  as  being  the  cause  of  prolonging  the 
convalescence.  For  although  the  leading  physical  signs  had  disappeared 
on  the  twenty-first  day,  he  could  not  eat  until  the  twenty-sixth  day,  in 
consequence  of  the  coppery  taste  in  his  mouth.  But  as  soon  as  nutri- 
ents could  be  taken,  he  recovered  rapidly.  No  fact  could  better  demon- 
strate the  utter  uselessness  of  the  drug,  and  its  occasional  mischievous 
effects. 

Case  CLII.^ — Pneumonia — ushered  in  by  Violent  Vomiting  and  Gastric 
Pain — Recovery  in  jive  days. 

History. — Edward  Nugent,  set.  28,  a waiter — admitted  November  8th,  1868. 
Has  always  enjoyed  good  health  until  about  three  weeks  ago,  when  he  went  to  Liver- 
pool from  Glasgow  by  water,  and  suffered  very  severely  from  sea  sickness.  Three 
days  afterwards,  on  the  return  passage,  he  was  again  very  sick,  and  for  a few  days 
after  felt  soreness  in  the  epigastric  region.  He  then  became  quite  well  until  Monday 
the  8th,  at  1 p.m.,  when,  whilst  cleaning  plate,  and  about  ten  minutes  after  eating  a 
hearty  dinner,  he  was  suddenly  seized  with  severe  pain  in  the  epigastrium,  cold 
sweats,  vertigo,  desire  to  vomit,  but  inability  to  do  so.  He  was  immediately  con- 
veyed to  the  infirmary. 

Symptoms  on  Admission. — The  patient  was  pale  and  livid,  almost  pulseless,  and 
complained  of  sickness,  cold,  profuse  clammy  perspiration,  and  great  pain  in  epigastri- 
um, increased  on  pressure.  Shortly  after  admission  he  vomited  what  he  had  taken  at 
dinner,  but  was  not  relieved ; warm  bottles  were  applied  to  his  feet,  and  hot  fomenta- 
tions to  the  painful  part.  His  suffering  continued  ; at  4 p.m.  six  leeches  were  applied 
to  the  epigastrium,  and  3 ss  of  Sol.  of  Morphia  administered.  These  remedies  gave 
some  relief,  and  he  remained  in  comparative  ease  till  about  10  p.m.,  when  some  Magn. 
Sulph.  was  given,  as  the  bowels  had  been  costive  for  some  days  previously. 

Progress  of  the  Case. — November  ^th. — He  had  no  sleep  during  the  night,  and 
his  symptoms  have  remained  stationary.  He  has  had  three  or  four  dark- colored 
stools.  Early  in  the  morning  he  was  ordered  for  the  vomiting  Creasoti  gtt,  ij  ; Sol. 
Mur.  Morph.  3 ss  ; ft.  haust;  also  a table-spoonful  of  Port  wine  every  hour.  At  the 
visit  (noon)  his  symptoms  had  in  no  way  abated,  and  he  was  ordered  to  continue  the 
wine  ; to  take  bej  tea  in  small  quantities  ; and  a tea-spoonful  of  the  following  mixture 
every  hour  until  the  pain  decreased : — ^ Sol.  Mur.  Morph.  3 ij  ; Sp.  uPth.  Sulph. 
3 vj  ; Ft.  mist.  The  mixture  caused  great  relief,  and  in  the  afternoon  he  was  able  to 
bear  further  examination.  The  cardiac  sounds  were  indistinct  ; pulse  58,  extremely 
feeble  and  intermitting.  Respiration  labored,  and  the  pain  in  epigastrium  increased 
during  inspiration.  There  was  slight  harshness  of  inspiration,  and  increased  vocad 
resonance  under  both  clavicles.  He  had  great  pain  at  the  back  of  his  head,  and  some 
giddiness  ; tongue  dry  and  furred  ; no  appetite ; great  thirst ; no  perceptible  swell- 
ing in  epigastrium  ; abdomen  tender  and  hot ; urine  natural  in  color  and  quantity, 
but  only  a slight  trace  of  chlorides.  In  the  evening  he  was  better,  the  pain  had 
greatly  subsided,  and  there  was  less  sickness  ; he  was  able  to  retain  sbme  small  quan- 
tities of  beef  tea.  Slight  dulness,  increase  of  vocal  resonance,  and  ci'epitation,  were 
detected  at  the  base  of  the  left  lung  posteriorly.  Nov.  10//i. — He  passed  a tolerably 
good  night,  and  had  some  sleep  ; the  epigastric  pain  and  sickness  still  further 
diminished.  Pulse  98,  weak.  The  physical  signs  observed  in  left  lung  last  evening 
were  not  audible  at  visit,  but  were  again  heard  in  the  evening.  Ordered  to  discon- 
tinue the  mixture.,  and  to  continue  the  wine  and  beef  tea  in  small  quantities.  Nov. 


* Reported  by  Mr.  Arthur  Garrington,  Clinical  Clerk. 


686 


DISEASES  OF  THE  RESPIEATOET  SYSTEM. 

WtJi. — He  passed  a good  night ; he  stUl  has  slight  sickness  and  tenderness  over 
epigastrium.  He  complains  of  pain  in  the  left  breast,  increased  during  inspiration  ; 
he  has  some  shortness  of  breath,  troublesome  cough,  and  a greyish,  tenacious  sputum 
containing  a few  rusty-colored  masses.  Marked  dulness,  with  increased  vocal  reson- 
ance, and  clear  crepitation,  audible  over  lower  third  of  left  side  posteriorly.  Pulse  88, 
tolerably  full ; tongue  loaded.  The  patient  says  he  has  liad  rigors  every  day  since  ad- 
mission, and  yesterday  was  so  cold  that  he  had  warm  bottles  applied  to  his  feet.  On 
examination  of  the  urine,  the  chlorides  were  still  diminished,  and  there  was  a deposit 
of  triple  phosphates.  Nov.  \2tJi. — Now  sleeps  well.  His  appetite  is  much  improved. 
The  epigastric  pain  and  tenderness  and  the  sickness  have  disappeared.  Pulse  90,  full 
and  regular.  Crepitation  very  fine ; vocal  resonance  still  increased.  Cough  not  so 
bad,  no  rusty  masses  in  the  sputum.  Nov.  1 Mh. — The  crepitation  has  disappeared  ; 
there  is  some  harshness  of  inspiration.  Sputum  muco-purulent.  Chlorides  abundant 
in  the  urine.  His  bowels  being  confined,  he  was  ordered  an  enema  of  warm  water. 
Nov.  15/A. — Respiration  quite  natural.  He  says  he  only  feels  a little 'w  eak,  but  is 
otherwise  so  well  that  he  insists  on  being  discharged. 

Commentary. — In  this  case  of  severe  gastric  irritation,  pneumonia 
came  on  in  the  Infirmary — was  well  characterized  by  all  the  symptoms 
and  physical  signs  of  the  disease,  was  limited  to  the  posterior  third  of  the 
left  lung,  occurred  in  a healthy  young  man,  and  was  treated  by  stimulants 
and  nutrients  from  the  beginning.  The  result  was  recovery  on  the  fifth 
day  and  discharge  from  the  hospital  at  his  own  request  quite  well  on  the 
seventh  day.  It  is  the  most  rapid  recovery  from  decided  pneumonia  that 
has  ever  fallen  under  my  notice.  The  facts  of  this  case  are  also  entirely 
opposed  to  the  notions  of  those  who  consider  that  inflammation  is  in 
some  way  connected  with  a sthenic  or  excited  state  of  the  system.  The 
man  was  in  perfect  health  when  seized  with  the  gastric  spasms,  and  was 
by  them  reduced  to  a pulseless  and  exceedingly  prostrated  state,  with 
cold  clammy  sweats.  It  was  in  this  weakened  condition  that  the 
pneumonia  arose,  and  its  limited  extent  and  short  course  I ascribe  to  the 
stimulants,  nutrients,  and  quietude  with  which  it  was  treated  from 
the  first. 

On  the  Diagnostic  Value  of  the  Absence  of  Chlorides  from  the  Urine 

in  Pneumonia. 

Simon  and  Redtenbacher  first  stated  that  chloride  of  sodium,  a salt 
always  present  in  healthy  urine,  was  absent  from  that  fluid  during  the 
onward  progress  of  pneumonia,  and  returned  to  it  when  absorption  of 
the  exudation  was  about  to  commence.  This  statement  was  confirmed  by 
Dr.  Beale  of  London,  who,  in  the  35th  vol.  of  the  Transactions  of  the 
Medico- Chirurgical  Society  of  London,  furthered  our  knowledge  regarding 
it  by  additional  valuable  researches.  My  attention  was  directed  to  this 
remarkable  fact  during  the  Session  1853-54,  by  Dr.  Robert  Cartwright,  a 
gentleman  attending  the  Clinical  Wards  of  the  Infirmary,  who  informed 
me  that  he  had  seen  it  occasionally  of  great  service  in  a diagnostic  point 
of  view,  in  the  clinical  wards  of  Professor  Oppolzer  at  Vienna.  It  so 
happened  that  a man,  John  McDonald,  set.  25,  had  just  been  admitted, 
laboring  under  well-marked  simple  pneumonia  at  the  apex  of  the  right 
lung.  He  was  a laborer,  who  had  enjoyed  perfect  health  until  two  days 
before  admission,  when,  on  being  exposed  to  wet  and  cold,  working  at 
drains,  he  was  seized  with  shivering,  followed  by  fever  and  the  usual 
symptoms  and  signs  of  pneumonia.  On  adding  a drop  of  nitric  acid  to 
some  of  his  urine  in  a test  tube,  and  then  dropping  into  it  a little  of  the 


PXEUMOXXA. 


687 


solution  of  the  nitrate  of  silver,  the  fluid  remained  clear,  although  so  great 
is  the  delicacy  of  this  test,  that  a white  cloudy  precipitate  is  at  once 
formed,  if  a very  minute  quantity  of  the  chloride  of  sodium  be  present. 
It  was  on  the  fourth  day  of  the  disease  that  the  observation  was  first 
made,  and  the  chlorides  remained  absent  during  the  fifth  and  sixth  days, 
during  which  period  the  disease  extended  from  above  downwards,  until 
it  occupied  the  upper  two-thirds  of  the  right  lung.  On  the  seventh  day 
a slight  haze  was  observed  in  the  urine,  indicating  that  the  salt  was  re- 
turning to  the  fluid,  and  the  man  expressed  himself  as  being  much 
better.  On  this  day  there  was  great  dulness  on  percussion,  all  crepitation 
had  ceased,  the  breathing  was  tubular  with  bronchophony.  On  the  eighth 
day,  slight  returning  crepitation  was  audible,  the  dulness  had  diminished, 
but  the  urine,  owing  to  some  accident  before  the  visit,  had  been  thrown 
away.  On  the  ninth  day,  however,  the  chlorides  were  abundant  in  that 
fluid,  together  with  lithates;  loud  crepitation  was  now  universal  through- 
out the  lung,  and  the  dulness  had  nearly  disappeared.  From  this  time 
the  man  made  a rapid  recovery,  never  having  been  bled,  and  was  dis- 
charged quite  well  on  the  sixteenth  day. 

I now  requested  Mr.  Seymour,  one  of  the  clinical  clerks,  to  test  the 
urine  of  all  the  patients  in  the  ward,  and  others  who  might  subsequently 
be  admitted,  which  he  did,  and  thus  collected  a large  number  of  observa- 
tions, the  results  of  which  I shall  allude  to  immediately.  In  the  mean 
time  another  case  entered,  which  seemed  to  point  out  the  value  of  this 
test  in  a diagnostic  point  of  view.  It  was  that  of  a man,  Donaldson,  set. 
26,  laboring  under  typhus  fever,  in  whom  the  disease  ran  its  usual 
course  to  the  tenth  day,  when  chlorides  were  demonstrated  in  it.  On  the 
eleventh  day,  however,  pulmonary  symptoms  came  on,  and  the  chlorides 
were  entirely  absent  from  the  urine.  This  led  me  to  make,  with  the 
clinical  class,  a careful  examination  of  the  chest,  when  all  the  signs  of 
pneumonia  were  detected  in  the  lower  half  of  the  right  lung.  On  the 
fourteenth  day  the  chlorides  reappeared,  the  pneumonic  signs  diminished, 
and  the  fever  ceased  with  a critical  sweat. 

A third  case  was  even  more  satisfactory  in  proving  the  moment  of 
commencing  and  departing  pneumonia  by  testing  the  urine  for  culoride 
of  sodium.  A man  called  David  Murray,  aet.  43,  entered  with  pneumonia 
of  the  lower  two-thirds  of  the  right  lung.  No  consistent  account  could 
be  obtained  from  him  as  to  when  the  disease  commenced,  and  it  was  im- 
possible, therefore,  to  determine  whether  the  coarse  crepitation  which  was 
audible  over  the  inflamed  lung  was  the  advancing  or  returning  crepita- 
tion; but  the  chlorides  were  absent  from  the  urine,  which  indicated  that 
the  disease  was  advancing.  The  following  day  complete  consolidation 
had  occurred,  with  dry  tubular  breathing  and  absence  of  crepitation,  and 
a minute  quantity  of  the  chlorides  was  found  in  the  urine.  The  patient, 
however,  instead  of  getting  better,  showed  no  improvement,  and  the  next 
day  the  chlorides  had  again  disappeared,  indicating  extension  of  the 
pneumonia.  On  the  evening  of  this  day  he  was  seized  with  acute 
meningitis,  of  which  he  died.  On  dissection,  in  addition  to  universal 
cerebral  meningitis,  the  whole  of  the  right  lung  presented  the  usual 
characters  of  grey  hepatization.  (See  Case  IV.) 

It  will  be  observed  in  all  the  preceding  cases,  thirteen  in  number, 


688 


DISEASES  OF  THE  EESPIEATORY  SYSTEM. 


that  with  the  exception  of  Case  CXXIX.,  the  absence  or  decided 
diminution  of  chlorides  marked  precisely  the  onward  march  of  the 
pneumonia,  whilst  their  presence  indicated  its  cessation,  and  was  generally 
accompanied  by  the  returning  crepitation  and  commencing  absorption 
of  the  exudation.  It  still  remains  to  be  determined  whether  the  absence 
of  the  salts  is  a cause  or  a result  of  exudation  into  the  lungs — whether 
the  interference  to  the  respiratory  functions,  by  diminishing  the  amount 
of  oxygen  absorbed,  gives  rise  to  these  chemical  changes  in  the  blood 
which  react  on  the  urinary  secretion.  If  so,  what  is  the  nature  of  these 
changes  ? Indeed,  a crowd  of  questions  will  be  suggested  to  the  mind  of 
the  physiologist  from  the  establishment  of  the  remarkable  clinical  fac*t 
of  which  we  are  now  speaking.  That  such  is  an  important  diagnostic  sign 
I have  no  doubt,  and  it  was  singularly  well  tested  in  the  following  case, 
in  which  there  were  many  signs  and  symptoms  of  pneumonia,  complicated 
with  heart  disease.  The  question  on  admission  was  whether,  with  heart 
disease  and  bronchitis,  pneumonia  might  not  be  conjoined,  and  I was 
assisted  in  answering  in  the  negative  by  the  abundance  of  chlorides  which 
the  urine  contained. 

Case  CLIII.^ — Bronchitis  and  Pulmonary  Congestion^  from  Morhus 
Cordis^  resembling  Pneumonia^  hut  no  absence  of  Chlorides  in  the 
Urine. 

History. — John  Dickson,  aet.  44,  pensioner — admitted  July  21st,  1854.  Says 
that  on  the  evening  of  the  19th  he  was  seized  with  chilliness,  followed  by  sweating, 
heat  of  sldii,  thirst,  impaired  appetite  and  expectoration  of  a frothy  fluid,  resembling 
liquorice  juice.  He  has  for  some  time  felt  an  uneasy  sensation  in  the  epigastrium, 
which,  since  his  recent  illness,  has  amounted  to  pain.  Yesterday  he  experienced  great 
dyspnoea  and  anxiety,  s^miptoms  which  have  continued  until  now. 

Symptoms  ox  Admission. — On  admission  there  is  excessive  dyspnoea,  with  expec- 
toration of  a tenacious  sputum,  of  a reddish-brown  color.  On  percussion,  there  is  no 
comparative  dulness,  but  posteriorly  the  resonance  is  impaired  on  both  sides.  On  aus- 
cultation anteriorly,  the  expectoration  is  everywhere  much  prolonged,  and  posteriorly 
there  is  considerable  crepitation  with  bronchophony.  Pulse  92,  of  good  strength. 
The  heart’s  sounds  are  entirely  masked  by  the  prolonged  wheezing  expiration  and  agi- 
tation of  the  chest.  He  cannot  lie  on  his  back  or  left  side,  is  easily  agitated,  frequently 
experiences  palpitations,  and  cannot  sleep.  Abundant  chlorides  in  the  urine.  Other 
functions  normal.  1^  8p.  jEther.  Sulph.  3 ss : Aq.  Cassice\  | iv.  One  table-spoonful 
to  he  taken  in  water  occasionally.  To  have  one-quarter  of  a grain  of  Antim.  Tart,  in 
solution  every  two  hours. 

Progress  of  the  Case. — July  T^th. — Since  last  report  the  dyspnoea  has  diminish- 
ed, the  crepitation  posteriorly  continues,  but  the  wheezing  anteriorly  is  less.  Still 
gelatinous  sputum,  specked  with  rusty-colored  blood.  The  apex  of  the  heart  cannot 
be  felt,  but  a double  blowing  murmur  is  now  recognizable,  accompanying  both  the 
flrst  and  second  sounds — the  systolic,  loudest  at  the  apex,  and  the  diastolic,  loudest  at 
the  base.  Omit  the  Antimony.  July  31s^. — The  pulmonary  symptoms  and  signs 
have  now  greatly  subsided,  whilst  the  cardiac  lesion  has  become  more  distinct.  For 
this  latter  he  remained  in  the  house  until  the  commencement  of  November,  when  he 
was  dismissed  greatly  relieved. 

Mr.  Seymour  tested  with  great  care,  and  at  repeated  times,  the  urine 
of  upwards  of  fifty  other  cases  in  the  wards,  embracing  a great  variety 
of  disease.  He  found  the  chlorides  absent  in  one  case  of  phthisis,  with 
intercurrent  pneumonia,  but  in  no  other.  They  were  also  absent  in  one 
case  of  peritonitis,  and  in  all  the  cases  of  small-pox.  Further  investiga- 
tion will  probably  discover  these  salts  to  be  absent  in  other  diseases 
* Reported  by  Mr.  Almeric  Seymour,  Clinical  Clerk. 


PNEUMONIA, 


689 


which,  although  it  may  diminish  the  importance  of  the  sign  as  distinctive 
of  pneumonia,  leaves  unaffected  its  value  as  pointing  out  the  onward 
progress  of  that  disease. 

In  one  or  two  cases  of  pneumonia,  in  which  the  disease  was  pro- 
gressing. traces  of  chlorides  were  seen  in  the  urine.  This  was  discovered 
by  Mr.  Seymour  (clinical  clerk)  to  depend  on  the  adulteration  of  the  nitric 
acid,  which,  for  testing  urine,  must  be  pure.  The  nitric  should  be  tested 
according  to  the  directions  of  the  Edinburgh  Pharmacopoeia  for  hydro- 
chloric acid,  with  which  it  is  very  apt  to  be  mingled.  It  is  of  import- 
ance that  pure  nitric  acid  be  added  to  the  urine  in  the  first  instance, 
otherwise  the  nitrate  of  silver  is  very  apt  to  throw  down  phosphates, 
which,  however,  may  be  distinguished  from  chlorides  by  being  dissolved 
in  an  excess  of  nitric  acid,  which  does  not  affect  the  latter  salts. 

What  is  very  remarkable  with  regard  to  the  absence  of  chloride  of 
sodium  from  the  urine,  is  that  it  appears  in  the  sputum  of  pneumonic 
persons,  and  as  it  returns  to  the  urine,  it  disappears  from  the  sputum. 
I have  not  myself,  however,  made  many  careful  observations  on  the 
chemical  reactions  of  the  sputum  in  this  disease,  but  propose  doing  so, 
in  the  hope  that  it  will  throw  further  light  on  its  diagnosis  and 
pathology. 

The  Pathology  of  Acute  Pneumonia. 

The  pathology  of  pneumonia  is  comprised  in  what  has  been  formerly 
said  on  exudation,  p.  166,  and  more  especially  p.  173,  the  lesion  con- 
sisting of  liquor  sanguinis  poured  into  the  air  vesicles,  minute  bronchial 
tubes,  and  parenchyma  of  the  lung.  It  maybe  well,  however,  to  dwell 
a moment  on  the  fact  that  the  exudative  process  may  be  very  limited, 
indeed  confined  to  a few  vesicles,  and  the  minute  bronchial  tubes  connected 
with  them.  This  is  vesicular  pneumonia.  We  know  it  may  be  confined 
to  a lobule  or  occupy  an  entire  lobe,  constituting  the  so-called  lobular 
and  lobar  pneumonia.  In  either  case  the  essential  phenomenon  of  in- 
flammation, that  is,  exudation,  has  occurred,  distinguishable  on  careful 
examination  of  the  pulmonary  tissue,  by  the  blocking  up  of  air  vesicles  in 
the  form  of  minute  granulations.  Occasionally  the  vesicular  exudation 
may  be  felt  on  handling  the  lung  in  the  form  of  minute  indurations, 
varying  in  size  from  a millet  seed  to  that  of  a pea — often  red,  but 
occasionally  yellow,  and  in  the  latter  case  very  liable  to  be  mistaken  for 
tubercles.  Such  small  indurations,  however,  at  length  soften,  and  are 
converted  into  pus,  like  the  lobar  and  lobular  forms  of  pneumonia. 

Microscopic  examination  of  the  pulmonary  tissues  shows  us  that,  in 
the  first  instance,  the  air  vesicles,  the  minute  bronchi,  and  the  areolar 
tissue,  are  infiltrated  with  a molecular  and  granular  exudation,  which 
often  forms  a complete  cast  or  mould  of  the  vesicles  and  bronchi,  easily 
separated  mechanically  by  washing  and  pressure.  Not  unfrequently,  as 
shown  by  Remak,  these  moulds  are  expectorated  entire,  and  may  be  dis- 
engaged from  the  gelatinous  matter  with  which  they  are  associated,  by 
throwing  the  contents  of  the  spit-box  into  water,  and  teazing  out  the 
branched  filaments.  These,  when  magnified,  present  a fibrous  exudation, 
in  which  are  embedded  commencing  pus  corpuscles,  with  a greater  or  less 
number  of  epithelial  cells  (Fig.  80).  Such  portions  of  exudation  as 
44 


690 


DISJ:ASES  of  the  EESPIRATORT  SYSTEir. 


remain  in  the  lung  are  transformed  into  pus  in  the  usual  manner  (Fig. 
154,  p.  174),  become  ultimately  disintegrated  and  absorbed  into  the 
blood,  where  they  are  chemically  changed,  and  at  length  excreted  from 
the  system,  principally  by  the  kidneys  (p.  174).  If,  from  the  extent  of 
the  disease,  or  weakness  of  the  patient,  this  process  is  checked,  the  patient 
may  die,  either  from  inability  to  excrete  the  effete  matter  in  the  blood, 
or  from  interruption  to  the  respiratory  functions.  If  the  exudation  be 
limited  in  extent,  or  have  been  poured  out  slowly  from  the  commence- 
ment, it  may  become  what  is  called  chronic.  Under  such  circumstances, 
the  epithelial  and  pus  corpuscles  of  the  pulmonary  tissues  may  undergo 
the  fatty  degeneration,  and  numerous  compound  granule  cells  be  the  re- 
sult. If  blood  should  have  been  extravasated,  mingled  with  the  other 
formations  described,  there  will  be  often  found  red  crystals  of  haematine, 
blood  corpuscles  surrounded  by  an  albuminous  layer,  and  presenting  the 
numerous  transformations  which  they  are  known  to  undergo  after  ex- 
travasation (Fig.  411,  p.  418). 

Dr.  Todd  ^ observes,  “ When  a patient  suffers  from  pneumonia,  the 
tendency  is  for  the  lung  to  become  solid,  then  for  pus  to  be  generated, 
and  at  last  for  the  pus-infiltrated  lung-structure  to  be  broken  down  and 
dissolved.  Such  are  the  changes  when  matters  take  an  unfavorable 
course.  On  the  other  hand,  recovery  takes  place,  either  through  the 
non-completion  of  the  solidifying  process,  or  by  the  rapid  removal,  either 
through  absorption,  or  a process  of  solution  and  discharge,  of  the  new 
material,  which  had  made  the  lung  solid.”  Now  I have  directed  especial 
attention  to  the  method  in  which  the  exudation  is  absorbed,  and  have 
frequently  examined  lungs  after  death  in  the  stage  of  red  hepatization, 
where  death  had  occurred  from  cerebral  hemorrhage  or  other  disease.  In 
some  lungs  there  has  been  a pneumonia  in  all  its  stages,  incipient  in 
some  places,  solidified  and  red  in  others,  grey  and  purulent  in  a third. 
In  all  these  places,  a gradation  in  pus  formation  has  been  observable. 
In  the  most  solid  hepatization,  young  pus  cells  may  be  observed  some- 
where beginning  to  form,  so  that  I am  convinced  that  the  exudation  is 
always  broken  down  through  the  agency  of  purulent  formation — in 
sh.ort,  that  this  is  the  normal  process.  I have  never  seen  any  evidence 
that  a coagulated  exudation  is  simply  disintegrated  and  absorbed  without 
the  development  of  pus  cells,  and  I conceive  that  all  analogy,  as  well  as 
direct  observation,  is  opposed  to  the  supposition.  It  follows  that,  so  far 
from  the  formation  of  pus  being  the  evidence  of  an  unfavorable  course 
of  the  disease,  it  is  the  normal  and  necessary  transformation  of  the  solid 
exudation,  whereby  it  is  broken  up  and  caused  to  be  absorbed.  (See 
Fig.  154,  p.  174.) 

This  view,  based  upon  numerous  careful  histological  examinations  of 
pneumonic  lungs,  and  easily  capable  of  demonstration  in  any  recent 
specimen  of  the  disease,  as  well  as  by  many  preparations  in  my  collection, 
shocks  the  notions  of  certain  pathologists  of  the  French  school.  M. 
Grisolle  recently  observes  of  it : — “ I cannot  accept  a doctrine  that  is 
not  justified  by  any  direct  proof,  from  which  the  clinical  sense  in  a 
manner  revolts,  and  which  is  manifestly  contrary  to  what  has  been  taught 
and  is  still  taught  every  day  by  the  simplest  observation  of  physicians 

* Beale’s  Archives  of  Medicine,  No.  1,  p.  2. 


PNEUMONIA. 


691 


throughout  the  world.”  ^ If,  before  writing  such  a criticism,  M.  Grisolle 
had  -investigated  the  subject  in  the  only  way  in  which  it  can  be  investi- 
g;ited— that  is,  with  the  microscope— he  would  have  seen  in  red  hepa- 
tization pus  corpuscles  in  all  stages  of  formation,  and  thus  convinced 
hiniself^f  a truth  which,  so  far  from  revolting  the  clinical  sense,  presents 
to  it  new  and  important  arguments  for  a more  successful  practice,  as  will 
be  subsequently  shown.  The  microscope  has  proved  that  many  so-called 
purulent  fluids  are  not  purulent  at  all,  whereas  it  distinctly  demonstrates 
that  the  disintegration,  softening,  and  liquefaction  of  the  plastic  exudation 
in  pneumonia — processes  admitted  by  M.  Grisolle — are  in  truth  the 
result  of  a vital  growth  of  pus-cells;  by  favoring  which  we  can  cause 
recovery  in  our  patients,  and  by  diminishing  or  interfering  with  which 
we  increase  the  mortality  among  them.  The  direct  proof  that  M. 
Grisolle  requires  he  may  himself  obtain  by  making  a few  sections  of  any 
pneumonic  lung  with  a Valentin’s  knife,  and  carefully  examining  them  first 
under  a magnifying  power  of  25,  and  then  of  250  diameters  linear,  when 
he  will  see  appearances  similar  to  those  now  figured,  and  recognise— 


ct 


Fig.  452.  Fig.  453. 


1st,  Molecular  exudation  in  the  air- vesicles ; 2d,  Passage  of  this  by 
molecular  coalescence  into  pus-cells  ; and,  3d,  Formation  and  subsequent 
degeneration  of  such  cells.  (See  Molecular  and  Cell  Theories  of  Organi- 
zation, p 115.  See  also  Fig.  154.)  Indeed,  so  constant  is  the  formation 
of  pus  in  pneumonia,  and  so  clearly  can  it  be  seen  to  form  by  mole- 
* Traite  de  la  Pneumonie,  2me  edit.,  1864,  p.  53. 


Fig.  452.  Yertical  section  through  the  outer  portion  of  a lung  affected  with 
pleuro-pneumonia.  Externally,  the  exudation  on  the  surface  has  formed  a thick  layer 
of  molecular  fibres,  and  shows  villi,  which,  on  becoming  vascular,  absoi’b  the  serous 
fluid.  The  lower  half  of  the  figure  shows  the  air  vesicles  of  the  lung  blocked  up  with 
the  coagulated  molecular  exudation.  25  diam. 

Fig.  453.  Two  moulds  of  coagulated  exudation  from  air  vesicles  in  red  hepatization 
of  the  lung,  a.  Molecular  exudation,  aggregating  into  small  masses  to  form  pus  cor- 
puscles. 6,  A neighboring  mass,  in  which  the  exudation  has  proceeded  further  in  de- 
velopment, and  is  forming  pus-cells.  250  diam. 


692 


DISEASES  OF  THE  EESPIRATORT  SYSTEM. 


cular  aggregation,  independently  of  pre-existing  cells,  as  in  itself  to  carry 
with  it  a complete  refutation  of  Virchow’s  doctrine,  “ omnis  cellula  e 
cellula.” 

The  exudation  having  been  transformed  into  pus-cells,  these,  after 
a time,  become  fatty,  break  down,  disintegrate,  and  liquefy,  and  are 
absorbed  into  the  blood,  whence  they  are  excreted  by  tbe  ernunctories, 
but  more  especially  by  the  kidneys,  in  the  form  of  urates,  as  previously 
explained.  (See  p.  174.) 

Treoiment  of  Acute  Pneumonia, 

In  the  first  place,  let  us  more  particularly  examine  the  effects  of  the 
four  kinds  of  treatment  recommended  in  Pneumonia — viz.,  by  bleeding, 
by  tartar  emetic,  by  an  antiphlogistic  diet,  and  what  may  be  called  a 
mixture  of  these  treatments. 

Results  of  the  Treatment  of  Pneumonia  hy  large  Bleedings. — It 
appears  from  the  published  statistics,  of  the  Koyal  Infirmary  of  Edin- 
burgh, that  upwards  of  one-third  of  all  the  patients  affected  with  pneu- 
monia died  who  entered  during  a period  of  ten  years,  when  bleeding 
was  universally  practised.  No  doubt  it  cannot  be  pretended  that  per- 
fect accuracy  as  to  diagnosis  was  attained  in  all  the  cases.  It  is  certain 
also  that  numerous  complications  and  the  debilitated  constitutions  so 
frequently  met  with  in  the  practice  of  a large  hospital,  served  to  swell 
the  mortality.  It  is  remarkable,  however,  that  this  proportion  of  deaths 
to  recoveries  is  nearly  the  same  as  has  occurred  in  the  Infirmary  since 
the  commencement  of  the  present  century,  as  well  as  what  resulted  in 
the  cases  so  carefully  observed  by  M.  Louis,  in  the  hospital  of  La  Chari- 
te,  at  Paris. 


TABLE,  showing  the  Number  of  Patients  affected  with  Pneumonia  treated 
in  the  Royal  Infirmary  of  Edinburgh,  and  the  results,  from  July  1st, 
1839,  to  October,  1st.  1849. 


Total  No.  of 
Patients 
entering  the 

Years. 

No.  ad- 
mitted. 

Cured. 

Re- 

lieved. 

Died. 

Statistician. 

Iniirmary. 

i 7,969* 

1st  July  1839  to  1st  Oct. 

1841 

139 

85 

5 

49 

Dr.  John  Reid. 

S,537 

1st  Oct.  1841  » 

1842! 

42 

23 

3 

16 

( 

> Dr.  T.  Pea-i 

2,760 

“ 1842  “ 

1843 

41 

26 

0 

15 

) cock. 

7,204* 

» 1843  » 

1844' 

31 

16 

4 

11 

1 

3,252 

3,638 

c:  1844  u 

“ 1845  “ 

1845; 

1846 

50 

61 

33 

40 

4 

6 

13 

15 

1 

1 Dr.  Hughes 
I Bennett. 

7,435* 

» 1846  “ 

1847 

93 

47 

5 

41 

7,44-6* 

“ 1847  “ 

1848 

103 

52 

6 

45 

J 

3,724t 

“ 1848  “ 

1849 1 

1 

88 

66 

5 

17 

i 

Ir.  M'Dougall. 

46,965 



i 

1 

648 

388 

38 

222 

*At  these  periods  there  were  great  epidemics  of  fever. 

I At  this  period  considerable  changes  took  place  among  the  medical  staff  of  the 
Infirmary. 


PNEUMONIA. 


693 


My  former  clerk,  Dr.  Thorburn,  was  kind  enough,  at  my  request,  to 
go  over  ’208  case-books  of  the  Infirmary,  dated  between  the  years  1812 
and  1837,  and  belonging  to  twelve  physicians,  all  of  whom  practised  an 
antiphlogistic  treatment.  He  found  that  of  103  cases  of  pneumonia,  55 
were  cured,  41  died,  and  7 were  relieved — that  is,  1 death  in  2|-  cases.  Dr. 
Thorburn  then  carefully  read  over  these  103  cases,  and  rejected  all  those 
that  were  incomplete,  or  which  presented  no  evidence  of  having  been 
pneumonia  The  remainder  were  tabulated,  and  it  may  safely  be  said  that 
they  were  all  cases  of  pneumonia,  or  of  acute  inflammations  of  the  chest 
closely  allied  to  that  disease,  and  the  result  was  ; — Number  of  cases,  50  ; 
died,  19  ; cured  or  relieved,  31 — that  is,  more  than  1 death  in  3 cases. 

The  total  number  of  cases,  recorded  by  M.  Louis,  was  107."^  Of 
these  32  died,  or  1 in  3i.  In  78  of  those  cases,  which  occurred  at 
La  Gharite,  bleeding  was  performed  from  the  first  to  the  ninth  day,  and 
the  deaths  were  28,  or  1 in  3|.  The  duration  of  the  disease  in  the 
cases  which  recovered  was  15i  days.  Of  the  remaining  29  cases,  which 
occurred  at  La  Pitie,  the  bleeding  was  performed  earlier,  that  is,  during 
the  first  4 days,  and  of  these  only  4 died,  that  is  1 in  7{.  The  dura- 
tion of  the  disease,  however,  in  the  cases  that  recovered,  was  18i  days. 
This  diminished  mortality,  but  greater  length  of  recovery,  M.  Louis  at- 
tributes to  the  bleedings  not  having  been  so  large,  and  the  greate  amount 
of  tartar  emetic  employed.  Hence,  the  proposition  he  sought  to  estab- 
lish, that  although  bleeding  has  a very  limited  influence  on  pneumonia, 
it  should  be  practised  early.  With  regard  to  M.  Louis’s  results, 
it  should  be  remembered  that  all  these  patients  enjoyed  excellent  health 
when  they  were  attacked,  that  the  cases  were  uncomplicated,  and  that 
the  duration  of  the  disease  was  estimated  from  the  occurrence  of  febrile 
symptoms,  up  to  the  time  when  light  food  could  be  taken,  which  was 
generally  three  days  after  the  fever  had  ceased. 

M.  Grisolle  f advocated  more  moderate  bleedings  than  those  so  fre- 
quently had  recourse  to,  his  conscience  preventing  the  abandonment  of 
venesection  altogether  (p.  561).  He  analyses  the  75  cases  of  Bouillaud, 
pointing  out  that  only  49  were  treated  by  the  coup  sur  coup  mode  of 
bleeding,  of  which  6 died,  or  1 in  8 cases,  a favorable  result,  which  he 
attributes  to  the  youth  of  the  patients  treated.  Of  his  own  cases,  one 
group  of  50  cases  were  bled  only  in  the  first  stage  of  the  disease  ; of  these 
5 died,  or  1 in  10.  Those  cases  that  died  were  bled  most,  each  losing 
about  4 lb.  4 oz.  of  blood  in  successive  bleedings.  All  the  cases  in  this 
group  were  uncomplicated,  and  of  the  average  age  of  40  years.  Of  the 
45  who  recovered,  convalescence  commenced  on  the  10th  day,  and  they 
resumed  their  occupations  on  the  21st  day,  as  an  average.  Of  182  cases 
that  were  bled  in  the  second  stage,  32  died,  or  more  than  1 in  6.  Here 
also  those  who  died  were  bled  most — the  bleedings  varying  in  amount 
from  8 or  12  oz.  to  8 lbs.  The  average  quantity  lost  was  3 lbs.  All  the 
cases  in  this  group  were  uncomplicated,  and  of  the  average  age  of  35 
years.  Of  the  150  cases  that  recovered,  convalescence  commenced  on 
the  17th  day,  and  they  resumed  their  occupations  on  the  22d  day — as 
an  average.  He  admits  that  the  pneumonia  can  never  be  jugulated  by 
* Recherches  sur  les  efFets  de  la  Saignee.  Paris,  1836. 

•j-  Traite  pratique  de  la  Pneumonie.  Paris,  1841. 


694 


DISEASES  OF  THE  RESPIRATORY  SA'STEil. 


bleeding.  Of  the  whole  232  cases,  37  died,  that  is,  about  1 in  6^  , as 
the  general  result  of  M.  Grisolle’s  hospital  practice,  a mortality  only 
one-half  that  of  M.  Louis’s  cases,  although  the  circumstances  under 
which  they  occurred  were  the  same,  with  the  exception  of  not  being  so 
heroically  treated.  Laennec  also,  who  only  bled  moderately  at  the  com- 
mencement of  the  disease,  regarded  the  mortality  to  be  1 death  in  6 or 
8 cases."^ 

In  1864  M.  Grisolle  published  another  edition  of  his  work,  in  which 
these  old  statistics  are  repeated  without  any  change  whatever,  and  this 
notwithstanding  his  acquaintance  with  the  author’s  researches,  and  the 
immense  improvements  which  have  taken  place  in  the  art  and  science  of 
medicine  during  the  long  interval  of  23  years.  What  seems  very  sur- 
prising is,  that  he  wishes  to  have  it  believed  that  his  antiphlogistic  treat- 
ment, with  a mortality  of  1 in  6 cases,  is  still  the  best. 

Dietl  treated  85  cases  by  large  bleedings,  of  whom  17  died,  that  is,  1 
in  5. 

Dr.  Glen,  my  former  resident  clerk,  was  so  good  as  to  tabulate  for  me 
all  the  cases  of  pneumonia  given  in  the  army  returns,  and  reported  by 
Colonel  Tulloch.f  These  returns  give  us  no  information  as  to  the  mode 
in  which  the  diagnosis  was  determined,  or  what  was  the  treatment.  The 
favorable  mortality  of  1 death  in  13  cases,  which,  according  to  Dr.  Glen, 
is  the  general  result,  is  supposed  to  result  from  the  bleedings  having 
been  performed  early,  and  in  young  vigorous  subjects. 

Yon  Wahl  treated,  in  St.  Petersburg,  by  bleeding  and  antiphlogistics, 
354  cases,  of  whom  84  died,  or  1 in  4f  cases.| 


Treatment  hy  large  doses  of  Tartar  Emetic. — Rasori,  § in  the  great 
hospital  of  Milan,  treated  648  cases  by  large  doses  of  tartar  emetic,  of 
which  555  were  cured,  and  143  died,  that  is,  1 in  4i.  In  publishing 
this  statement,  Rasori  gives  the  result  as  one  more  favorable  than  the 
practice  of  blood-letting,  which  of  course  he  would  not  have  done  unless 
the  latter  treatment  was  then  well  known  to  have  been  attended  with  a 
greater  mortality  than  that  by  tartar  emetic,  or  1 death  in  4i  cases. 

M.  Grisolle  treated  154  cases  with  large  doses  of  tartar  emetic,  of 
which  29  died,  that  is,  1 in  5i,  and  Dietl  treated  106  cases,  of  which  22 
died,  that  is,  a little  more  than  1 in  5. 

Treatment  hy  Diet. — This  treatment  essentially  consists  in  allowing 
the  disease  to  go  through  its  natural  course.  During  the  stage  of  fever 
diet  is  light,  or  withheld  altogether,  and  cold  water  allowed  for  drink ; 
subsequently  better  diet  is  allowed,  and  occasionally  wine,  according  to 
the  nature  of  the  symptoms.  Sometimes  a dietetic  is  converted  into  an 
expectant  treatment.,  when  remedies  are  given  to  meet  occasional  symp- 
toms, as  in  the  practice  of  Skoda,  in  the  Charity  Hospital  of  Vienna. 

* Forbes’  Translation.  Fourth  Edition,  p.  237. 

f Government  Statistical  Reports  on  Mortality  among  the  Troops.  1853. 

\ Petersburg  Med.  Zeit.,  i.  6.  1861. 

^From  an  Analysis  of  Rasori’s  Practice — Annales  de  Therapeutique,  Jan^der 
1847. 


PNEUMONIA. 


695 


An  account  of  this  has  been  given  to  us  by  Dr.  George  Balfour,  who 
found  from  the  books  of  the  hospital,  that  during  a period  of  three 
years  and  five  months,  commencing  1843,  392  patients  were  treated,  of 
whom  54  died,  or  1 in  7^.  Occasionally  opium  was  given  in  small 
doses  if  there  was  much  pain.  Venesection  was  also  practised  early  if 
there  was  much  dyspnoea,  and  emetics  given  if  the  expectoration  con- 
sisted of  tough  mucus. 

Dr.  G.  Balfour  has  also  given  some  statistics  of  the  Homoeopathic 
Hospital  of  Vienna,  accompanied,  however,  with  statements  which  ren- 
der it  doubtful  whether  every  case  that  applied  was  admitted,  and  con- 
sequently not  fairly  comparable  with  other  hospital  statistics.  There  can 
be  no  doubt,  however,  that  many  severe  cases  of  pneumonia  recovered 
under  a system  of  treatment,  which,  it  appears  to  me,  most  medical  men 
must  consider  to  be  essentially  a dietetic  one. 

Dr.  Dietl  published,  in  1848,  an  account  of  189  cases  treated  by  diet 
only,  of  which  14  died,  that  is,  1 in  I3i-.  The  following  is  his  table  of 
380  cases,  exhibiting  the  result  of  the  three  kinds  of  treatment: — - 


f!iired 

Vene- 

Bection. 

68  

Tartar 

Emetic. 

84  

Diet. 

175 

Dipd 

17  

22  

14 

85  

106  

189 

Per  cent 

20.4 

20.7  

Deaths 

1 in  5.22 

1 in  134 

It  was  further  observable  that  of  the  85  cases  treated  by  blood-letting,  7 
of  the  fatal  cases  were  uncomplicated;  whilst  of  the  189  cases  treated  by 
diet,  not  one  of  the  deaths  was  an  uncomplicated  one.  In  1852  he  gave 
the  result  of  750  cases,  treated  dietetically,  of  which  69  died,  or  one  in  10.9. 


Mixed  treatment. — In  recent  times  cases  of  pneumonia  have  been 
treated  after  a mixed  fashion,  according  to*  the  nature  of  the  symptoms, 
but  with  no  very  marked  beneficial  result.  As  examples  of  this  system, 
I may  refer  to  the  results  given  by  Huss,  Bamberger,  and  Flint. 

The  most  important  memoir  recently  published  is  that  of  Professor 
Huss  of  Stockholm,*  who  employed  bleeding  and  heroic  remedies  in  the 
early  stage,  and  in  the  later  ones  antimony,  mercury,  and  various  reme- 
dies— among  the  rest,  turpentine,  morphia,  and  quinine.  The  number  of 
cases  given  is  2616,  of  which  281  died;  that  is,  1 in  9^  cases.  The  un- 
complicated cases  were  1657,  of  whom  96  died,  or  1 in  17  cases.  The 
complicated  cases  were  959,  of  whom  185  died,  or  1 in  5 cases.  The 
treatment  employed  was  adapted,  as  it  was  thought,  to  the  emergencies 
of  the  case,  and  may  be  called  a modified  antiphlogistic  practice,  many 
cases  not  having  been  bled  at  all.  Its  superiority  over  the  rigid  system, 
and  even  over  that  of  Grisolle,  therefore,  is  marked. 

Dr.  Bambergerf  treated  186  cases  without  general  blood-letting. 

* Die  Behandlung  der  Lungen-entzundung,  etc.  Leipsig,  1861. 
f Wiener  Wochenschrift,  No.  50,  1857;  and  Canstatto  Jahnuberricht,  1858,  iii. 
p.  284. 


] 


696 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


Only  a few  leeches  and  fomentations  were  applied  in  some  cases,  and 
inf.  digitalis  given  internally.  Occasionally,  also,  expectorants,  emetics 
and  other  remedies  were  employed.  Nothiug  is  said  of  diet  or  wine. 
Of  these  cases,  21  died,  or  1 in  9.  Number  of  complicated  cases  not 
stated. 

Dr.  Flint  has  given  the  result  of  133  cases  he  treated,  of  whom  35 
died — more  than  1 in  4.  Among  the  uncomplicated  cases  were  19 
deaths,  and  among  the  complicated  16 — a strange  result.  The  treat- 
ments varied  according  to  the  case ; 12  were  bled.* 

The  Author's  Treatmenthy  Restoratives^  directed  to  further  the  natural 
progress  of  the  disease,  and  supporting  the  vital  strength. — A study  of 
the  pathology  of  the  disease,  which  I have  previously  explained  many 
years  ago,  forced  upon  my  mind  the  conviction  that  blood-letting  and 
antiphlogistics  must  be  injurious.  Pus-cells  must  be  regarded  as  living 
growths,  and  as  such  require  an  excess  of  blood,  good  nutrition,  and 
exalted  vital  force  to  hurry  on  their  development  and  carry  them  success- 
fully through  the  natural  stages  of  their  existence.  If  the  resolution 
of  a pneumonia  simply  consisted  of  a retrograde  process,  of  a so-called 
necrosis  of  the  exudation,  a previous  antiphlogistic  practice,  by  favoring 
it,  might  be  expected  to  relieve  the  lung  rapidly  and  cure  the  disease. 
But  my  conviction  that  such  removal  was  dependent  upon  vital  pro- 
cesses of  growth,  led  me  to  an  opposite  treatment,  viz.,  never  to  attempt 
cutting  the  disease  short,  or  to  weaken  the  pulse  and  vital  powers,  but, 
on  the  contrary,  to  further  the  necessary  changes  which  the  exudation 
must  undergo  in  order  to  be  fully  excreted  from  the  economy.  To  this 
end,  during  the  period  of  febrile  excitement  I content  myself  with  giv- 
ing salines  in  small  doses,  with  a view  of  diminishing  the  viscosity  of 
the  blood.  At  the  commencement  of  the  treatment  I order  as  much 
beef-tea  as  can  be  taken,  and,  as  soon  as  the  pulse  becomes  soft,  nutri- 
ents, and  from  4 to  8 oz.  of  wine  daily.  As  the  period  of  crisis  ap- 
proaches 1 give  a diuretic,  consisting  of  half  a drachm  of  nitric  ether, 
and  sometimes  ten  minims  of  colchicum  wine,  three  times  daily,  to  favor 
excretion  of  urates.  But  if  crisis  occurs  by  sweat  or  stool,  I take  care 
not  to  check  it  in  any  way. 

The  object  of  this  practice  has  been  greatly  misunderstood,  and  by 
none  more  so  than  by  M.  Grisolle,  who  calls  it  an  expectant  treatment. 
It  seems  to  me  to  differ  entirely  from  it  in  the  care  which  is  taken  to 
nourish  the  weakened  frame  from  the  beginning^  and  thus,  according  to  the 
pathological  views  formerly  explained,  assist  the  vital  powers  to  change 
the  coagulated  exudation,  first  into  a new  morbid  growth  (pus),  and 
then  into  a fluid  capable  of  absorption.  I cannot  call  it  a dietetic  treat- 
ment, because  this  term  has  been  applied  on  the  Continent  to  with- 
holding diet  rather  than  giving  it — the  “ diete  absolue  ” of  the  French 
meaning  starvation — a fact  which  explains  the  fatal  result  of  this 
practice,  and  especially  the  ill  success  of  M.  Grisolle,  when  he  tried 
expectancy — or,  as  he  understands  by  that  practice,  withholding  all 
nourishment — while  at  the  same  time  the  bowels  are  acted  on  by 
injections  and  castor-oil  (p.  559,  2d  edit.)  My  pathology,  in  his 

* American  Journal  of  Medical  Sciences,  1861. 


PNEUMONIA. 


097 


opinion,  appears  strange,  and  useless  to  refer  to  (Idem^  p.  568) ; but  as 
it  has  led  me  to  cure  every  case  of  single  and  double  uncomplicated 
pneumonia,  whereas  among  M.  Grisolle’s  cases  there  is  a mortality  of 
one  in  every  six,  I may  be  permitted  to  think  my  theory  better  founded 
on  observation,  while  my  practice  supports  its  correctness. 

In  order,  however,  that  there  may  be  no  farther  misapprehension  as 
to  the  facts  which  demonstrate  the  success  of  the  restorative  practice  fol- 
lowed in  my  clinical  wards,  I give,  in  a tabular  form,  all  the  cases  which 
have  entered  since  the  year  1848. 

The  following  Table  includes  all  the  cases  of  acute  pneumonia  which 
have  been  admitted  into  the  clinical  wards  of  the  Royal  Infirmary  under 
m}’^  care  since  the  1st  of  October  1848  to  the  31st  of  January  1865. 
During  this  period  my  term  of  service  was  at  first  four  months  in  the 
year,  and  then,  on  alternate  years,  six  months  and  three  months.  I find 
that,  altogether,  I have  treated  cases  in  the  wards  for  75  months,  or  a com- 
puted period  of  6^  years.  The  Table  presents  the  leading  facts  presented 
by  the  cases,  so  as  to  enable  the  reader  to  judge  of  the  effects  of  the  treat- 
ment employed.  The  columns  indicate — 1st,  The  number  of  the  case  ; 
2d,  The  name  of  the  patient — D marks  a double  case,  and  Uns.  one  un- 
satisfactory as  to  the  duration  of  the  disease;  3d,  The  age;  4th,  The 
previous  health,  whether  good  or  bad,  or  in  any  way  particularly  affected  ; 
5th,  The  day  of  admission,  counting  from  the  rigor,  which  indicates  the 
commencement  of  the  disease ; 6th,  The  duration  of  the  disease,  or  the 
commencement  of  the  convalescent  state,  counting  in  days  from  the  period 
when  the  rigor  occurred;  7th,  The  number  of  days  in  the  hospital  after 
admission,  or,  should  the  disease  have  commenced  in  the  hospital,  count- 
ing from  the  rigor — this  is  a very  uncertain  period,  which  ought  to  re- 
present the  duration  of  the  convalescence,  but  which  in  many  cases  was 
lengthened  by  a variety  of  circumstances  having  no  relation  to  the 
pneumonia ; 8th,  The  frequency  and  character  of  the  pulse  on  admis- 
sion ; 9th,  The  number  and  character  of  the  respirations  on  admission ; 
10th,  The  side  of  the  chest,  and  extent  of  pulmonary  tissue  involved ; 
llth.  If  complicated  with  other  diseases  it  is  marked  by  a X ; 12th, 
The  treatment;  13th,  General  remarks;  and  llth.  The  volume  and 
page  where  the  case  may  still  be  found.  It  must  be  remembered  that 
the  cases  were  not  recorded  in  reference  to  any  statistical  inquiry,  but 
are  those  drawn  up  by  the  clerks  in  the  Clinical  Wards,  at  the  bed-side, 
in  obedience  to  long-established  usage.  They  vary  greatly,  therefore,  in 
value,  and  in  a few  the  information  on  certain  points  required  is  defec- 
tive. This  is  indicated  in  the  Table  by  a note  of -interrogation. 

This  Table  was  commenced  by  my  former  able  resident  physician. 
Dr.  Glen,  whose  early  death,  as  medical  superintendent  in  the  Dundee 
Infirmary,  in  1863,  deprived  the  profession  of  a singularly  well-informed 
and  highly-educated  physician.  It  was  continued  by  Drs.  Smart,  Duck- 
worth, and  Macdonald,  also  my  resident  physicians  in  the  Infirmary 
during  the  years  1863,  1864,  and  1865,  to  whom  I am  greatly  indebted 
for  the  pains  they  bestowed  upon  it.  The  fact  that  the  table  has  been 
carefully  revised  by  each  of  these  four  gentlemen  in  succession,  affords 
the  most  convincing  proof  of  the  accuracy  of  its  details. 


Tabular  View  of  all  th-e  Cases  of  Acute  Pneumonia  treated  in  the  Clinical  Wards  of  the  Royal  Infirmary  by  the  Author,  from  1st  October  1848  to 
31st  January  1865,  while  on  service  for  76  months,  or  a computed  period  of  6|^  years. — Average  number  of  Beds,  40. 

MALE  CASES. 


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DISEASES  OF  THE  EESPIRATORT  SYSTEM. 


In  addition  to  the  four  fatal  cases  here  recorded,  I have  found  in  the 
pathological  registers  kept  bj  Drs.  Gairdner,  Haldane,  and  Grainger 
Stewart,  thirteen  other  cases,  in  which,  as  the  result  of  chronic,  cerebral, 
spinal,  cardiac,  hepatic,  renal,  or  other  pulmonary  disease  (such  as  phthisis 
and  chronic  bronchitis),  pneumonia  appeared  before  death,  adding  a fatal 
complication  to  previously  existing  maladies.  Not  one  of  these  can  pro- 
perly be  considered  as  a case  of  acute  pneumonia,  or  indeed  of  pneumonia 
at  all.  They  have  all  been  entered  by  the  clerks  in  the  ward-books  as 
softening  of  the  brain  or  spinal  cord,  morbus  cordis,  phthisis,  Bright’s 
disease,  cirrhosis  of  the  liver,  or  other  lesion,  for  which  the  patients 
entered  the  Infirmary  and  were  treated.  In  most  of  them  it  was  the 
pneumonie  des  agonhans  of  the  French,  and  in  all  must  be  regarded  as 
the  consecutive  chronic  or  latent  pneumonia  of  medical  writers. 

These,  then,  are  positively  all  the  cases  of  acute  pneumonia  which 
have  entered  the  clinical  wards  of  the  Infirmary,  when  under  my  care, 
during  the  last  sixteen  years,  so  far  as  I can  discover  them.  Every  case 
has  been  treated  publicly,  and  is  open  for  inspection  in  the  ward- books, 
and  the  result  is  that  the  mortality  of  the  acute  pneumonias,  in  the 
practice  of  the  clinical  wards  while  under  my  care,  is,  up  to  February 
1865,  1 in  32^  cases ; and  that  of  all  the  cases  of  uncomplicated  pneu- 
monia, 105  in  number,  not  one  has  died,  although  many  of  them  have 
been  very  severe,  involving  the  whole  of  one  lung  in  15,  and  portions  of 
both  lungs  in  26  cases. 

In  the  four  fatal  cases,  death  was  evidently  caused  by  complications 
independent  of  the  pneumonia.  They  ought  to  be  regarded  as  patho- 
logical accidents,  for  in  not  one  of  them  could  the  pulmonary  disease  be 
properly  regarded  even  as  assisting  the  mortality.  The  Table  shows 
that  in  many  instances  where  weakness  was  much  greater  than  existed 
in  any  of  them,  pneumonia  rapidly  passed  through  its  natural  progress. 
To  arrive  at  true  statistics  with  regard  to  treatment^  therefore,  it  becomes 
necessary  to  eliminate  these  four  cases,  as  has  been  done  by  many  other 
hospital  physicians,  and  to  fix  our  attention  on  the  first  125  cases  re- 
ported in  the  previous  table. 

Sex.  Of  these  125  cases,  85  were  males  and  40  females.  The  latter 
have  been  enumerated  after,  and  so  separated  from  the  former. 

Age.  The  average  age  of  the  males  was  31^  years;  the  average  age 
of  the  females  28^  years  ; the  average  age  of  both  30^  years.  Between 
the  ages  of  5 and  15  years  was  1 case — a girl ; between  10  and  20 
years,  29  cases — 12  females;  between  20  and  30  years,  35  cases — 11 
females ; between  30  and  40  years,  23  cases — 7 females ; between  40 
and  50  years,  24  cases — 6 females;  between  50  and  60  years,  11  cases 
— 1 female;  between  60  and  70  years,  1 case — a female;  and  between 
70  and  80  years,  1 case — a female. 

Simple  or  uncomplicated  Fneumonia. — Of  the  125  cases  there  were 
105  simple  or  uncomplicated,  and  20  complicated.  Of  the  former  there 
were  74  males  and  31  females.  79  were  single  and  26  double  cases. 
Of  these  I find  that  the  clerk  has  omitted  to  state  either  the  exact  day 
of  rigor  or  of  convalescence  in  six,  so  that  no  conclusion  can  be  derived 
from  them  as  to  the  duration  of  the  disease.  Of  the  remaining  99  cases, 
73  were  single,  and  26  double. 


PNEUMONIA. 


709 


The  duration  of  the  disease  in  the  73  cases  of  single  uncomplicated 
pneumonia,  counting  from  the  occurrence  of  rigor  to  the  commencement 
of  convalescence,  was  as  follows  : — 2 cases  recovered  in  five  days;  4 cases 
in  7 days;  5 cases  in  8 days;  2 cases  in  9 days;  8 cases  in  10  days; 
7 cases  in  11  days;  7 cases  in  12  days;  4 cases  in  13  days;  13  cases 
in  14  days;  2 cases  in  15  days;  3 cases  in  16  days;  3 cases  in  17  days; 
3 cases  in  18  days;  1 case  in  19  days;  2 cases  in  20  days;  3 cases  in 
21  days;  1 case  in  22  days;  2 cases  in  23  days,  and  1 case  in  26  days. 
The  average  duration  13|  days. 

The  duration  of  the  disease  in  the  26  cases  of  double  uncomplicated 
pneumonia,  counting  from  the  occurrence  of  the  rigor  to  the  commence- 
ment of  convalescence,  was  as  follows : — 2 cases  recovered  in  8 days ; 1 
case  in  9 days;  2 cases  in  10  days;  2 cases  in  11  days;  1 case  in  12 
days;  1 case  in  13  days;  4 cases  in  14  days;  1 case  in  15  days;  2 cases 
in  16  days;  2 cases  in  18  days;  2 cases  in  19  days;  1 case  in  20  days; 
3 cases  in  21  days;  1 case  in  27  days;  1 case  in  55  days.  The  average 
duration  16f  days.* 

Of  the  105  simple  or  uncomplicated  cases,  there  were  9 bled  by 
venesection  and  subjected  to  an  antiphlogistic  treatment,  before  or  im- 
mediately upon  admission,  before  I saw  them.  The  amount  of  blood  ex- 
tracted varied  from  12  to  30  oz.,  the  latter  in  two  bleediims.  The  dura- 
tion  of  one  case  is  not  stated.  Of  the  remaining  8 cases,  the  duration 
was  as  follows: — One  case  recovered  in  7 days;  2 cases  in  14  days;  1 
case  in  16  days;  1 case  in  17  days;  1 case  in  20  days;  1 case  in  27 
days,  and  1 case  in  55  days.  The  average  duration  was  2^-  days. 

The  average  duration  of  residence  in  hospital  of  the  single  uncompli- 
cated cases  of  pneumonia — excluding  2 cases  in  which  tlie  date  of  dismis- 
sion is  omitted,  making  77  cases — was  21|  days.  For  the  males  (52) 
18|  days,  and  for  the  females  (25)  27^  days.  Of  the  26  double  uncom- 
plicated cases,  the  average  duration  of  residence  in  hospital  was  23^ 
days.  Of  the  males  (20)  23ii(  days;  of  the  females  (6)  22|  days.f 

The  average  duration  of  residence  in  hospital  of  8 cases,  bled  early 
in  the  disease  (the  9th  case  being  excluded  in  consequence  of  the  day 
of  dismission  not  being  entered  in  the  case-book),  was  32  days. 

The  extent  of  pulmonary  tissue  involved  in  the  pneumonia  was  care- 
fully determined  by  percussion  and  auscultation — from  the  amount  of 
dulness,  crepitation,  tubular  breathing,  and  increased  vocal  resonance 
present  in  each  case.  The  average  duration  of  the  disease  in  the  95 
single  cases  remaining  after  deduction  of  the  10  unsatisfactory  ones, 
counting  from  the  rigor  to  the  commencement  of  convalescence,  was  as 
follows : — ^ of  the  lung  (2  cases),  average  duration,  days ; ^ the 
lung  (12  cases),  12  days;  \ the  lung  (25  cases),  15f  days;  f the  lung 

* If  the  case  of  Hogg  (No.  6),  a weak  young  man,  much  reduced  by  bleeding  and 
other  antiphlogistic  treatment  before  admission,  and  the  duration  of  whose  disease  in 
consequence  was  55  days,  be  subtracted,  the  average  duration  of  these  double  cases 
would  only  be  14  days. 

f All  these  averages  are  far  too  high,  as  will  be  at  once  seen  on  referring  to  the 
Column  of  Observations  in  the  Table,  Nos.  14,  17,  18,  19,  27,  29,  50,  51,  100,  104, 
105,  107,  109,  in  all  which,  detention  in  the  house,  for  various  reasons  irrespective  of 
the  pneumonia,  makes  the  period  of  residence  on  account  of  that  disease  much  too  long. 


710 


DISEASES  OF  THE  EESPIRATOKY  SYSTEM. 


(34  cases),  14  days;  f the  lung  (6  cases),  14|  days ; | the  lung  (1  case), 
12  days;  the  whole  lung  (15  cases),  lOf  days.  Of  these  95  cases,  the 
right  lung  was  affected  in  58,  the  left  lung  in  37. 

Among  these  95  cases,  also,  the  pneumonia  was  confined  to  the  upper 
lobe  in  11  cases,  or  nearly  1 in  9 of  the  whole;  and  the  average  dura- 
tion of  the  disease  in  these  was  13  days,  and  of  their  residence  in  the 
hospital  14^  days. 

Complicated  cases  of  Pneumonia. — Of  the  20  complicated  cases  of 
pneumonia,  16  were  single  and  4 double.  Of  the  16  single  complicated 
cases,  the  duration  of  the  disease  cannot  be  determined  in  3.  Of  the 
remaining  13,  the  duration  was  as  follows : — One  case  recovered  in  7 
days;  2 cases  in  9 days;  1 case  in  10  days;  1 case  in  12  days;  2 cases 
in  14  days;  1 case  in  15  days ; 2 cases  in  16  days;  2 cases  in  19  days; 
and  1 case  in  48  days.  The  average  duration,  16  days. 

Of  the  4 double  cases  of  complicated  pneumonia,  1 case  recovered 
in  9 days;  1 case  in  14  days;  1 case  in  15  days;  and  1 case  in  18  days. 
The  average  duration  14  days. 

A careful  study  of  the  preceding  facts  will,  I think,  tend  to  establish 
some  new  truths,  and  correct  several  prevailing  errors  with  regard  to 
pneumonia.  I would  remind  those,  however,  who,  being  yet  skeptical 
as  to  the  value  of  a restorative  treatment,  may  imagine  that  some  of 
these  cases  might  not  have  been  pneumonia  at  all,  that  they  were  all  di- 
agnosed, and  treated  publicly  in  the  Royal  Infirmary  ; were  examined 
not  only  by  myself,  but  by  my  intelligent  clerks  and  assistants,  and 
were  all  made  the  subject  of  Clinical  Lectures  and  commentaries  at  the 
bedside.  There  is,  therefore,  the  positive  certainty,  not  only  that  every 
one  of  these  cases  was  a genuine  case  of  pneumonia,  but  that  no  other 
cases  of  the  disease  but  what  are  tabulated  were  treated  by  me  during 
the  period  referred  to.  It  should  be  explained,  however,  that  a few  cases 
were  partly  treated  by  my  colleagues,  either  before  I assumed  duty,  or 
after  I left  it,  in  the  too  frequent  rotations  which  occur  among  the  Clin- 
ical Professors  in  the  Infirmary.  Such  cases  are  not  inserted.  It  is 
further  necessary  to  point  out  that  two  or  three  cases  brought  into  the 
house  by  the  police  in  an  exhausted  condition,  and  who  died  before  I 
saw  them,  are  also  not  inserted.  It  is  the  more  important  to  refer  to 
such  occurrences,  because  they  serve  to  account  for  the  differences  which 
must  always  exist  between  hospital  and  clinical  statistics.  Grisolle  has 
very  unjustly  alluded  to  this  difference  in  the  hospital  of  Vienna,  with 
a view  of  throwing  distrust  on  the  conclusions  of  Dietl.  But  every  hos- 
pital physician  must  be  aware  that  the  general  records  of  the  House  af- 
ford no  index  whatever  to  the  number  of  acute  pneumonias  treated  clin- 
ically, comprehending  as  they  do  not  only  consecutive,  latent,  and 
chronic  pneumonias,  but  not  unfrequently  cases  of  pneumonia  which 
have  entered  in  a dying  condition,  and  have  not  been  treated  at  all. 

1.  The  first  great  fact  which  the  preceding  figures  serve  to  establish 
is,  that  simple  primary  pneumonia,  whether  single  or  double,  if  treated 
by  the  restorative  plan,  is  not  a fatal  disease.  Surely  105  cases,  of  which 
26  were  double,  are  sufficient  to  establish  this  proposition,  especially 
when  it  is  considered  that  they  were  diffused  over  sixteen  years,  and  oc- 


PNEUMONIA. 


711 


ourred  In  all  seasons.  Among  these,  also,  the  whole  of  one  lung  was 
iuyolved  in  no  less  than  15  cases,  and  the  symptoms  in  many  of  them 
were  exceedingly  severe.  Neither  will  anything  as  to  strength  of  con- 
stitution, or  change  of  type,  explain  the  result,  as  several  of  the  cases 
were  those  of  healthy,  vigorous  young  laborers,  whilst  others  were  those 
of  weak  and  broken-down  sempstresses.  In  any  and  every  case  the  dis- 
ease goes  through  its  natural  progress,  if  the  system  be  not  too  much 
exhausted,  either  naturally  or  by  the  interference  of  the  physician ; and 
if  a judicious  restorative  treatment  be  adopted. 

2.  As  a general  rule,  it  will  be  observed  that  prostration  and  weaken- 
ing complications  or  remedies  not  only  materially  lengthen  the  period 
of  the  disease,  but  especially  prolong  the  convalescence.  This  will  be 
seen  on  referring  to  Nos.  6,  20,  71,  100,  101,  104,  118,  and  119  in  the 
Table.  It  is  easily  understood,  therefore,  how  it  happened  that  the  anti- 
phlogistic treatment  of  former  days  proved  so  fatal.  The  facts  collected 
for  mo  by  Dr.  Thorburn  from  former  case-books  of  the  Iloyal  Infirmary, 
prove  that  in  weak  cases  a lowering  treatment  was  still  employed, 
though  not  to  so  great  an  extent  as  in  robust  persons. 

8.  It  is  generally  supposed  that  the  amount  of  lung  affected  by 
pneumonia  must  influence  the  result  and  duration  of  the  disease.  As 
to  the  results,  all  my  cases  recovered,  even  the  15  cases  where  the  whole 
of  one  lung  was  involved,  as  well  as  the  26  cases  where  portions  of  both 
lungs  were  affected.  In  one  complicated  case  (No.  56)  the  whole  lung 
on  the  right  side,  and  two-thirds  of  the  lung  on  the  left  side,  were  si- 
multaneously affected,  thus  leaving  only  one-third  of  a lung  to  respire 
with,  and  yet  without  bleeding,  but  aided  by  nutrients  and  restoratives, 
she  was  convalescent  on  the  14th  day,  and  left  the  house  quite  well,  after 
a sixteen  days’  residence.  With  regard  to  duration,  the  extent  of  the 
disease  does  not  exert  so  much  influence  as  is  generally  supposed.  If 
only  a fourth  of  one  lung  be  affected,  the  recovery  may  take  place  in 
eight  days ; but  after  that,  whether  the  half  or  the  whole  of  one  lung,  or 
two-thirds  of  both  lungs,  be  involved,  it  does  not  appear  to  cause  much 
difference.  Cases  with  half  a lung  pneumonic  recovered  in  15,  with 
two-thirds  of  a lung  in  14,  with  a whole  lung  m 10,  and^with  portions 
of  both  lungs  in  14  days,  on  the  average. 

4.  Since  the  observations  of  Louis,  it  has  been  supposed  that  a pneu- 
monia at  the  apex  of  a lung  was  more  fatal  and  more  prolonged  than  one 
at  the  base ; and  so  it  may  be  with  an  antiphlogistic  treatment.  But 
with  a restorative  treatment,  the  preceding  facts  show  that  in  eleven 
cases  where  the  disease  was  confined  to  the  apex,  recovery  took  place  in 
all,  and  on  an  average  on  the  thirteenth  day. 

5.  For  palliating  symptoms,  and  especially  pain  and  dyspnoea,  warm 
fomentations  and  poultices  I believe  to  be  the  best  and  safest  remedies. 
Chloroform  has  been  given  by  Varentrapp,  and  others,  with  good  effect. 
No  doubt  also  small  bleedings,  to  the  extent  of  8 or  12  ounces,  give  re- 
lief; but  in  debilitated  persons  they  are  dangerous,  and  in  all  tend,  by 
weakening  the  strength  at  a period  when  the  depressed  system  is  strug- 
gling to  regain  its  equilibrium,  to  prolong  the  convalescence  and  favor 

angerous  sequelae.  Still,  a small  bleeding  may  be  employed  as  a pallia- 
tive with  caution,  to  relieve  engorgement  of  the  lungs,  and  congestion  of 


712 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


the  right  side  of  the  heart,  although  it  is  very  rarely  required.  (See 
p.  313.)  It  should  be  remembered,  in  cases  of  double  pneumonia,  that 
there  is  often  great  dyspnoea  on  the  sixth  or  seventh  day,  which  will  gen- 
erally yield  to  warm  poultices  locally,  and  moderate  doses  of  wine.  (See 
Commentary,  p.  681.) 

6.  As  a curative  treatment  I am  satisfied  that  the  best  plan  is  rest  in 
bed,  nutritive  drinks,  especially  good  beef-tea,  from  the  firsts  assisted  by 
4 to  8 oz.  of  port  wine,  if  the  pulse  becomes  weak,  and  solid  nutrients 
as  soon  as  they  can  be  taken.  The  elimination  of  the  exudation  may  be 
further  assisted  by  salines  (Acetate  of  Ammonia,  and  small  doses  of 
Tartar  Emetic,  l-16th  of  a grain)  and  diuretics  (Nitric  Ether),  although 
nature  will  accomplish  this  herself  if  the  strength  of  the  body  be  main- 
tained. All  active  purgatives,  contra-stimulants,  depressants,  anodynes, 
and  lowering  remedies  of  every  description,  should  be  avoided. 

7.  As  a further  proof  of  the  advantage  of  the  Restorative  treatment, 
it  may  be  mentioned  that  in  no  single  instance  has  a case  of  acute  pneu- 
monia in  my  hands  degenerated  into  the  chronic  form,  or  become  gan- 
grenous, even  in  the  11  cases  where  the  disease  was  confined  to  the  apex. 
Several  cases  have  entered  the  house  already  chronic  from  neglect,  want 
of  nutrients,  or  as  the  result  of  a lowering  treatment — circumstances 
that  indicate  sufficiently  well  the  causes  which  produce  it. 

After  carefully  studying  all  that  has  been  written  on  the  subject  of 
Pneumonia,  as  well  as  the  numerous  statistical  tables  of  the  results  of 
various  kinds  of  practice,  I can  only  account  for  the  remarkable  success 
which  has  followed  the  restorative  treatment  in  my  hands,  by  supposing 
that  Acute  Pneumonia  is  not  a fatal  disease  if  the  strength  be  supported 
and  there  be  no  complication.  The  former  idea  of  medical  practitioners, 
that  it  was  a dangerous  disorder,  and  recjuired  active  depletion  and  anti- 
phlogistics  to  prevent  its  passing  into  the  suppurative  or  fatal  stage,  was 
erroneous,  and  the  result  of  the  imperfect  knowledge  of  pathology  which 
then  existed.  Suppuration,  so  far  from  being  fatal,  is,  as  we  have  en- 
deavored to  show,  necessary  to  the  resolution  of  the  disease ; and  death, 
so  far  from  being  prevented  by  depletion,  occurred  once  in  every  three 
cases.  The  late  Dr.  Todd,  while  he  supported,  also  stim.ulated  to  a 
great  extent,  and  the  result  of  his  practice  was  a mortalit}"  of  one  in 
nine  cases.^  In  not  one  of  my  uncomplicated  cases  has  there,  I repeat, 
been  a death  for  sixteen  years,  although  twenty-six  were  double  cases, 
and  fifteen  were  cases  in  which  the  whole  lung  was  involved.  Why, 
therefore,  any  such  case  should  have  died  in  the  practice  of  Dr.  Todd,  I 
can  only  ascribe  to  unnecessary  stimulation,  as  that  seems  to  be  the  only 
point  in  which  his  practice  differed  from  mine. 

As  to  the  numerous  remedies  given  in  this  complaint,  I believe  that, 
when  not  injurious,  they  are  for  the  most  part  inert.  It  will  be  observed 
that  in  several  of  the  first  cases  given  in  the  Table,  antimony  was  ad- 
ministered in  grain  doses,  and  that  gradually  its  amount  was  diminished. 
Rv  some  (Todd)  this  drug  is  thought  to  act  best  w’hen  it  occasions  no 
symptoms;  bv  others  (Scoda)  it  is  only  thought  to  be  beneficial  when 
it  causes  vomiting  or  diarrhoea.  Rut  in  none  of  the  cases  tabula  ted  vas 
any  influence  produced  by  it  on  the  progress  of  the  disease.  Scoda,  who 
* Clinical  Lectures  by  Beale,  p.  310. 


PNEUMONIA. 


713 


has  experimented  largely  and  carefully  as  to  the  effect  of  numerous  drugs 
in  pneumonia,  admits  that  no  kind  of  treatment  exerts  any  influence  on 
the  rate  of  mortality,  which  he  thinks  is  always  about  1 in  8 or  9.  The 
rate  of  the  best  homoeopathic  statistics  (Tessier)  is  1 in  13|,  and  that  of 
the  most  judicious  kind  of  mixed  practice,  by  which  different  remedies 
are  adapted  to  various  symptoms,  according  to  the  age  of  the  patients 
and  stage  of  the  disease,  is  1 in  9 (Huss,  Bamberger).  It  follows  that 
no  practice  hitherto  proposed  has  been  so  successful  as  mine — that  is, 
1 death  in  32l  cases.  In  the  uncomplicated  cases  of  Huss,  the  mortality 
was  1 in  17,  whereas  among  mine  there  was  no  death  at  all. 

The  author  of  an  able  article  in  the  British  and  Foreign  Medical 
Review  for  July  1858,  endeavored  to  show  from  the  contrary  results 
obtained  by  statistics,  that  the  result  was  governed  by  hygienic  laws,  or 
peculiarities,  such  as  age,  season,  climate,  neglect  of  the  disease  at  an 
early  period,  its  stage,  and  especially  its  sthenic  or  asthenic  type.  I 
consider  that  my  table  is  calculated  to  show  the  fallacy  of  such  reason- 
ing, and  that,  looking  at  the  time  over  which  it  extends,  as  well  as  all 
the  other  circumstances  to  which  he  has  adverted,  it  might  easily  be 
shown  that  the  uniform  good  results  in  my  uncomplicated  cases  depend 
on  some  other  cause. 

That  cause,  I can  have  no  doubt,  is  simply  supporting  the  patient 
by  nutrients  and  restoratives  from  the  commencement.  The  want  of 
that  support  explains  the  mortality  in  the  practice  of  those  who,  while 
they  do  not  actually  lower  their  patients  by  treatment,  fail  to  see  that, 
in  a certain  proportion  of  cases,  either  the  disease  itself,  or  excessive 
stimulation,  exhausts  and  proves  fatal. 

Case  CLIY.* — Chronic  Fneumonia  of  Upper  Third  of  Right  Lung — 
Gangrenous  Abscess — Recoverg. 

IItstory. — Betsy  Brown,  at.  48,  married,  a washerwoman — admitted  September 
12tb,  1856.  Had  always  enjoyed  good  health  until  the  22d  of  last  month,  when,  in 
consequence  of  exposure  to  cold  and  wet,  she  experienced  rigors,  followed  by  heat, 
but  without  headache,  thirst,  or  loss  of  appetite.  This  was  followed  by  cough  and 
expectoration,  symptoms  which  have  continued  ever  since.  Two  days  ago  she 
brought  up  a tea-spoonful  of  blood. 

Symptoms  on  Admission. — She  complains  of  pain  in  the  right  hypochondrium, 
under  the  false  ribs,  not  increased  by  inspiration.  On  percussion  there  is  dulness 
over  right  apex  anteriorly,  and  upper  third  of  the  right  lung  posteriorly.  Inspiration 
heard  over  dull  area  is  harsh,  with  occasional  snoring  during  expiration.  Vocal 
resonance  greatly  increased.  Sputum  scanty,  tenacious,  purulent,  with  brownish 
streaks.  Other  portions  of  lungs  healthy ; no  friction  audible.  Slight  giddiness, 
tinnitus  aurium,  and  feeling  of  weakness.  Pulse  80,  equal,  and  of  moderate  strength. 
Hepatic  dulness  normal.  Other  functions  well  performed.  B Opii  Camph. 
^ ss  ; Vin.  Ipecac.  3 ij  ; Mist.  Scillce  ad  § vj.  A table-spoonful  to  be  taken  three  or 
four  times  a day. 

Progress  op  the  Case. — September  Ath. — Expectoration  more  free.  A blister  to 
be  applied  to  upper  part  of  right  chest  anteriorly.  Sept.  29^/i. — There  has  been  little 
change,  except  on  the  day  before  yesterday,  when  she  vomited  her  food,  complained 
of  headache,  and  presented  slight  febrile  symptoms.  Pulse  to-day  is  80,  and  weak ; 
no  shivering.  Bowels  costive.  R saline  mixture.,  with  of  wine.,  and  to  have  ^ ss 
of  castor-oil.  Oct.  Id. — Sputum  and  breath  during  the  last  few  days  have  been  of 
an  offensive  odor.  Sputum  is  copious,  purulent,  of  a somewhat  dirty  yellow  color. 
Fine  crepitation  is  now  audible  on  inspiration  under  the  clavicle,  and  down  to  third 
rib,  with  sibilus  during  prolonged  expiration.  Posteriorly  over  dull  region,  respira- 

* Reported  by  Mr.  John  Glen,  Clinical  Cl  erk. 


714 


DISEASES  OF  THE  EESPIRATORY  SA^STEM. 


tion  is  feeble.  Over  lower  two-thirds  of  right  lung,  respiratory  murmurs  greatly 
exaggerated  ; patient  feels  very  weak.  To  have  | vj  of  wine  daily.  Oct.  hth. — Over 
right  lung  posteriorly,  moist  rales  are  now  heard ; below  spine  of  scapula  they  are 
very  coarse.  Expiration  is  prolonged,  loud,  and  tubular.  Vocal  resonance  amounts 
to  bronchophony  immediately  below  spine  of  scapula.  Oct.  lOth. — Since  last  report 
has  continued  to  be  very  weak,  with  feeble  pulse  at  80,  notwithstanding  employment 
of  nutrients  and  wine,  which  she  has  no  appetite  to  avail  herself  of  Cheeks  flushed ; 
skin  hot,  with  general  febrile  symptoms.  Sputum  copious,  still  foetid,  and  consider- 
ably stained  with  dark  blood.  No  evidence  of  lung- tissue  on  microscopic  examination. 
Posteriorly,  immediately  below  spine  of  scapula,  the  moist  rattles  are  very  coarse,  with 
bronchial  resonance  of  the  voice  approaching  pectoriloquy.  Continue  nutrients  and 
wine.  Oct.  %)th. — The  amount  of  sputum  has  gradually  declined  since  last  report,  and 
the  coarse  moist  rales  have  slowly  disappeared  from  right  back.  There  is  now  dry 
cavernous  breathing,  with  pectoriloquy  below  spine  of  right  scapula.  Tec.  llth. — 
Since  last  report  she  has  been  alternately  better  and  worse,  the  sputum  being  at  some 
times  copious,  and  at  others  scanty,  but  not  foetid.  Moist  rales  also  have  occasionally, 
on  the  former  occasions,  returned  in  the  right  back,  with  more  or  less  sibilus  on  ex- 
piration. For  some  days  there  has  been  harsh  inspiratory  murmur  at  apex  of  left 
lung,  and  prolonged  expiration,  without  dulness  on  percussion,  but  with  considerable 
increase  of  vocal  resonance.  Has  been  taking  cod-liver  oil.  Tec.  26^A. — Since  last 
report  there  has  been  a gradual  improvement  in  her  general  health.  Appetite  has 
returned,  and  her  strength  permits  her  to  sit  up  during  the  day.  No  moist  rales  are 
audible  in  right  back,  but  loud  tubular  breathing,  with  increased  vocal  resonance. 
Jan.  20/A. — Has  been  for  some  time  apparently  quite  well,  and  says  she  enjoys  perfect 
health.  Tubular  breathing  and  broncliophonic  resonance  of  voice,  with  dulness  on 
percussion,  are  still  present  over  upper  third  of  right  back.  At  left  apex  also,  inspira- 
tion somewhat  harsh,  with  increase  of  vocal  resonance.  Dismissed. 

Commentary . — In  this  case  a woman,  48  years  of  age,  who  tells  us 
she  had  always  enjoyed  good  health,  is  attacked  with  moderate  fever, 
cough,  and  expectoration,  with  all  the  physical  signs  of  a pneumonia  in 
the  upper  third  of  the  right  lung.  The  sputum  becomes  foetid,  and  a 
gangrenous  abscess  forms,  from  which  she  slowly  recovers,  under  the 
action  of  nutrients  and  wine,  leaving,  however,  as  traces  of  the  disease, 
evidences  of  condensation  in  the  pulmonary  tissue  affected.  In  all  such 
cases  there  is  extreme  difficulty  in  separating  the  disease  from  phthisis. 
Indeed,  there  is  little  pathological  distinction  between  a chronic  pneu- 
monia and  pulmonary  phthisis.  Moreover,  the  latter,  though  the  real 
disease,  may  supervene  upon  the  former,  of  which  the  following  is  an 
example  : — 

Case  CLY.* — Chronic  Pneumonia  of  loth  Lungs.,  with  Ulceration — 
Tenth — Great  Conde^isation,  with  Cavities  and  Pigmentary  Teposits 
in  the  Lungs — Chronic  Tubercle  in  various  Organs — Tisease  of  both 
Bupra-renal  Capsules.,  without  bronzing  of  the  shin. 

History. — John  Cunningham,  get.  52,  married,  a shoemaker — admitted  December 
8th,  1856.  He  states  that  having  previously  been  in  the  enjoyment  of  good  health, 
three  months  ago  while  walking  he  became  heated,  and  took  off  part  of  his  apparel. 
On  his  return  home  he  was  attacked  with  shivering  and  severe  pains  in  the  breast  and 
lumbar  regions.  A violent  cold  ensued,  but  he  continued  his  employment.  Three 
weeks  ago  he  was  obliged  to  give  up  work.  A blister  applied  to  the  chest  to-day, 
before  admission,  has  mitigated  the  pain  there. 

Symptoms  ox  Admission. — Percussion  over  left  front  of  chest  gives  almost  tym- 
panitic resonance,  but  the  tone  is  flat,  with  a strong  sense  of  resistance.  Crack-pot 
sound  is  elicited  in  second  intercostal  space.  Over  right  side,  resonance  more  full  and 
less  tympanitic,  but  still  somewhat  flat.  Posteriorly  some  flat  tone,  with  a resonance 
not  fully  clear.  On  auscultation,  marked  increase  of  vocal  resonance  over  left  apex. 


* Reported  by  Mr.  W.  Guy,  Clinical  Clerk. 


PNEUMONIA. 


715 


abo  over  left  supra-scapular  region  ; elsewhere  normal.  At  left  apex,  inspiration  and 
expiration  are  blowing  and  cavernous  in  character,  and  expiration  is  prolonged.  After 
cough,  fine  moist  sounds  ai’e  heard  at  close  of  inspiration.  Laterally  large  moist 
sounds  are  more  or  less  heard  with  inspiration,  and  coarse  in  character,  while  expira- 
tion is  loud  in  tone.  On  right  side  the  same  moist  sounds  are  heard,  coarser  in  char- 
acter, with  both  inspiration  and  expiration.  Posteriorly,  respiratory  murmurs  somewhat 
loud.  No  moist  rales,  except  over  right  supra-scapular  region.  Expiration  is  every- 
where prolonged.  Cough  is  violent,  accompanied  with  a great  quantity  of  frothy, 
tenacious,  and  somewhat  dirty  and  blackish-looking  sputum,  with  a few  streaks  of 
blood.  Pulse  88,  small  and  weak.  Urine,  sp.  gr.  1020 ; voided  in  small  quantities, 
of  a high  color,  throwing  down  a large  quantity  of  lithates.  Chlorides  plentiful ; other 
functions  normal. 

Progress  of  the  Case. — December  Wth. — Under  left  clavicle  to-day,  hoarse 
c'avernous  rales,  with  both  respiratory  murmurs,  accompanied  with  faint  but  distinct 
crepitation  and  bronchophony.  Posteriorly  at  left  apex,  loud  tubular  breathing,  with 
both  murmurs ; inferiorly  fine  crepitation,  mixed  at  the  termination  of  insi>iration  with 
a loud  sibilant  murmur.  Dec.  \Mh. — To  have  a blister  applied  over  sternum.  Dec. 
\^th.  Complains  of  indigestion  and  feverishness.  Pulse  100,  hard,  but  compressible. 
U Acetalis  Potass.  3j;  Aquce  Acet.  Ammon.  §j;  Aquam  ad  | vj.  M.  A table- 
spoonful to  he  taken  every  three  hours.  Dec.  18^A. — Feverishness  has  disappeared; 
sputum  of  a dark-brown  color ; is  not  foetid.  On  microscopic  examination,  numerous 
well-formed  pus  cells  are  seen,  but  no  pulmonary  tissue.  Dec.  2Zd. — Takes  nourish- 
ing diet  with  3 iv  of  wine.  Says  he  eats  all  his  food.  Anxious  to  go  out,  but  cannot 
on  account  of  weakness.  January  2d. — Countenance  expressive  of  great  weakness, 
sallow  and  pale.  Tongue  covered  with  a brown  crust ; dry,  hard,  and  cracked.  Pulse 
108,  weak ; cough  at  night  severe,  preventing  sleep.  Physical  signs  unaltered ; cannot 
rise  to  sitting  posture  without  aid.  Jan.  %th. — Died  at  1 o’clock  p.m. 

Sectio  Cadaver  is. — Forty -seven  hours  after  death. 

Thorax. — The  upper  lobe,  and  upper  half  of  middle  lobe,  of  right  lung  condensed 
and  indurated.  On  section,  the  cut  surface  presented  an  iron  grey  passing  into  a 
black  color.  At  the  apex  there  was  a cavity  resembling  a tubercular  one  about  the  size 
of  a walnut.  The  inferior  portion  of  this  lung  also  somewhat  condensed,  but  more 
spongy.  The  whole  of  left  lung  condensed  and  indurated.  On  section,  the  same  iron- 
grey  color  was  everywhere  observable  except  at  the  base,  where  there  existed  masses 
varying  in  size  from  a hazel-nut  to  that  of  a chestnut,  of  a dirty  red  colored  hepatiza- 
tion. Portions  of  the  condensed  tissue  everywhere  sunk  in  water.  At  the  apex  and 
at  the  back  of  this  lung  below  the  pleurae,  which  were  adherent,  there  was  a cavity 
four  inches  long,  and  about  an  inch  in  breadth,  with  very  irregular  broken  down  walls. 
This  communicated  with  several  smaller  anfractuous  cavities.  Heart  normal. 

Abdomen. — Slight  simple  constriction  of  the  pyloric  orifice  of  the  stomach.  Over 
the  mucous  surface  of  the  small  intestine,  extending  from  the  termination  of  the  ileum 
to  about  two  feet  of  the  end  of  the  duodenum,  were  numerous  cicatrices  of  former 
ulcers,  with  everted  edges,  and  the  surrounding  mucous  membrane  puckered  and  drawn 
in.  There  were  a few  similar  cicatrices  in  the  large  intestine.  The  mesenteric  glands 
were  a little  enlarged,  and  contained  yellow  tubercular  matter.  The  right  supra-renal 
capsule  felt  thick  and  hard,  and  weighed  290  grains.  It  was  everywhere  infiltrated 
with  yellow,  opaque,  tubercular-looking  matter  of  solid  consistence,  but  friable  under 
pressure.  Perhaps  about  one-tenth  only  of  the  gland  presented  its  natural  texture. 
Two  tubercular  masses,  the  size  of  filbert-nuts,  were  present  in  the  left  supra-renal 
capsule,  surrounded  by  indurated  tissue.  One-fourth  of  its  texture  was  natural.  Other 
organs  normal. 

Microscopic  Examination. — Fluid  pressed  from  the  iron-grey  and  black  hepatiza- 
tion contained — First,  A great  number  of  large  granule  cells.  Secondly,  Numerous 
pigment  cells.  Thirdly,  Colorless  epithelial  cells,  isolated  and  aggregated  in  masses. 
Some  of  these  cells  were  peculiarly  colorless,  and  resembled  those  in  waxy  textures. 
Fourthly,  A few  starch  and  celloid  bodies.  Fifthly,  Numerous  pigment  and  fatty 
granules  floating  loose.  On  making  a section  of  this  tissue  with  a Valentine’s  knife, 
these  elements  were  seen  everywhere  infiltrating  the  pulmonary  texture.  The  fluid 
pressed  from  the  dirty  red  colored  hepatization,  in  the  base  of  the  opposite  lung,  con- 
tained numerous  pus  corpuscles  with  epithelial  cells ; comparatively  few  granule  cells, 


V16 


DISEASES  OF  THE  EESPIEATORY  SYSTEM. 


and  no  pigment.  A portion  of  the  grey  exudation,  which  here  and  there  resembled 
infiltrated  tubercle,  was  composed  of  amorphous  molecular  matter.  The  yellow  masses 
in  the  supra-renal  capsules  presented  the  characteristic  structure  of  tubercle. 

Commentary. — This  man’s  account  of  his  case  (and  he  seemed  very 
intelligent)  was,  that  the  pulmonary  disease  commenced  in  the  manner 
described,  three  months  before  admission.  He  also  denied  having  been 
ever  seriously  ill  before.  Yet  the  examination  after  death  revealed 
evidences  in  the  lungs,  intestines,  mesenteric  glands,  and  supra-renal 
capsules,  of  chronic  tubercular  disease.  The  fever,  rapid  ulceration  of 
both  lungs,  and  subsequent  prostration,  as  in  the  last  case,  however, 
were  apparently  owing  to  a pneumonia,  which  became  chronic.  In  such 
a case,  the  vital  powers  were  unable  to  effect  those  rapid  changes  which 
we  have  seen  to  be  the  characteristic  of  acute  pneumonia,  and  he  died. 
The  diagnosis  between  such  a disease  and  phthisis  pulnionalis,  I regard 
as  impossible.  The  two  forms  of  exudation  present  similar  physical  and 
vital  characters.  In  neither  this  nor  the  former  case,  was  the  general 
appearance  of  the  patient,  or  history  of  the  disease,  in  any  way  similar 
to  that  of  phthisis;  and  practically  it  is  of  little  moment  whether  we 
have  to  do  with  a low  form  of  exudation  m young  persons,  which  we  call 
tubercle,  or  a similar  one  in  old  persons,  which  we  call  chronic  pneu- 
monia. In  this  case,  however,  there  was  tubercle  of  a chronic  character 
in  several  organs,  and  among  others  in  both  supra-renal  capsules,  although 
there  was  certainly  no  bronzing  of  the  skin  during  life. 

Case  CLVI.'^ — Gangrene  of  the  Lunge — Dysentery. 

History. — Thomas  Marshall,  set.  29,  a chimney-sweep — admitted  November  23, 
1852.  He  states  that  he  has  been  troubled  with  slight  cough  for  many  years  back. 
Eight  weeks  ago  he  experienced  rigors  without  any  obvious  cause,  followed  by  increase 
of  the  cough,  looseness  of  the  bowels,  severe  griping  pains  in  the  abdomen,  and  fre- 
quent desire  to  go  to  stool,  with  much  straining  and  tenesmus.  He  observed  a small 
quantity  of  blood  in  the  stools,  which  sometimes  consisted  only  of  about  a table- 
spoonful of  blood  mixed  with  frothy  mucus.  The  calls  to  stool  were  at  first  so  numer- 
ous that  he  cannot  state  even  the  probable  number  in  the  twenty-four  hours.  They 
abated  somewhat  under  treatment  at  one  of  the  dispensaries,  but  the  diarrhoea  has 
continued  more  or  less  ever  since.  During  the  last  eight  weeks  the  cough  has  become 
much  aggravated,  and  the  sputa  increased  in  quantity.  Two  days  before  admission,  he 
observed  that  the  sputa  were  of  a dirty  red  color,  having  formerly  consisted  of  thick 
purulent  masses  without  any  tinge.  He  states  that  for  the  last  eight  or  ten  weeks  he 
has  been  losing  flesh  and  strength  to  a great  degree,  though  he  does  not  present  a very 
emaciated  appearance.  His  diet,  also,  during  that  period,  has  been  very  defective, 
both  in  quantity  and  quality ; but  previously  he  had  always  been  able  to  procure  good 
food.  He  is  addicted  to  the  immoderate  use  of  spirits,  and  has  several  times  had 
delirium  tremens. 

Symptoms  on  Admission. — On  admission,  the  chest  on  percussion  appears  resonant 
throughout,  except  over  the  upper  third  of  right  lung,  where  very  slight  dulness  can 
be  detected.  The  respiratory  murmur  is  heard  all  over  the  chest,  but  under  the  right 
clavicle  it  is  harsh  and  exaggerated,  and  the  vocal  resonance  greatly  increased.  Pos- 
teriorly, there  is  comparative  dulness  on  percussion,  and  increased  vocal  resonance 
over  the  whole  of  riglit  side,  but  most  marked  at  the  apex.  Over  the  lower  third,  on 
the  same  side,  fine  crepitation  can  be  heard  during  forced  inspiration.  Sputum  in  large 
quantity,  consisting  of  frothy  tenacious  mucus,  of  a dirty  brown  color,  becoming  more 
fluid  upon  standing,  and  of  very  offensive  odor.  When  examined  by  the  microscope, 
numerous  pus-cells,  some  blood  corpuscles,  and  large  quantities  of  disintegrated  epi- 
thelium, can  be  detected.  Has  no  pain  in  chest.  Breathing  is  not  labored,  but  cough 
is  troublesome,  especially  at  night,  occurring  in  paroxysms.  Expectoration  difficult. 
The  tongue  is  dry,  with  slight,  dirty-yellow  fur ; troublesome  thirst,  but  appetite  good. 

^ Reported  by  Mr.  W.  M.  Calder,  Clinical  Clerk. 


PNEUMONIA. 


Ill 


No  nausea,  but  frequent  inclination  to  vomit  when  the  cough  is  severe.  No  uneasiness 
iu  the  bowels  when  at  rest,  but  griping  pains  are  generally  present  when  at  stool. 
There  is,  distinct  tenderness  on  percussion  in  the  right  iliac  region,  over  a space  of 
about  two  inches.  The  bowels  have  been  open  six  times  during  the  last  twenty-four 
hours.  The  stools  are  very  copious,  of  thin  fluid  consistence,  and  of  a brownish-red 
color.  They  contain  numerous  blood-corpuscles,  as  determined  by  the  microscope. 
The  urine  is  passed  in  small  quantity,  but  otherwise  normal.  There  are  slight  tremors 
of  the  hands,  but  no  other  symptoms  of  delirium  tremens.  Other  functions  normal. 
IJ  Tinct.  Opii  3 ij  ; I'inct.  Catechu  ? ss ; Confect.  Aromat,  3 ij  ; Mist.  CretcB  | v. 
M.  A tab’ e-spoonful  to  he  taken  every  four  hours.  Haheat  enema.,  cum  Tinct.  Opii  3 j- 

jElh.  Sulph.  m.  xl ; Mucilaginis  3 ij  ; Mist.  Camph.  ^ j.  Fiat  haustus.  To  he 
taken  at  bed-time.  Ordered  also  nutritious  diet  and  4 oz.  of  wine. 

Progress  op  the  Case. — November  26. — Bowels  open  nine  or  ten  times  during 
the  twenty-four  hours ; stools  watery,  having  distinct  traces  of  blood.  Much  griping 
pain  when  at  stool.  Cough  severe.  Expectoration  copious.  Dec.  1. — Diarrhoea  con- 
tinues, notwithstanding  he  has  taken  regularly  the  astringent  mixture  and  opiate 
euemata.  To-day  the  skin  is  hot  and  dry,  the  appetite  bad,  with  great  thirst.  To 
have  a 5 gr.  pill  of  lead  and  opium  every  third  hour.  Dec.  2. — Has  had  four  or  five 
stools  since  last  night.  They  are  faeculent,  but  of  very  thin  consistence,  unmixed  with 
blood.  He  feels  very  weak,  and  complains  much  of  pain  in  the  chest,  especially  on 
the  right  side.  Dulness  on  percussion  is  increased  over  the  whole  of  the  right  side 
posteriorly,  and  is  most  marked  over  the  lower  third.  There  is  great  increase  also  of 
the  vocal  resonance,  amounting  to  pectoriloquy  in  the  supra-scapular  region;  loud 
moist  rales,  like  gurgling,  are  heard  over  the  right  back.  On  the  left  side  the  respira- 
tion is  harsh  and  exaggerated,  and  the  vocal  resonance  is  also  loud.  Breath  and  ex- 
pectoration foetid.  Omit  the  lead  and  opium  pill  and  continue  the  medicine  ordered  on 
the  2Uh.  Dec.  6. — Diarrhoea  abated,  but  he  feels  very  weak,  and  the  cough  is  trouble- 
some ; crepitation,  with  increased  vocal  resonance,  pretty  general  over  the  left  back. 
To  have  3 oz.  of  spirits.  Dec.  9. — Diari'hoea  has  returned — stools  thin  and  fmcal,  con- 
taining a good  deal  of  blood.  To  have  a starch  injection  with  Tinct.  Opii  3 iss.  Dec. 
14. — Diarrhoea  abated  somewhat  until  to-day,  when  it  has  again  returned  as  severely 
as  before.  Much. pain  in  lower  part  of  abdomen  ; consideraVfle  griping  and  tenesmus; 
pulse  100,  small  and  weak,  but  regular.  The  opiate  enema  has  heeyi  continued  every 
evening  since  last  report.,  and  he  has  been  taking  a chloric  ether  and  morphia  mixture  to 
relieve  the  spasmodic  cough.  Apply  a blister  {f  by  2>)  to  the  abdomen.  Increase  the  wine 
to  6 oz.  Dec.  18. — Has  rallied  greatly  since  last  report,  but  to-day  the  diarrhoea  has 
again  returned.  The  cough  is  very  troublesome — sputa  tinged  with  blood ; over  the 
whole  of  the  right  back  there  are  harsh  gurgling  rales,  with  a noise  approaching  to  a 
metallic  character  when  he  coughs ; mucous  rattles  heard  over  left  back ; the  offen- 
sive odor  of  breath  and  sputa  has  increased  since  last  noticed.  To  have  the  follow- 
ing draught  at  bedtime.  B Mur.  Morph.  3j;  continue  the  2>  oz  of  spirits. 
Tinct.  Catechu  3j;  Mist.  Cretce  ^j;  Spir.  Ammon.  Aromat.  3 ss.  M.  Sumat  hora 
somni.  Jan.  1. — Died  this  morning  at  five  a.m.  Little  change  took  place  in  the  symp- 
toms after  last  report.  One  day  he  appeared  to  sink,  but  h^e  rallied  again  the  next. 
Diarrhoea  continued,  averaging  about  twelve  stools  in  twenty-four  hours.  The  stools 
consisted  of  very  small  quantities  of  dark  matter,  with  mucus,  and  occasionally  a little 
blood.  He  continued  taking  the  mixture  of  ammonia,  etc.,  and  the  astringents  wit’i 
an  opiate  enema,  which  latterly  was  administered  twice  a day. 

Sedio  Cadaver  is. — Thirty -one  hours  after  death. 

Body  much  emaciated. 

Thorax. — Heart  and  pericardium  normal.  Right  lung  united  to  thoracic  walls  by 
firm  and  universal  pleuritic  adhesions.  On  its  being  removed  and  bisected,  a black 
gangrenous  cavity,  five  inches  long  and  four  broad,  was  exposed,  occupying  the  upper 
and  middle  lobes.  It  contained  an  extremely  foetid  olive-green  diffluent  matter,  having 
no  distinct  structure.  The  walls  of  the  cavity  presented  a firm  lining  membrane  of 
condensed  fibrous  tissue,  internally  of  pulpy  consistence  and  blackish-brown  color. 
The  surrounding  pulmonary  tissue,  posteriorly  and  inferiorly,  was  hepatized  and  friable, 
with  a few  anfractuous  cavities  also  gangrenous.  Anteriorly  the  lung  was  emphyse- 
matous, with  here  and  there  portions  of  collapsed  tissue.  The  left  lung  adhered  to  the 
thoracic  walls  posteriorly  by  pleuritic  adhesions.  On  being  removed  and  bisected,  the 
lower  lobe  end  inferior  portion  of  upper  lobe  was  congested,  and  presented  a brick-red 
color  ; hepatized  and  dense  in  various  places,  with  irregular  cavities  containing  foetid 


V18 


DISEASES  OF  THE  KESPIKATORY  SYSTEil. 


brown  sloughs,  varying  in  size  from  that  of  a pea  to  a pigeon’s  egg,  and  communicating 
more  or  less  with  each  other. 

AbdomexN. — Mucous  surface  of  cascum  and  ascending  colon  closely  studded  with 
irregular-shaped  ulcerations,  varying  in  size  from  a pin’s  head  to  a sixpence.  Some  oi 
these  were  evidently  chronic,  and  in  process  of  healing,  with  a thickened  worm-eaten 
edge  and  a bluish  granular  base ; others  contained  a sloughing  centre,  involving  more 
or  less  of  the  muscular  coat.  Similar  ulcers  were  scattered,  but  more  sparsely, 
through  the  transverse  and  descending  colon.  Other  abdominal  organs  healthy. 

Cimmentary . — In  this  case  we  have  an  example  of  pneumonia  in  both 
lungs,  which  passed  into  gangrene,  associated  with  acute  dysentery, 
occurring  in  an  individual  whose  constitution  had  been  impaired  by  ad- 
diction to  intoxicating  drinks.  Dysentery,  generally  prevails  during  the 
autumn  months,  in  Edinburgh,  to  a greater  or  less  extent;  and  in  the 
case  of  Marshall  it  came  on  without  any  obvious  cause  in  September,  and 
was  ushered  in  by  rigors,  followed  by  bloody  and  purulent  discharges  at 
stool,  with  tenesmus  and  abdominal  pain.  About  the  same  time,  also, 
pectoral  symptoms  were  complained  of,  although  it  is  not  probable  that 
decided  pneumonia  was  then  occasioned.  Even  when  he  came  into  the 
house  it  was  limited  in  extent,  and  ran  a tolerably  acute  course  subse- 
quently. The  febrile  symptoms,  therefore,  v/hich  existed  previous  to  his 
admission,  were  most  probably  connected  with  the  dysentery.  This  ran 
its  usual  course,  producing  sloughing  ulcers  in  the  mucous  membrane  of 
the  large  intestines  to  a considerable  extent ; and  by  the  irritation  and 
continued  discharge  they  occasioned  (which  could  not  be  checked), 
gradually  prostrated  the  patient,  and  was  the  chief  cause  of  his  death. 

It  is  seldom  we  have  an  opportunity  of  seeing  a more  illustrative  case 
of  gtingrene  of  the  lungs,  than  this  man  presented — large  and  circum- 
scribed on  the  right  side,  extended  and  diffused  on  the  left  side.  That  the 
gangrene  was  preceded  by  pneumonia  in  both  lungs  there  can  be  little 
doubt,  as  all  the  functional  signs  of  the  lesion  were  present  during  life, 
whilst  after  death  the  gangrenous  cavities  were  everywhere  surrounded  by 
distinct  pulmonary  hepatization.  There  is  every  reason  to  suppose  that 
the  same  general  causes  which  produced  the  sloughing  sores  in  the  intes- 
tines, occasioned  the  gangrenous  cavities  in  the  lungs.  A deficiency  of 
vital  power  in  the  organism  prevented  those  transformations  necessary  for 
the  absorption  of  the  exudation,  and  thus  it  died  and  underwent  putre- 
faction. Inflammatory  gangrene  and  ulceration  both  depend  on  death 
of  the  exudation,  but  in  the  former  case  there  occur  those  peculiar  chemi- 
cal changes  which  induce  putrefaction.  The  only  symptom  which  in- 
dicates this  change  is  foetor  of  the  breath  or  of  the  sputum,  which  was 
very  apparent  in  Marshall  on  his  admission  to  the  house,  and  was  greatly 
increased  afterwards.  In  the  following  case  I diagnosed  a gangrenous 
cavity  in  the  right  lung,  and  separated  it  from  phthisis,  partly  on 
account  of  the  foetid  odor,  and  partly  on  account  of  the  situation  and 
limitation  of  the  cavern. 

Case  CL VII. — Gangrenous  Abscess  of  the  Right  Lung^  caused  hg  sxcallow- 
ing  a piece  of  Chicken  Bone  four  and  a half  xjears  previously. 

History. — Thomas  Neal,  set.  27,  a footman,  of  sober  habits — admitted  December 
4th,  1848.  He  says  that  he  was  quite  well  up  to  four  years  and  a half  ago,  when, 
while  eating  part  of  a chicken,  and  laughing,  he  was  suddenly  seized  with  coughing 


* Reported  by  Mr.  James  Struthers,  Clinical  Clerk. 


PNEUMONIA. 


n9 

and  a sense  of  suffocation,  producing  lividity  of  the  face.  He  thinks  he  swallowed  a 
portion  of  chicken  bone,  but  is  by  no  means  sure.  At  ail  events,  he  experienced  a severe 
pain  at  the  time  across  the  lower  part  of  the  chest,  followed  by  a short,  dry,  tickling 
cough,  accompanied  by  a wheezing  noise  in  the  throat.  In  an  hour  he  recovered  and 
went  about  his  usual  employment.  The  cough,  however,  continued,  and  after  three 
months  was  accompanied  by  a frothy  expectoration,  which  gradually  increased. 
About  three  years  ago  he  entered  St.  George’s  Hospital,  London,  but  was  dismissed  in 
a fortnight.  Shortly  after,  he  observed  blood  in  the  sputum,  which  now  became 
foetid.  He  has  labored  under  constant  cough,  with  expectoration  of  foetid  pus  and 
moi’e  or  less  blood  ever  since. 

Symptoms  on  Admission. — On  admission  he  complained  of  frequent  cough  and 
profuse  expectoration  of  a viscid,  slightly  frothy  matter,  stained  with  blood  and  of 
gangrenous  odor.  He  was  pale,  but  by  no  means  emaciated.  On  percussing  the 
chest,  there  was  considerable  dulness  over  the  two  inferior  thirds  of  the  right  lung, 
both  anteriorly  and  posteriorly.  At  a point  a little  below  the  right  nipple,  the  dulness 
was  more  marked  than  either  above  or  below.  On  auscultation  there  was  great 
increase  of  the  vocal  resonance  over  the  whole  right  side  of  the  chest,  most  so  over 
the  dull  spot  below  the  nipple.  Posteriorly,  about  the  middle  of  the  lung,  there  was 
a circumscribed  gurgling  rale,  heard  over  an  extent  about  two  inches  square,  and  not 
audible  above  or  below  it.  At  this  point  also  there  was  perfect  pectoriloquy.  The 
respiratory  murmur  over  the  other  parts  of  the  lung  was  harsh,  and  here  and  there 
accompanied  by  mucous  and  sibilant  rales.  These  signs  were  less  evident  at  the 
upper  than  over  the  lower  two-thirds  of  the  organ.  Over  the  left  lung  the  percussion 
was  normal,  the  respiratory  murmurs  puerile  but  otherwise  healthy.  All  the  other 
functions  were  well  performed,  if  we  except  the  occasional  loading  of  the  urine  with 
lithates,  and  trifling  perspiration  at  night. 

Progress  op  the  Case. — The  treatment  was  directed  to  supporting  his  strength, 
giving  cough  and  antispasmodic  mixtures,  and  introducing  a seton  below  the  right 
nipple.  This  produced  considerable  local  irritation,  but  caused  diminution  in  the 
gurgling  rale,  expectoration,  and  cough,  so  much  so,  that  he  insisted  on  leaving  the 
Infirmary,  February  8,  1849.  He  continued,  however,  to  be  attended  by  the  clinical 
clerk,  now  Dr.  James  Struthers  of  Leith,  from  whose  report  the  following  account  is 
taken  : — “ Towards  the  middle  of  March  his  appetite  and  strength  began  to  fail ; he 
lost  flesh  and  became  feverish,  thirsty,  and  restless ; was  obliged  to  confine  himself 
to  the  house,  and  suffered  from  shortness  of  breath,  even  when  at  rest  ; the  cough 
and  expectoration  continued  much  the  same  ; he  had  no  rigors,  and  was  free  from 
pain.  On  the  morning  of  the  24th,  he  awoke  suffering  from  great  increase  of  cough 
and  shortness  of  breath,  and  continued  during  the  day  to  expectorate,  at  intervals  of 
a few  minutes,  large  quantities  of  frothy  sputa,  deeply  tinged  with  blood,  and  much 
more  foetid  than  usual.  I was  asked  to  visit  him  at  his  own  house  on  the  25th,  and 
found  him  much  weaker  than  when  I had  seen  him  fome  weeks  previously.  The 
cough  was  constant,  the  expectoration  profuse,  the  sputa  frothy  and  mixed  with  florid 
blood  ; the  breath  and  sputa  had  a gangrenous  odor  which  was  very  perceptible  on 
approaching  the  bed.  He  had  no  pain,  his  chief  complaint  being  of  great  weakness, 
dyspnoea,  and  occasional  feeling  of  suffocation.  The  respirations  were  45  ; the  pulse 
130,  weak  and  wiry.  On  examining  the  chest,  the  right  side  was  found  scarcely  to 
move  on  inspiration,  and  was  universally  dull  on  percussion  ; all  natural  respiratory 
sound  was  absent  ; gurgling  was  audible  over  its  greater  part,  both  in  front  and  be- 
hind, with  coarse  mucous  and  subcrepitant  rale  towards  the  upper  and  lower  parts. 
Although  the  voice  was  weak,  the  vocal  resonance  was  much  increased,  and  there  was 
very  distinct  bronchophony  over  the  inferior  two-thirds.  There  was  no  friction  sound 
audible.  The  left  side  was  very  resonant,  and,  with  the  exception  of  puerile  respira- 
tion, and  some  subcrepitous  rale,  inferiorly,  presented  nothing  unusual.  During  the 
next  three  days,  he  became  rapidly  weaker  ; the  cough  and  dyspnoea  increased  ; he 
could  speak  only  in  monosyllables  ; the  respirations  rose  to  68,  and  the  pulse  to 
140 ; he  expectorated  daily  about  two  pints  of  thin  bloody  sputa,  which  had  a strong 
gangrenous  odor,  and  latterly  flowed  in  an  almost  continuous  stream  from  the 
mouth.  On  the  29th,  he  became  typhoid,  had  hiccup  and  slight  delirium,  and  died  in 
the  evening.” 

Sectio  Cadaveris. — Thirty-six  hours  after  death. 

The  features  were  much  collapsed ; there  was  some  yellowness  of  the  skin ; and  a 
copious  discharge  of  thin  brown  fluid  from  the  mouth  and  nostrils.  Percussion  of  the 
chest  elicited  the  same  sounds  as  during  the  last  days  of  life. 


120 


DISEASES  OF  THE  EESPIRATOKY  SYSTEM. 


Thorax. — The  right  lung,  with  the  exception  of  the  lower  part  of  the  anterior 
border,  was  found  firmly  adherent  to  the  walls.  The  adhesions  were  short,  dense, 
and  of  a white  color.  The  lung  was  removed  without  laceration  ; it  was  somewhat 
diminished  in  bulk,  of  a dark  red  color,  and  had  a pulpy  feel.  The  apex  was  occupied 
by  a closed  cavity,  the  size  of  a small  orange,  which  was  distended  with  a 
brown  dirty-looking  fluid  of  the  consistence  of  cream,  and  having  a most  intense 
gangrenous  odor.  The  wall  of  this  cavity  approached  the  pleura  superiorly;  its 
inner  surface  was  very  irregular,  presenting  numerous  shreds  of  disorganised  pulmo- 
nary tissue.  At  the  middle  of  the  lung  posteriorly,  and  about  half  an  inch  from 
the  surface,  there  was  another  cavity,  the  size  of  a walnut,  lined  with  a dense  grey- 
colored  membrane,  one  line  in  thickness,  and  broken  up  in  several  places  ; it  was 
partially  filled  with  a dirty-colored  fluid,  and  opened  directly  into  a 
bronchial  tube,  the  size  of  a crow-quill,  at  the  other  extremity  of 
which  the  foreign  body  was  found  at  a future  stage  of  the  dissec- 
tion.  In  the  neighborhood  of  this  cavity,  and  throughout  the 
Fig  454  whole  of  the  inferior  and  posterior  parts,  the  lung  was  riddled  with 
numerous  small  cavities,  varying  in  size  from  that  of  a hazel-nut  to 
that  of  a pea.  Some  of  these  were  closed  and  filled  with  a fluid  similar  to  that  found 
ill  the  one  at  the  apex ; others  were  nearly  empty,  more  or  less  anfractuous,  and 
communicated  freely  with  the  bronchial  tubes  ; the  walls  of  some  were  formed  of 
a thick  dense  membrane ; those  of  others  were  soft  and  ragged.  The  middle  part  of 
the  anterior,  and  a small  portion  of  the 
inferior  border,  were  in  a state  of  grey 
hepatization,  and  were  the  only  parts 
free  from  cavities.  On  laying  open  the 
nchus,  a small  piece  of  bone  was 
found  at  the  bifurcation  of  the  middle 
primary  division ; it  was  lying  almost 
loose,  and  came  away  without  any  force 
being  used  ; it  was  quite  clean,  and  bore 
a strong  resemblance  to  part  of  a verte- 
bra of  a small  animal,  being  of  an  irre- 
gular elongated  form,  and  presenting 
several  sharp  spicula.  The  mucous  mem- 
brane at  the  part  was  thickened,  but 
quite  free  from  ulceration,  and  not 
more  vascular  than  that  of  the  other 
bronchi.  The  trachea  and  the  bronchi 
of  both  lungs  were  stained  of  a dark 
grey  color,  but  otherwise  presented  nothing  abnormal.  In  the  pleura,  there  were 
three  or  four  ounces  of  clear  serum.  The  lung  was  healthy,  except  a small  portion  at 
the  inferior  border,  which  was  hepatized,  and  studded  with  small,  grey,  indurated  no- 
dules, the  size  of  corn-pickles.  These  consisted,  as  ascertained  by  the  microscope,  of 
accumulations  of  altered  epithelium,  with  much  granular  fatty  matter.  The  apex  of 
the  lung  was  free  of  deposit,  and  there  was  no  tubercle  in  any  part.  The  bronchial 
gland^^  especially  those  on  the  right  side,  were  greatly  hypertrophied,  several  of  them 
being  as  large  as  pigeon’s  eggs  ; they  contained  no  foreign  matter.  The  heart  was  of 
the  normal  size  ; its  muscuiar  and  valvular  structures  were  healthy ; and  all  the  cavi- 
ties contained  both  firm  decolorised  and  dark  loose  clots.  The  bloody  examined  under 
the  microscope,  presented  the  red  and  white  corpuscles  in  the  usual  proportions 

Abdomen. — The  abdominal  viscera  were  in  all  respects  normal. 

Microscopic  Examination. — The  fluid  from  the  abscess  at  the  apex  of  the  right 
lung,  on  being  examined  under  the  microscope,  was  found  to  contain  small  shreds  of 
fibrous  tissue,  broken  down  pus  globules,  and  a large  number  of  crystals  of  the  triple 
phosphate  and  of  the  urate  of  ammonia  (Fig.  455). 

Commentary. — The  physical  signs  in  this  case  clearly  indicated  the 
existence  of  a cavity  in  the  right  lung,  which,  from  its  position,  and 

Fig.  454.  Fragment  of  chicken-bone  found  in  the  right  bronchus,  in  Neal’s  case. 

Fig.  455.  Fluid  in  the  chronic  abscess  of  the  right  lung  in  Neal’s  case,  a.  Fibrous 
tissue ; A,  broken-down  pus  cells  ; c,  crystals  of  triple  phosphate ; and  6^,  urate  of 
ammonia. — {James  Struthers.)  250  dia7n. 


PNEUMONIA. 


721 


from  the  general  history  of  the  case,  was  not  likely  to  be  tuberculai. 
On  the  other  hand,  its  gangrenous  character  was  revealed  by  the  pecu- 
liar odor,  and  his  account  of  its  origin  rendered  it  probable  that  the 
cause  was  a foreign  body  impacted  in  the  bronchus.  At  the  same  time, 
he  was  never  very  certain  as  to  the  fact  of  having  swallowed  the  piece 
of  bone,  and,  in  many  conversations  I had  with  him  on  that  point,  he 
invariably  stated  that  such  was  merely  his  impression,  but  he  was  not 
sure.  It  is  of  importance  to  notice  this  fact,  because  it  seems  very  pro- 
bable that  when  iu  St.  Gleorge’s  Hospital,  his  account  may  have  been  a 
doubtful  one  there  also,  and  may  have  prevented  recourse  to  an  opera- 
tion which  then  might  possibly  have  been  undertaken  with  success.  It 
would  be  interesting  to  know  whether  at  that  time  his  chest  had  been 
carefully  examined  by  auscultation,  or  whether  general  symptoms  only 
were  attended  to,  and,  in  consequence  of  these  being  slight,  he  was  dis- 
missed in  a fortnight.  Certainly,  it  cannot  be  imagined  that  if  any  cer- 
tainty existed  as  to  the  impaction  at  that  time  of  a foreign  body  in  the 
lung,  no  eifort  would  have  been  made  to  extract  it,  especially  when  the 
uniform  ultimate  fatality  of  such  an  occurrence  is  taken  into  considera- 
tion. At  all  events,  this  case  points  out  how,  in  a young  man  of  perfect 
health,  structural  disorganization  slowly,  but  surely,  proceeds  after  such 
an  occurrence,  and  it  strongly  inculcates  the  necessity  of  early  careful 
examination  and  of  operative  interference. 

Another  cause  of  gangrene  in  the  lung  is  the  occasional  impaction 
of  clots  of  blood,  whether  the  result  of  phlebitis  or  from  floating  coagula 
coining  from  the  right  side  of  the  heart.  As  an  example  we  may  cite  a 
well-marked  case  given  by  Mr.  Gr.  W.  Callender,  in  the  ninth  volume 
of  the  Pathological  Society’s  Transactions.  One  of  the  tertiary  divisions 
of  the  pulmonary  artery  was  oc- 
cupied by  a clot  of  decolorized 
fibrin  in  the  form  of  a hollow 
globule.  Its  diameter  was  about 
two  lines  greater  than  that  of 
the  artery  below,  so  that  at  this 
point  the  vessel  seemed  to  have 
undergone  some  slight  dilata- 
tion. Just  beyond  the  place  at 
which  this  clot  had  obstructed 
the  canal,  the  artery  bifurcated. 

The  blood  had  penetrated  one  of 
its  divisions  by  means  of  a short 

and  narrow  channel,  formed  45^ 

by  the  side  of  the  abo  vementioned  clot,  which  was  prolonged  into 
the  vessel,  occupying  about  half  its  calibre.  The  other  division  at 
the  point  where  it  again  bifurcated,  had  one  of  it^  divisions  obstructed 
by  another  clot,  which,  unlike  the  others,  was  solid  throughout.  The 
portion  ot  pulmonary  tissue  with  which  this  artery  communicated,  was 
in  a state  of  gangrene,  as  also  was  its  pleural  covering.  In  this  case 
various  masses  of  coagulated  fibrin  were  adherent  to  the  tricuspid  valve, 

Fig.  456.  Part  of  the  left  lucg,  with  clots  occupying  branches  of  the  pulmonary 
artery. — {Callender.^  wo  j 

46 


722 


DISEASES  OF  THE  EESPIRATOEY  SYSTEM. 


and  the  clots  found  in  the  branches  of  the  pulmonary  artery  in  the  lung 
were  most  likely  derived  from  them,  as  the  vein  itself  was  healthy. 
The  hollowing  out  of  the  nearer  of  these  coagula  to  the  heart  also  was 
probably  owing  to  the  subsequent  action  of  the  current  of  blood,  whilst 
the  one  further  distant  remained  solid,  and  completely  arrested  the  cir- 
culation. 

PHTHISIS  PULMONALIS. 

Case  CLVIII.* — Phthisis  Pulmonalis  in  its  last  stage,  with  Incompe- 
tency  of  the  Aortic  Valves — Cod  liver  Oil  and  Nutrients — Complete 
Recovery. 

History. — Patrick  Barclay,  get.  15,  admitted  June  26,  1849.  His  previous  history 
indicated  that  he  had  been  of  scrofulous  habit  from  infancy.  He  attended  the  indus- 
trial school  regularly  until  a week  ago,  but  could  not  take  much  exercise  on  account 
of  a sore  leg,  which  originated  twelve  months  previously  in  a fall.  His  diet  has  for  a 
long  time  been  very  poor.  On  the  18th  he  was  attacked  with  cough,  and  this  has  con- 
tinued till  admission.  He  also  complains  of  dyspnoea  on  exertion. 

Syme’Toms  on  Admission. — On  admission,  he  is  excessively  emaciated.  He  com- 
plains of  cough,  which  is  sometimes  very  prolonged,  but  has  no  pain  or  difficulty  of 
breathing.  The  chest  expands  well  on  inspiration.  Cough  easily  excited,  and  occa- 
sionally severe.  Sputa  viscid,  frothy,  and  tinged  with  blood.  On  percussion,  there  is 
great  dulness  on  the  right  side,  especially  under  the  clavicle ; the  left  side  is  also  dull 
to  a slight  extent.  On  auscultation,  distinct  bronchophony,  loud  friction  rale,  and 
mucous  rale,  approaching  cavernous,  are  heard  in  the  upper  right  side  in  front ; and 
these  become  more  faint  towards  the  lower  part  of  the  lung.  On  the  left  side,  friction 
l ales  are  also  heard  in  the  upper  part  in  front.  Behind,  on  the  right  side,  vocal  re- 
sonance not  so  distinct,  but  lales  the  same  as  in  front.  Pulse  114,  strong  and  sharp. 
The  heart’s  apex  beats  below  sixth  rib  ; impulse  increased  ; but  percussion  does  not 
indicate  internal  expansion.  On  auscultation,  a chirping  musical  murmur  is  heard 
over  the  apex  of  the  heart,  at  the  end  of  the  first  sound.  This  murmur  becomes  much 
more  faint  towards  the  base.  To  the  left  of  the  manubrium  of  the  sternum,  a bellows 
murmur  takes  the  place  of  the  second  sound.  This  murmur  is  quite  concealed  by  loud 
friction  rales,  when  respiration  is  going  on,  but  is  immediately  perceived  when  the 
]iatient  holds  his  breath.  Tongue  slightly  furred ; appetite  good ; some  thirst. 
Bowels  regular.  Urine  natural;  sp.  gr.  1020 — not  coagulable.  Chest,  face,  and 
arms,  are  covered  with  an  eruption  of  prurigo,  which  he  has  had  several  times.  On  the 
t!ic  right  thigh,  towards  the  lower  part  there  are  several  cicatrices,  and  three  sinuses, 
which  communicate  with  dead  bone.  Is  much  troubled  with  sweating,  which  at 
night  is  very  profuse.  To  have  good  diet  with  sweet  milk  morning  and  evening, 
and  a dessertspoonful  of  cod-liver  oil  three  times  a day.  Mist.  Seillce  3 iv.  ; 

Tinct.  Opii  Ammon.  3 ss ; Aq.  Cinnam.  § iss  ; Aquee  5 iij.  M.  Hedf-an-ounce  three 
times  a day. 

Progress  of  the  Case. — June  30^7i. — Friction  rale  less.  Gurgling  rale  on  right 
side.  Upper  part  of  chest  to  he  rubbed  with  Tartar  Emetic  Ointment.  July  2d. 
Chirping  murmur  has  become  faint,  and  occasionally  is  inaudible.  Has  vomited  his 
food  several  times.  Half  a drachm  of  Naphtha  to  be  added  to  mixture;  to  have  beer  for 
drink.  5th. — Chirping  murmur  quite  gone.  8^/t. — Chirping  murmur  returned. 

Cough  severe,  causing  vomiting.  Eruption,  brought  out  by  ointment,  painful. 
Omit  the  Ointment  and  Mixture.  Pidv.  Tragacanth.  Co.  3 1 ; N aphthae  Medic.  3 i; 
Pol.  Mur.  Morph.  3 iij  ; Syrup.  Aurantii  3SS;  Mist.  Scillce  § v.  M.  A table-spoon- 
ful thrice  a day.  21s?. — A seton  was  introduced  beneath  the  right  clavicle.  Still 
vomits  in  the  morning,  but  takes  food  and  medicine  better.  Aug.  6?/t. — The  expiratory 
murmurs  under  right  clavicle  are  now  quite  dry.  V omiting  is  diminished.  Omit  the  Mix- 
ture. Ferri  Citrat.  3 ss  ; Tinct.  et  Syrupi  Aurantii  f ss  ; Inf  us.  Calumbce  ^ vi. 
M.  A table-spoonful  three  times  a day.  \2th. — The  seton  discharges  freely,  causing 
great  irritation,  and  is  to  be  withdrawn.  Sept.  7th. — Appearance  of  patient  much  im- 
proved. Sounds  of  cavity  in  chest  continue  dry.  Takes  now  again  a table-spoonful  of 
the  oil  three  times  a day.  Oct.  28?/i. — Musical  murmur  has  entirely  disappeared.  He  is 
becoming  quite  fat,  and  is  able  to  go  about  the  ward  all  day.  Complains  only  of  slight 

* Reported  by  Messrs.  Hugh  Balfour,  Sanderson,  and  Dewar,  Clinical  Clerks. 


PHTHISIS  PULMONALIS. 


723 


cough  at  night,  and  palpitation  on  exertion.  The  right  infra-clavicular  region  is  be^ 
coming  flat.  Omit  the  mixture  aud  also  the  cod-liver  oil.  Nov.  \%th. — Cough  has 
returned,  with  slight  mucous  expectoration;  and,  on  auscultation,  mucous  and 
sibilant  rales  are  h(‘ard  all  over  the  chest.  Ordered  to  recommence  the  oil.  Mist. 
Scillie  Vini  Ipecac.  3 ij  ; Sol.  Mur.  Morph.  3 i.  M.  A table-spoonful  three 

ti  nes  a day.  From  this  time  he  rapidly  improved.  The  cavity  became  perfect  ly  dry, 
and  respiration  over  it  was  accompanied  by  blowing  murmurs.  Cough  and  expecto- 
ration greatly  diminished.  His  general  appearance  is  healthy,  and  he  is  very  stout. 
On  January  18<'A,  it  is  noted  that,  on  percussion,  a distinct  cracked-pot  sound  is  heard 
in  the  right  infra-clavicular  region,  and  faintly  also  on  the  left  side.  On  auscultation 
the  heart’s  sounds  are  loud  all  over  the  chest,  the  second  sound  being  accompanied 
with  a distinct  bellows  murmur.  Musical  murmur  has  never  returned.  There  is 
bronchophony  and  prolonged  expiration  in  the  right  infra-clavicular  region,  but  no 
moist  sounds.  Sleeps  well,  and  is  very  little  troubled  with  cough.  Does  not  sweat ; 
is  very  fat ; appetite  good.  This  boy,  as  far  as  all  general  symptoms  are  concerned, 
may  be  regarded  as  having  been  in  good  health  for  the  last  two  months.  Feb.  Fith. — 
On  percussion,  the  chest  was  tolerably  resonant  on  both  sides ; but  there  was  slight 
dulness  under  the  right  clavicle.  On  auscultation,  the  inspiration  is  loud,  and  of  a 
blowing  character,  in  right  infra-clavicular  region ; but  the  murmur  is  much  softer 
than  formerly.  Expiration  is  still  prolonged,  and  there  is  considerable  vocal  resonance, 
but  not  amounting  to  bronchophony — no  moist  rales.  In  the  corresponding  situation 
on  the  left  side,  the  inspiration  is  somewhat  harsh,  and  respiration  slightly  prolonged ; 
vocal  resonance  normal ; loud  bellows  murmur,  with  the  second  sound  of  the  heart, 
heard  over  nearly  the  whole  chest.  His  general  health  is  good  ; he  expresses  himself 
as  being  quite  well.  He  appears  stout  and  strong ; but  his  countenance  is  somewhat 
sallow  and  cachectic.  He  has  no  expectoration  or  sweating,  and  the  cough  is  trifling, 
and  only  present  in  the  morning.  He  is  about  to  return  to  the  Industrial  School,  and 
resume  the  learning  of  his  trade  as  a shoemaker.  Dismissed. 

He  was  re-admitted  August  ‘•I'oth^  1850.  Since  leaving  the  house  he  has  been  at 
the  Industrial  School,  but  has  been  frequently  exposed  to  cold;  and  latterly  the  cough 
and  expectoration,  which  ho  says  had  quite  left  him,  have  returned,  and  been  gradually 
getting  more  severe.  The  sweating  returned  with  the  cough.  A week  before  admis- 
sion, he,  with  the  other  boys  of  the  school,  went  to  Portobello  to  bathe,  and  notwith- 
standing his  remonstrances,  the  master  insisted  on  his  going  into  the  water,  saying  it 
would  do  him  good.  He  however  became  much  worse.  On  admission,  the  physical 
signs  were  coarse  moist  rale  under  the  right  clavicle,  imperfect  pectoriloquy,  and 
creaking  friction  noises,  harsh  inspiration,  and  prolonged  expiration  under  left  clavicle  ; 
but  the  dulness  in  this  position  is  very  slight,  when  compared  with  that  of  the  opposite 
side.  He  again,  by  means  of  cod-liver  oil,  good  diet,  and  counter-irritation,  became 
strong  and  stout;  again  the  cough,  expectoraiion,  and  other  symptoms  ceased,  and  he 
was  discharged  J/arc/i  1851.  The  report  on  that  day  is  “marked  dulness  and 
increased  vocal  resonance  under  right  clavicle ; the  inspiration  is  harsh  but  dry.’’ 

Once  again  admitted  July  5th,  1851. — He  says  that  on  leaving  the  ward  in  March 
last,  he  had  two  detached  pieces  of  the  right  thigh-bone  extracted  by  Mr.  Syme,  and 
remained  in  the  surgical  hospital  for  five  tveeks.  Since  then  he  has  been  constantly 
etnployed  in  light  garden  work,  and  notwithstanding  poverty  of  food,  he  continued  in 
tolerably  good  health  till  a week  ago.  On  percussion,  there  is  slight  dulness  only 
under  the  right  clavicle,  and  posteriorly  the  resonance  is  good  and  equal  on  both  sides. 
Under  the  right  clavicle  the  inspiration  is  heard  to  be  harsh  and  blowing — no  moist 
rale.  There  is  also  loud  double  friction  murmur  over  the  upper  fourth  of  right  lung, 
especially  at  the  apex,  and  slight  friction  may  be  detected  here  and  there  over  the 
whole  of  the  right  side.  Under  the  left  clavicle,  inspiration  somewhat  exaggerated  in 
tone,  but  the  breath  sounds  everywhere  normal.  He  looks  pale  and  thin.  There  is 
severe  cough,  with  mucous  expectoration,  but  the  appetite  is  good,  and  there  is,  on 
tlie  whole,  a marked  improvement  in  his  general  appearance.  Impulse  of  the  heart 
and  loud  blowing  murmur  at  the  base  still  present.  Wound  in  the  thigh  nearly  healed. 

Further  Progress  of  the  Case. — He  has  continued  to  do  well  since  his  admission 
into  the  house.  The  cough  rapidly  diminished,  and  is  now  only  present  in  the  morn- 
ing on  waking.  His  bodily  functions,  he  says,  are  in  every  respect  perfectly  well  per- 
formed. The  wound  in  the  thigh  is  cicatrised,  and  were  it  not  for  the  cardiac  disease, 
this  lad  might  be  considered  in  robust  health.  The  following  is  the  result  of  a careful 
e.xamination  of  the  chest  made  December  23</,  1851 : — “On  percussion  slight  dulness 


724 


DISEASES  OF  THE  RESPIEATOEY  SYSTEM. 


under  the  right  clavicle.  On  auscultation,  inspiratory  murmur  somewhat  harsh  under 
both  clavicles,  but  most  so  on  right  side.  The  vocal  resonance  also  is  slightly  exag- 
gerated over  the  apex  on  right  side.  In  every  other  respect,  the  lungs  appear  to  be 
healthy.  There  is  great  impulse  of  the  heart  still,  and  over  the  apex  there  is  heard, 
with  the  second  sound,  a blowing  murmur,  which  is  very  loud  at  the  base.  He  remained 
in  the  house  until  March  1S52,  when  he  was  dismissed  in  all  respects  perfectly  well. 

Auymt  9^A,  1852. — Presented  himself  at  the  visit  to-day.  Since  his  dismissal  in 
March,  has  been  employed  by  a dyer,  and  during  his  occupation  has  been  greatly 
exposed  to  wet  and  cold.  He  has  only  been  able  to  earn  five  shillings  a-week,  so  that 
his  diet  has  been  very  poor,  both  in  quantity  and  quality.  His  health,  notwithstanding, 
has  been  tolerably  good,  although  he  is  now  much  thinner  than  when  he  left  the  In- 
firmary. On  percussion,  there  is  clear  resonance  under  both  clavicles,  but  on  the 
light  side  very  slight  dulness  with  increased  resistance  is  perceptible.  On  ausculta- 
tion, the  inspiration  under  right  clavicle  is  somewhat  harsh,  but  the  respiratory  mur- 
murs on  the  whole  are  very  good.  Vocal  resonance  slightly  increased.  Under  the 
left  clavicle  there  is  harshness,  with  fine  sibilation  and  friction  during  inspiration. 
The  expiration  is  prolonged,  and  there  is  also  slight  increase  of  vocal  resonance.  The 
blowing  murmur  at  the  base  of  the  heart  with  the  second  sound  still  very  distinct. 
Otherwise  is  quite  healthy.  He  has  a sister  settled  at  Philadelphia,  and  has  formed 
the  intention  of  joining  her  in  the  United  States. 

February  6^A,  1853. — Presented  himself  at  the  Infirmary  to-day,  and  was  carefully 
examined  by  Dr.  Bennet,  Dr.  Christison,  the  various  clerks  and  students.  The  physi- 
cal signs  are  the  same  as  at  last  report,  the  breath  sounds,  however,  being  more  soit 
and  natural.  He  has  been  prevented  leaving  for  Philadel])hia,  as  he  intended  last 
August,  and  since  then  has  been  carrying  on  the  occupation  of  light  porter  to  a dyer. 
His  general  health  has  been  good,  although  he  has  undergone  much  exposure  to  eo'd 
and  wet.  He  leaves  for  Philadelphia  to-morrow,  taking  with  him  a letter  recommend- 
ing him  to  the  care  of  Professor  Wood  of  that  city. 

In  a letter  from  Dr.  Wood  to  Dr,  Bennett,  dated  March  28th,  1853,  it  was  stated 
that  Barclay  had  presented  himsclfa  week  previously.  “Being  at  the  time  extremely 
busy,  I gave  the  boy,  who  told  me  that  he  as  quite  destitute,  a small  sum  of  money, 
telling  him  to  use  it  for  his  support ; in  the  meantime  to  look  out  for  employment,  which 
is  not  difficult  to  be  had  in  this  country  for  persons  of  his  class,  and  to  call  on  me 
again  before  long.  He  promised  to  do  so.  1 have  not  seen  him  since.”  In  a subse- 
quent letter  (1856)  from  Dr.  Dunglison,  who  at  Dr.  Bennett’s  request  asked  Dr.  Wood 
concerning  him,  it  appeared  that  he  had  not  since  been  heard  of. 

Commentary. — I am  not  acquainted  with  any  recorded  case  which, 
throughout  its  progress,  has  been  examined  with  more  care,  in  which 
phthisis,  in  its  last  stage,  was  more  unequivocally  manifested,  and  which 
w'as  more  decidedly  the  subject  of  a complete  cure  than  the  one  now' 
given.  The  lad  w'as  under  my  observation  from  June  1849  to  February 
1853,  a period  of  forty-three  months,  and  during  that  time  he  W'as 
respectively  examined  in  the  clinical  ward  by  four  winter  and  two 
summer  classes  of  students,  as  well  as  by  professorial  colleagues.  Of 
the  facts  and  accuracy  of  the  record  in  the  ward  bock  there  can  be  no 
doubt ; and  it  is  equally  certain  that  we  watched  the  arrest  of  tuber- 
cular condensation  at  the  apex  of  the  left  lung,  and  the  cicatrization  of  a 
large  tubercular  excavation  in  the  apex  of  the  right  lung.  Moreover,  a 
careful  study  of  this  case  wdll  show  that  this  result  was  not  brought 
about  by  the  mere  spontaneous  efforts  of  nature.  On  the  contrary',  great 
difficulties  had  to  be  surmounted,  numerous  symptoms  removed,  and  most 
important  complications  guarded  against.  Indeed,  the  effects  of  treat- 
ment could  never  be  more  unequivocally  manifested  in  any  case  than  they 
have  been  in  this.  On  admission,  he  presented  the  W'asting  characters 
of  the  disease  in  its  last  stage.  The  emaciation  w'as  extreme  ; the  cough 
and  sweating  most  distressing ; and  the  physical  signs  demonstrated  a 
cavity  as  large  as  the  fist,  in  the  right  lung.  Under  the  use  of  the  oil 


PHTHISIS  PULMONALIS. 


725 


his  strength  rallied.  After  a time  it  was  given  up,  on  account  of  his 
becoming  so  fat.  Gurgling  rales,  and  other  signs  of  softened  exudation, 
however%nce  more  became  apparent,  and  again  disappeared  when  the 
use  of  the  oil  was  resumed.  He  continued  to  take  it  from  time  to  time 
afterwards,  and  it  became  apparent  that  the  pulmonary  signs  varied 
according  to  liis  ability  of  digesting  the  oil.  The  same  fact  was  demon- 
strated throughout  the  progress  of  the  case,  clearly  showing  the  intimate 
relation  which  exists  between  the  local  disease  and  the  general  nutritive 
powers  of  the  economy. 

During  no  part  of  the  time  this  boy  was  under  treatment  did  he 
experience  any  difficulty  in  taking  the  oil.  On  the  contrary,  it  occa- 
sioned no  uneasiness  in  the  stomach,  and  was  readily  digested,  and  this, 
although  the  food  was  at  one  period  frequently  vomited,  owing  apparently 
to  the  violence  of  the  cough.  Its  inlluence  on  his  general  health  was 
most  remarkable,  as  well  as  upon  the  local  disease  in  the  lungs.  From  a 
state  of  extreme  emaciation  he  became  so  stout  that  it  was  feared  the  oil 
wouid  occasion  obesity ; and  was  therefore,  for  a time,  discontinued. 
His  appetite  was  always  good — a circumstance  I have  noticed  as  being 
very  favorable,  not  only  for  the  beneficial  action  of  cod-liver  oil,  but  for 
the  successful  treatment  of  phthisis  generally.  Indeed,  it  is  the  anorexia, 
nausea,  and  dyspeptic  symptoms  which  constitute  the  great  difficulty  the 
physician  has  to  overcome  in  the  management  of  the  disease,  as  is  well 
illustrated  in  the  following  case  : — 

Case  CLIX.^ — Phthisis  Piilmonalis — Amcidment  from  Treatment  and 
Disappearance  of  Symptoms — Their  subsequent  Return — Death. 

History. — Jane  Hamilton,  a dressmaker,  mt.  18 — admitted  September  12,  1849. 
She  stated  that  last  April  her  general  health  began  to  fail ; the  appetite  was  bad ; 
cough  with  expectoration  came  on  ; cold  sweats  appeared  on  the  face,  hands,  and  feet ; 
the  catamenia,  which  had  never  been  very  regular,  were  suppressed ; and  she  became 
so  weak  that  she  could  not  stand.  Since  then  there  has  been  a temporary  improve- 
ment ; but  for  some  time  back  she  has  again  become  worse. 

Symptoms  on  Admission. — On  admission  she  was  pale  and  emaciated,  and  so 
weak  that  she  was  unable  to  sit  up  above  a few  minutes  at  a time.  Tlicre  was 
copious  perspiration  during  sleep,  a severe  cough,  with  abundant  yellowish  viscid 
sputa — no  pain  in  the  chest,  which  was  well  formed  externally.  The  tongue  was 
covered  with  a brown  fur ; appetite  capricious  and  bad  ; bowels  open  every  second 
day.  The  treatment  consisted  of  tonics,  expectorants,  and  counter-irritation  to  the 
chest,  which  produced  considerable  amendment.  I took  charge  of  the  case  in  the 
middle  of  October.^  and  found,  on  careful  percussion,  dulness  below  the  right  clavicle, 
with  loud  mucous  rale  over  the  upper  third  of  right  chest.  There  were  also  sonorous 
and  sibilant  rales  over  the  greater  part  of  both  lungs,  anteriorly  and  posteriorly.  By 
means  of  expectorants  and  counter-irritants,  the  bronchitic  symptoms  and  signs  were 
subdued  by  the  l.s<  of  November  ; but  the  dulness  and  moist  rales  under  the  right 
clavicle  still  continued.  A table-spoonful  of  cod-liver  oil  was  then  ordered  to  be  taken 
three  times  a day. 

Progress  of  the  Case. — The  remedy  was  suspended  on  the  8th,  on  account  of  a 
febrile  attack  she  then  experienced,  which  was  ushered  in  with  headache  and  rigors, 
and  accompanied  with  accelerated  but  soft  pulse,  heat  of  skin,  loss  of  appetite,  fre- 
quent nausea  and  vomiting,  and  considerable  spinal  irritation.  It  was  not  until 
November  30^A  that  these  symptoms  were  so  far  removed,  and  the  tone  of  the 
stomach  augmented — by  means,  first,  of  antimonials,  and  subsequently  of  naphtha, 
alkalies,  vegetable  bitters,  and  stimulants — that  the  oil  was  again  ordered.  It  pro- 
duced considerable  nausea,  however,  so  that,  after  persevering  in  its  use  for  ten  days, 
it  was  again  suspended.  It  was  once  more  had  recourse  to  on  the  lAth  of  December^ 

* Reported  by  Mr.  Alexander  Struthers,  Clinical  Clerk. 


726 


DISEASES  OF  THE  EESPIRATORY  SYSTEM. 


and  was  readily  retained  on  the  stomach.  A few  days  subsequently,  the  dose  was 
increased  to  four  table-spoonfuls  daily.  December  30^A. — There  is  now  a very  evident 
improvement  in  the  general  health.  Her  strength  is  so  far  increased  that  she  sits 
up  a considerable  portion  of  the  day.  The  perspirations  have  nearly  disappeared.  The 
expectoration  is  still  thick  and  purulent,  but  not  so  copious.  She  is  evidently  much 
stouter,  and  the  skin  is  of  a more  healthy  color.  The  catamenia  have  also 
reappeared.  There  is  still  dulness  under  the  right  clavicle  on  percussion.  The  coarse 
moist  rale  has  disappeared,  and  a fine  crepitating  murmur  only  is  heard  with  the 
inspiration  towards  the  acromial  end  of  the  clavicle.  There  is  prolonged  expiration, 
and  increased  vocal  resonance.  From  this  time  she  continued  to  impi'ove.  On  the 

of  January  the  oil  was  reduced  to  three  table-spoonfuls  daily.  A small  blister 
was  occasionally  applied  to  the  upper  part  of  the  right  chest  anteriorly,  and  an 
expectoi’ant  mixture  given  to  facilitate  the  expectoration,  which,  though  diminished 
in  quantity,  retained  its  viscid  and  purulent  character.  On  the  SO/A  of  January 
the  inspiratory  murmur  had  acquired  a certain  degree  of  harshness,  but  here  and 
there  very  fine  crepitation  could  still  be  detected.  She  left  the  Infirmary  on  the  24/A 
of  February. 

I examined  the  chest  carefully  on  the  ^th  of  March.  There  was  still  dulness,  but 
not  so  marked  as  formerly,  under  the  right  clavicle ; no  crepitation  on  auscultation, 
but  harshness  of  the  inspiratory  murmur,  prolonged  expiration,  some  friction  noises 
and  increased  vocal  resonance.  She  was  stout,  of  healthy  appearance,  and  expressed 
herself  as  being  quite  well ; but  the  expectoration  of  purulent  matter  still  continued 
to  a slight  degree,  with  occasional  cough.  Shortly  afterwards  she  went  to  Dundee  to 
carry  on  her  occupation  as  a milliner,  when  the  confinement,  late  hours,  and  irregular 
food,  soon  caused  a return  of  her  more  urgent  symptoms.  She  again  entered  the 
Infirmary,  and  once  more,  after  a few  months,  was  dismissed  relieved.  On  the  last 
occasion,  she  was  admitted  under  another  physician,  August  19/A,  1852,  the  disease 
having  progressed  to  its  last  stage  during  the  interval.  She  died  September  8/A.  No 
examination  of  the  body  could  be  obtained. 

Commentary. — The  physical  signs  in  this  girl  on  admission  exhibited 
at  most  bronchitis,  with  softening  of  the  tubercular  exudation  at 
the  apex  of  the  right  lung,  whereas  in  the  boy  they  demonstrated 
that  a large  cavity  existed  in  one  lung,  whilst  the  other  was  also 
affected.  There  was  the  same  general  prostration,  however,  and  the 
same  emaciation,  excessive  weakness,  profuse  perspiration,  purulent 
expectoration,  and  distressing  cough.  But  there  was  this  difference 
in  the  antecedent  circumstances  of  the  two  cases — namely,  that  the  boy 
had  a good  appetite,  but  had  been  subjected  to  an  insufficient  diet, 
whilst  the  girl  had  no  appetite,  although  she  possessed  the  means 
of  gratifying  it.  In  the  first  case  nutrition  was  imperfect  from  deficient 
quantity  of  food,  the  digestive  organs  being  tolerably  healthy  ; in  the 
second,  it  was  imperfect  on  account  of  the  dyspepsia  and  disordered  state 
of  the  stomach  rendering  it  impossible  that  a sufficient  quantity  could  be 
consumed.  The  result  in  both  was  the  same, — namely,  impoverishment 
of  the  blood,  and  tubercular  exudation  into  the  pulmonary  organs. 

The  practical  management  of  these  two  cases  was  considerably  modi- 
fied by  the  circumstances  to  which  I have  just  alluded.  In  the  boy, 
there  was  no  difficulty  in  overcoming  the  imperfect  nutrition.  We  have 
seen  that  he  took  the  cod-liver  oil,  and  digested  it  and  his  food  with  the 
greatest  facility.  In  the  girl  all  thoughts  of  food  caused  disgust,  and  the 
cod-liver  oil  produced  nausea,  and  for  some  time  could  not  be  tolerated. 
For  a considerable  period,  therefore,  the  treatment  of  this  case  was  pre- 
paratory, and  directed  to  the  diminution  of  the  dyspeptic  symptoms,  and 
removal  of  those  complications  which  prevented  any  successful  attack  on 
the  more  important  disease. 

Thus  my  first  efforts  were  directed  to  alleviating  the  bronchitis. 


PHTHISIS  PULMONALIS. 


727 


which  was  accomplished  by  means  of  expectorants  and  counter-irritants. 
Cod-liver  oil  was  then  ordered,  but  it  occasioned  nausea,  aud  was  sus- 
pended on  account  of  a febrile  attack  she  now  experienced.  On  her  re- 
covery from  this,  the  nausea,  vomiting,  and  dyspeptic  symptoms  were 
treated  by  means  of  naphtha,  alkalies,  vegetable  bitters,  and  carminatives, 
with  apparent  benefit ; but,  on  recurring  to  the  oil,  they  again  returned ; 
so  that,  after  persevering  for  ten  days,  it  became  again  necessary  to  give 
up  its  employment.  In  a few  days,  however,  it  was  once  more  tried, 
and  on  this  occasion  with  success.  It  was  then  taken  readily ; a marked 
amendment  followed ; the  dose  was  increased  to  four  table-spoonfuls 
daily,  and  it  was  astonishing  to  see  how  rapidly  she  improved.  Her 
strength  increased,  the  emaciation  and  cachectic  look  disappeared,  the 
skin  assumed  a healthy  color,  and  she  became  positively  stout  and  fat, 
so  that  she  was  scarcely  recognizable.  The  cough  almost  ceased,  the  ex- 
pectoration greatly  diminished,  the  perspiration  did  not  appear  at  night, 
the  catamenia  returned,  she  sat  up  the  entire  day,  and  at  length  considered 
herself  so  well,  that,  on  being  allowed  to  leave  the  hospital  for  a day,  she 
did  not  return.  She  called  on  me  a few  days  afterwards,  when  I found 
that,  although  the  constitutional  symptoms  had  almost  entirely  disappear- 
ed, and  her  general  health  might  be  called  good,  traces  of  the  local  disease 
were  still  apparent,  as  stated  in  the  report.  Tliis  case,  therefore,  exhibits 
the  obstacles  which  the  physician  has  not  unfrequently  to  overcome  before 
he  can  carry  out  that  line  of  treatment  by  means  of  which  the  abnormal 
nutrition  is  to  be  obviated,  and  the  tubercular  exudation  checked  ; but 
it  also  inculcates  the  importance  of  perseverance,  and  exhibits  the  good 
effects  which  may  result  from  persisting  in  a treatment  dictated  by  cor- 
rect pathological  principles. 

Notwithstanding  the  great  benefit  produced  in  this  case,  a return  to 
imperfect  diet  and  a sedentary  employment  once  more  induced  all  the 
symptoms  and  dangerous  effects  which  in  the  hospital  were  removed 
with  so  much  trouble.  Nor,  unless  we  could  convert  such  institutions 
into  establishments  for  the  permanent  support  and  surveillance  of  phthisi- 
cal cases,  is  it  easy  to  sec  hovv^  this  can  be  prevented.  Certain  it  is,  that 
we  are  very  seldom  enabled  to  retain  a case  so  long  under  treatment,  as 
we  did  that  of  Barclay.  Although  by  means  of  judicious  treatment,  we 
frequently  check  the  progress  of  phthisis,  and  restore  the  patient  to  a 
good  state  of  health,  it  most  commonly  happens  that  the  patient,  if  he 
be  in  a public  hospital,  insists  on  going  out,  and,  if  a private  case,  he 
abandons  those  remedies  and  precautions  which  are  absolutely  necessary 
to  his  existence.  Hence  it  too  frequently  happens,  that,  even  after  such 
considerable  amendment  as  we  have  seen  takes  place — after  restoration 
from  a state  of  the  most  complete  prostration  to  one  of  almost  vigorous 
health — the  causes  which  originated  the  disease  induce  its  return,  and 
the  patient  sinks,  after  one  or  more  relapses.  It  is  of  all  things  most 
important,  therefore,  to  keep  a careful  watch  over  phthisical  cases  long 
after  the  constitutional  symptoms  have  disappeared,  and,  in  fact,  so  long 
as  the  physical  signs  indicate  any  traces  of  the  disease. 

Case  CLX.* — Phthisis  Pulmonalis — Large  Vomica  on  Left  Side—^ 
Cirrhosis  of  Lung — Caries  of  Left  Wrist- Joint — Scrof  ulous  Nephritis. 

History. — John  Finlay,  set.  19 — admitted  into  the  clinical  ward  December  20th, 

* Reported  by  Messrs.  Sanderson  and  Dewar,  Clinical  Clerks. 


728 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


1850.  Says  that  he  has  been  troubled  with  cough  and  expectoration,  more  or  less, 
for  the  last  six  years,  accompanied  by  occasional  diarrhoea.  For  the  last  three  weeks 
he  has  been  in  the  surgical  clinical  ward,  under  Mr.  Syrae,  for  scrolulous  caries 
of  the  left  wrist-joint.  He  has  spat  blood  now  and  then,  but  to  no  great  extent. 

Symptoms  on  Admission. — On  percussion,  the  right  chest  is  everywhere  reson- 
ant ; but  there  is  marked  dulness  over  the  whole  of  left  chest,  most  complete  in  the 
subclavicular  and  supra-scapular  regions.  On  auscultation,  loud  mucous  rales 
are  heard  over  the  whole  of  left  chest  anteriorly,  with  gurgling  and  peetorilo({uy 
under  the  clavicle.  Posteriorly  and  inferiorly  on  this  side,  there  is  a harsh  tubular 
breathing,  with  prolongation  of  the  expiration.  There  is  puerile  respiration  on  the 
right  side,  but  otherwise  nothing  abnormal.  His  external  appearance  is  pale,  pre- 
senting all  the  so-called  characters  of  the  scrofulous  diathesis.  There  is  great  emacia- 
tion, and  development  seems  to  have  been  arrested,  as  he  does  not  look  above  12 
years  of  age.  The  left  wrist-joint  is  immovable,  considerably  swollen,  with  several 
carious  openings  discharging  pus.  Frequent  cough,  with  copious  muco-purulent  ex- 
pectoration. Pulse  80,  feeble.  Tongue  clean.  Considerable  nausea,  and  total  loss 
of  appetite.  His  diarrhoea  has  recently  been  checked  by  lead  and  opium  pills.  (For 
treatment,  see  Commentary.) 

Progress  of  the  Case. — For  the  next  three  months  the  loss  of  appetite,  sickness, 
and  vomiting  occurred  art  intervals,  and  the  physical  signs  remained  the  same.  From 
this  period,  ho w^ ever,  his  general  health  underwent  gradual  improvement,  the  cough 
was  not  so  severe,  and  the  expectoration  became  more  mucous.  The  sweating 
greatly  diminished,  and  he  took  food  more  readily.  Towards  the  end  of  May,  he  had 
cviJently  gained  much  in  flesh,  and  the  discharge  from  the  scrofulous  sores  in  the 
wrist  was  trifling.  The  physical  signs  were  so  far  altered,  that  the  mucous  rales 
over  greater  part  of  left  side  were  not  so  coarse  or  diffused,  and  the  gurgling  under 
the  clavicle  was  now  of  a splashing  character,  and  more  limited.  Pectoriloquy  in> 
this  situation  was  complete,  and  there  was  absence  of  expansion  during  respiration. 
There  could  now  also  be  heard  harsh  inspiration,  with  prolonged  expiration  under 
the  right  clavicle ; the  resonance  on  percussion  also  was  here  slightly  in, paired. 
During  June,  he  was  much  troubled  with  nausea  and  vomiting.  On  the  21st  he 
was  attacked  with  rigors,  followed  by  all  the  symptoms  of  continued  fever,  which 
terminated  by  diaphoresis  on  the  seventh  day.  Shortly  after,  he  was  attacked  with 
variola,  which  ran  its  usual  course.  During  July  and  August,  there  was  gradual 
but  marked  improvement  of  his  general  health.  At  the  end  of  the  last-named 
month,  the  left  wrist-joint  was  firmly  anchylosed,  and  all  the  carious  openings  had 
closed  up.  He  still  had  occasional  diarrhoea.  There  was  still  dulness  on  left  side, 
but  the  mucous  rales  were  not  heard  so  low  down  anteriorly.  Fine  crepitation 
with  increased  vocal  resonance  was  now  audible  under  the  right  clavicle.  Up  to  the 
middle  of  October  he  continued  slowly  to  improve ; the  sweatings  and  diarrhoea  had 
ceased,  and  the  cough  was  much  less  seveie.  He  now  complained  of  considerable 
pain  during  micturition,  and  on  examining  the  urine  it  was  found  to  contain  nume- 
rous pus-corpuscles,  and  to  be  coagulable  by  heat  and  nitric  acid.  He  continued  to 
feel  pain  on  urinating,  and  to  pass  pus  by  the  urethra  during  the  month  of  October. 
On  the  3c?  of  November  the  report  is : — “ Marked  dulness  on  percussion  over  the 
left  cliest  anteriorly,  and  under  the  clavicle  cracked-pot  sound.  Posteriorly  it  is 
resonant.  On  auscultation,  loud  friction  is  heard  from  below  up  to  the  level  of  the 
nipple,  and  above  this,  loud  mucous  rattles  passing  into  gurgling  under  the  clavicle. 
Perfect  pectoriloquy  in  this  situation.  On  right  side,  puerile  respiration ; and  pos- 
teriorly sibilant  rale  at  the  termination  of  the  inspiration.  No  sweating  or  diarrhoea. 
Still  occasional  nausea  and  vomiting.  General  strength  much  impioved,  and  now 
walks  about  the  ward,  sitting  up  a great  portion  of  the  day.”  The  report  on  the 
21s?  of  December  is: — “Still  marked  dulness  over  the  whole  of  left  side,  exci'pt 
under  the  clavicle,  where  it  is  tympanitic,  with  cracked-pot  sound.  Resonance  on 
right  side  good.  Under  acromial  end  of  left  clavicle  feeble,  and  distant  gurgling  is 
heard — the  respiration  having  more  of  a blowing  character  than  formerly,  with 
perfect  pectoriloquy.  The  moist  rales  over  the  other  parts  of  this  side  have  disap- 
peared. On  right  side,  puerile  respiration  is  heard  over  the  inferior  half  of  lung ; 
otherwise,  the  breath-sounds  are  normal.  Posteriorly,  dulness  of  the  whole  of  left 
side,  but  there  is  no  cracked-pot  sound.  On  auscultation,  the  signs  are  the  same  as 
are  licard  anterioily.  His  general  health  has  much  improved.  Still  complains  of 
occasional  nausea  and  vomiting,  but  on  the  whole  takes  his  food  well.  Urine  limpid, 
containing  small  shreds,  winch,  on  examination  with  the  microscope,  are  seen  to  be 
composed  of  numcrou.s  pus-corpusc  es  embedded  in  mucus,  slightly  coagulable  on 


PHTPIISIS  PULMONALIS. 


729 


the  addition  of  heat  and  nitric  acid.  Pain  on  micturition  diminished.”  From  this 
time  he  continued,  on  the  whole,  to  improve  steadily,  and  was  so  well  during  the 
summer  of  1862,  as  to  walk  about  constantly  in  the  open  air,  and  went  out  of  the 
house,  by  his  own  desire,  on  the  1st  of  the  following  August.  About  tlie  middle 
of  October,  however,  having  been  well  in  the  interval,  he  fell  down  and  injured  his 
back.  On  the  following  day,  he  experienced  rigors,  followed  by  febrile  symptoms, 
total  loss  of  appetite,  and  hmmaturia.  He  was  re-admitted  November  1,  when 
it  was  ascertained  that  considerable  quantities  of  pus  were  passed  with  the  urine, 
which,  he  says,  had  also  been  occasionally  tinged  with  blood.  There  was  pain  on 
micturition,  but  none  in  the  lumbar  region.  On  examining  the  left  lung,  loud 
gurgling  was  heard  both  with  inspiration  and  expiration,  extending  from  the  clavicle 
down  to  the  upper  margin  of  the  third  rib.  There  was  great  dulness  on  percussion. 
Below  the  clavicle,  loud  pectoriloquy,  and  lower  down,  aegophony.  Under  the 
right  clavicle  there  were  fine  moist  rale  on  inspiration,  and  increased  vocal  resonance, 
but  the  chest  expanded  well  on  this  side,  and  was  otherwise  normal.  The  fever, 
prosti'ation,  and  discharge  of  pus  by  urine,  continued  without  intermission,  and  he 
died  December  4,  1852. 

Sectio  Cadaver  is. — Forty  hours  after  death. 

Body  greatly  emaciated ; the  right  carpal  bones  anchylosed,  with  marks  of  nume- 
rous old  sinuses  on  the  skin  in  their  neighborliood. 

Chest. — Pleurae  on  the  right  side  adherent  at  the  apex,  by  loose  bands  of  chronic 
lymph.  The  right  lung  indurated  at  the  apex  over  an  extent  the  size  of  a hen’s 
egg,  and  strongly  puckered  externally.  On  section,  this  indurated  portion  was  seen 
to  contain  several  encysted  cretaceous  concretions  with  the  intervening  pulmonary 
substance  condensed,  hard,  and  fibrous.  A few  chronic  miliary  tubercles  w^ere  also 
scattered  through  the  upper  lobe ; but  the  rest  of  the  lung  was  spongy,  crcj)itant, 
and  healthy.  The  pleurae  on  the  left  side  were  everywhere  firmly  adherent,  and 
over  the  superior  half  of  the  lung,  which  was  much  atrophied,  they  were  converted 
into  a dense  white  fibrous  mass,  three-fourths  of  an  inch  thick,  which  gradually 
diminished  in  thickness  inferiorly.  The  left  lung  was  not  the  volume  of  the  closed 
fist;  it  was  non-crepitant,  felt  indurated,  but  at  the  same  time  flaccid,  evidently 
from  internal  cavities.  On  section,  the  entire  mass  was  riddled  with  cavities  more 
or  less  communicating  with  each  other,  containing  purulent  matter,  and  having  a 
smooth  lining  membrane.  Many  of  them  ])resented  a pouch-like  foian,  and  were 
identical  with  what  liave  been  described  as  dilatations  of  the  bronchi.  At  the  apex 
were  two  encysted  calcareous  concretions,  of  the  size  of  millet  seeds,  but  there  were 
no  other  traces  of  tubercular  deposits.  The  fibrous  structure  between  the  cavities 
co.isisted  01  a close  dense  fibrous  texture,  of  bluish  color,  fi'om  pigmentary  deposits, 
in  which  no  remains  of  pulmonary  structure  could  be  found.  The  bronchi  con- 
tained a considerable  quantity  of  viscid  muco-purulent  matter.  Heart,  larynx,  and 
trachea  healthy. 

Abdomen. — The  large  intestines,  especially  the  caecum,  were  congested  ; exhi- 
biting here  and  there  patches  of  slate-colored  pigment,  with  traces  of  cicatrized 
ulcerations,  together  with  one  superficial  chronic  erosion  about  half  an  inch  in 
diameter,  of  irregular  form.  The  kidneys  were  of  natural  size,  and  on  section  dis- 
played dilatation  of  the  pelves,  with  pouch-like  enlargements,  the  result  of  scro- 
fulous abscesses,  filled  with  pus.  The  secreting  substance  was  everywhere  atro- 
phied, and  the  tubular  substance  in  many  places  obliterated.  Mesenteric  glands 
and  other  organs  healthy. 

Microscopic  Examination. — A careful  microscopic  examination  of  the  lining 
membrane  of  the  pulmonary  abscesses  exhibited  nothing  but  fibrous  tissue,  destitute 
of  epithelium.  There  was  nowhere  any  trace  of  a mucous  surface. 

Commentarif . — The  treatment  of  this  case  was  conducted  on  the 
principles,  and  according  to  the  rules  afterwards  to  be  detailed.  It  was 
directed  principally  to  improve  the  appetite,  diminish  the  nausea,  vomit- 
ing, and  diarrhoea,  and  support  the  strength  by  means  of  cod-liver  oil 
and  generous  diet.  Externally,  repeated  blisters  were  applied.  During 
the  attack  of  febricula  and  variola,  antimonials  were  given  in  small  doses. 
Latterly  numerous  remedies  were  administered  to  lessen  the  pains  during 
micturition,  such  as  anodynes;  u.va  ursse;  bals.  copaibae ; diuretics,  etc. ; 
but  an  enema  of  starch  and  solution  of  morphia  succeeded  better  than 


730 


DISEASES  OF  THE  EESPIRATORY  SYSTEM. 


anything  else.  It  was  always  observed  that  in  proportion  as  the  d3^s- 
peptic  symptoms  were  relieved,  and  the  assimilation  of  cod-liver  oil  and 
food  took  place,  so  his  health  improved ; and  by  great  care  he  was  not 
only  kept  alive  for  two  years,  but  I had  sanguine  expectation  of  an  ulti- 
mate recovery,  when  he  met  with  the  accident  which,  by  exciting  acute 
disease  in  the  kidneys,  caused  his  death. 

This  case  presented  many  points  of  resemblance  to  that  of  Barclay 
(Case  CLVIII.),  especially  in  the  scrofulous  diathesis  and  scrofulous 
caries  of  the  bones,  and  the  cavity  under  one  clavicle,  on  admission.  The 
diseased  lung  was  more  extensively  afiected  however,  and  the  derange- 
ment of  the  stomach  more  violent  and  persistent.  Indeed,  throughout 
the  progress  of  his  case,  the  chief  difficulty  in  the  treatment  was  the 
management  of  the  stomach  and  bowels.  The  cod-liver  oil  and  diet  did 
not  produce  the  same  marked  effect  as  in  the  case  of  Barclay,  but  their 
operation,  though  slow,  was  still  very  decided ; and  for  a long  time  I 
considered  that  the  pulmonary  lesion  in  this  lad  was  in  progress  of  cure, 
exactly  in  the  same  manner  as  took  place  in  Case  CLVIII.  The  dissec- 
tion after  death  demonstrated  that  in  fact  the  lung  was  undergoing  con- 
traction, and  that  the  tubercular  disease  was  being  arrested.  It  presented 
a remarkable  specimen  of  one  of  the  modes  in  which  this  is  occasionally 
accomplished,  namely,  by  the  formation  of  pouches  or  cavities,  the  lining 
membranes  of  which  become  smooth,  and  cease  to  exude  tubercle.  This 
condition  of  the  lung  has  been  described  by  morbid  anatomists  under 
the  name  of  dilated  bronchi,  and  by  Dr.  Corrigan  as  cirrhosis  of  the 
lung.* * * §  In  the  first  case,  it  has  been  imagined  to  result  from  chronic 
bronchitis,  whereby  the  bronchi  are  dilated  from  within  ; j-  and  in  the 
second,  from  the  formation  of  fibrous  matters,  the  contraction  of  which 
causes  this  enlargement  from  without.  A consideration  of  the  details  of 
this  case,  however,  must  convince  every  physician  that  we  had  here  to 
do  with  large  tubercular  excavations,  which,  by  compressing  the  lung, 
had  obliterated  the  whole  of  its  texture,  and  converted  it  into  a con- 
tracted fibrous  envelope  of  these  excavations.  All  trace  of  tubercular 
matter  had  disappeared,  with  the  exception  of  two  small  cretaceous  con- 
cretions, and  the  respiratory  function  was  entirely  carried  on  by  means 
of  the  opposite  lung,  in  which  chronic  tubercle  to  a limited  extent,  and 
very  latent,  was  found.  Whether,  under  such  circumstances,  the  pul- 
monary lesion  would  ultimately  have  healed,  it  is  difficult  to  say ; but 
there  can  be  no  doubt  he  might  have  lived  a long  time  in  this  condition 
had  he  not  met  with  the  accident  which  caused  his  death.  But  that 
many  such  lesions  maj"  be  arrested,  and  life  continue,  is  proved  by  the 
observations  of  Benaud,  who  has  given  figures  of  what  he  calls  dilata- 
tions of  the  bronchi,  many  of  which  were  evidently  the  result  of  tuber- 
cular ulceration.  J Cruveilhier  ^ has  also  figured  a lung  presenting 
similar  appearances. 

In  the  case  of  another  man,  called  Joseph  Finnie,  which  closely 
resembled  that  of  Finlay,  I diagnosed,  during  life,  the  same  contraction 
of  the  lung  from  tubercular  excavations,  and  the  same  chronic  dilatations 
in  connection  with  the  bronchi.  This  man  died  of  Bright’s  disease  in 

* Dublin  Medical  Journal,  vol.  xiii.  1838.  f Laennec,  vol,  i.  p.  201. 

f Memoires  de  I’Academie  Royale  de  Medecine,  tome  4"'®,  Plate  4,  Fig.  1 ; Plate  5, 

Fig.  1 ; Plate  7,  Fig.  2. 

§ Anatomic  Pathologique,  Livraison  32,  Plate  5,  Fig.  3. 


PHTHISIS  PULMONALIS. 


731 


the  Koyal  Infirmary,  January  1853  ; and  on  dissection  a similar  state 
of  the  pulmonary  texture  was  discovered,  with  the  exception  that  the 
atrophy  of  the  organ  was  not  so  great,  whilst  traces  of  tubercular  infil- 
tration were  more  evident. 

Case  CLXI.^ — Chronic  Phthisis — Enlarged  Liver — Albuminuria — Large 
Evcavation  in  Left  Lung — Cicatrices  and  Induration  of  Right  Lung 
— JVaxg  Liver  and  Kidnegs — Tubercular  Ulceration  of  Intestines. 

History. — Margaret  Clark,  aet.  39 — admitted  November  12th,  1844.  She  says 
that  for  two  years  previous  to  admission  she  was  laboring  under  frequent  attacks  of 
cough,  with  profuse  expectoration  and  spitting  ol  blood.  During  this  period  she 
has  become  greatly  emaciated  and  very  weak,  sweating  all  night,  with  occasional 
diarrhoea.  Catamenia  have  been  absent  during  the  last  three  months. 

Symptoms  on  Admission.— There  is  frequent  prolonged  cough,  often  causing 
vomiting,  with  copious  purulent  expectoration.  Marked  dulness  on  left  side  of  chest, 
with  loud  cracked-pot  resonance,  and  flattening  of  ribs  under  the  clavicle.  Under 
right  clavicle  dulness  also  evident,  but  resonance  good  over  the  rest  ot  the  lung.  On 
auscultation  over  left  side,  loud  gurgling  is  audible,  with  pectoriloquy,  extending  over 
the  whole  anterior  surface,  but  diminishing  somewhat  towards  the  base.  Under 
right  clavicle  there  is  loud  mucous  rale  on  inspiration,  with  bronchophony.  Breath 
sounds  inferiorly  normal.  Posteriorly,  the  physical  signs  are  similar  to  those  in 
front.  There  is  considerable  dyspncea  on  exertion.  Heart  sounds  normal.  Pulse 
110,  feeble.  Total  loss  of  appetite  with  anorexia  and  vomiting  after  taking  food. 
Tongue  slightly  furred.  No  diarrhoea  at  present,  but  says  she  is  very  subject  to 
attacks  of  it.  Body  greatly  emaciated,  and  copious  sweating  at  night.  Other  func- 
tions normal.  Naphthce  Medecin.  3 j ; Tr.  Card.  comp.  | j ; Mist.  Camph.  3 v.  M. 
A sixth  part  to  be  taken  three  times  a-day.  Milk  mixed  with  an  equal  part  of  lime 
water and  strong  beef-tea  with  toast,  to  be  taken  frequently  in  small  quantities. 

Progress  op  the  Case. — April  \&th. — From  the  time  of  her  admission  until  now 
the  physical  signs  have  remained  the  same,  with  the  exception  that  the  moist  rattles 
at  the  apex  of  right  lung  have  gradually  diminished,  and  have  now  nearly  disappeared. 
At  each  catamenial  period  there  has  been  considerable  haemoptysis,  continuing  several 
days,  and  amounting  often  to  several  ounces  per  day.  Shortly  after  admission  the 
appetite  impx’oved,  she  took  nutrients  with  § iij  of  wine,  and  two  and  sometimes  three 
table-spoonfuls  of  cod-liver  oil  daily.  From  time  to  time  the  latter  remedy  was  sus- 
pended, and  bitter  vegetable  infusions  and  tinctures  administered,  occasionally  mixed 
with  chalybeates.  Every  now  and  then  an  attack  of  diarrhoea  has  come  on,  which 
has  been  restrained  by  chalk  mixture  and  astringents.  Hence  she  has  been  alternate- 
ly better  and  worse  as  to  symptoms,  but  at  present  she  is  decidedly  better  than  when 
she  entered  the  house.  July  1th. — Since  last  report  the  liver  has  been  observed  to 
have  gradually  enlarged.  It  can  now  be  felt  extending  below  the  level  of  the  umbili- 
cus on  the  right  side,  presenting  a rounded  margin  and  forming  a distinct  abdominal 
tumor.  The  emaciation  is  extreme,  and  latterly  there  have  been  considerable  vomit- 
ing and  diarrhoea.  There  is  a hectic  flush  on  the  cheeks.  The  skin  is  warm  ; pulse 
120,  feeble;  profuse  sweating  at  night ; loud  gurgling  rales  still  audible  on  left  side 
of  chest,  with  cracked-pot  sound  on  percussion,  and  pectoriloquy.  On  right  side  there 
are  loud  vocal  resonance  under  clavicle,  slight  dulness  on  percussion,  and  dry  cavern- 
ous or  hoarse  tubular  breathing.  Cough  still  troublesome,  especially  at  night.  Sputum 
purulent  and  copious,  occasionally  tinged  with  blood.  For  the  last  few  days  has 
passed  little  urine,  which  is  albuminous,  and  the  feet  are  slightly  oedematous.  To  have 
1 ij  of  gininstead  of  wine.  Sp.  jEther.  Nit.  § ss  ; Tr.  Digitalis  3 ij  ; Mist.  Scillce  c. 

ad  I vj.  M.  One  table-spoonful  to  be  taken  three  times  a day.  July  ‘14:th. — Urine 
still  highly  albuminous  and  scanty,  though  diuretics  have  been  freely  given,  including 
supertartrate  of  potass.  Liver  now  much  larger,  and  extends  down  to  Poupart’s  liga- 
ment when  she  sits  up.  ffidema  has  extended  above  the  knee.  Weakness  has  in- 
creased. August  l^th. — Has  continued  in  the  same  exhausted  condition,  every  care 
having  been  taken  to  support  her  strength  by  small  quantities  of  nutritious  food.  She 
has  experienced  little  pain,  and  latterly  obtained  sleep  at  night  by  ether  and  morphia 
draughts.  At  4 a.m.  this  morning,  respiration  became  very  difficult,  and  shortly  after 
she  died. 


* Reported  by  Mr.  Bum  Murdoch,  Clinical  Clerk. 


732 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


Sectio  Cadaver  is. — Thirty -one  hours  after  death. 

Body  greatly  emaciated. 

Thorax. — Both  pleurae  strongly  adherent  throughout  by  chronic  adhesions. 
Apices  of  both  lungs  much  puckered  externally.  The  whole  of  the  superior  lobe  of 
left  lung  hollowed  out  so  as  to  form  a cavern  the  size  of  a large  cocoa-nut,  containing 
foetid  air  and  about  four  ounces  of  dirty  pus.  Its  walls  were  lined  by  a distinct  pyogenic 
membrane,  and  consisted  externally  only  of  thickened  pleura,  and  internally  of  a 
layer  of  indurated  lung  about  half  an  inch  in  thickness.  In  the  inferior  lobe  were 
several  masses  of  infiltrated  tubercle,  which  in  some  places  were  softened,  formino" 
small  purulent  collections,  varying  in  size  from  a pea  to  that  of  a hazel  nut.  Through- 
out the  upper  lobe  of  right  lung  there  were  a few  excavations,  quite  dry,  varying  in 
size  from  a millet  seed  to  that  of  a small  nut.  The  parenchyma  between  these  was 
much  indurated  by  chronic  pneumonia,  and  of  an  iron-gray  color  from  pigmentary 
deposits.  At  the  apex  were  several  cretaceous  concretions  about  the  size  of  peas. 
One  of  these  was  the  size  of  an  almond  nut,  elongated  in  form,  and  all  were  enclosed 
in  indurated  capsules.  The  two  inferior  lobes  were  emphysematous  anteriorly.  In  the 
centre  of  the  lowest  one  was  an  indurated  white  patch,  the  size  of  half-a-ciown,  with 
radii  stretching  from  it  in  all  directions.  On  cutting  through  it,  it  was  seen  to  con- 
sist externally  of  dense  white  fibrous  tissue,  an  eighth  of  an  inch  in  thickness,  and 
immediately  below  it  was  a mass  of  indurated  tubercle,  the  size  of  a hazel  nut,  of 
iron-gray  color,  containing  gritty  points  of  cretaceous  matter.  Other  similar  masses  of 
varying  size,  but  widely  scattered,  gave  a nodulated  feel  to  the  two  inferior  lobes  on 
this  side.  Heart  healthy. 

Abdomen. — The  liver  was  not  only  enlarged,  but  altered  greatly  in  shape.  The 
right  lobe  was  so  elongated  as  to  extend  down  to  the  crest  of  the  ilium.  The  length 
f.om  above  downw’ards  was  12  inches  ; breadth  8 inches.  Length  of  left  lobe  was  8 
inches  ; breadth,  6 inches.  Its  entire  weight  was  '7  lbs.  9 oz.  The  greatest  thickness 
of  the  organ  from  behind  forwards  was  four  inches.  In  texture  it  was  of  waxy  con- 
sistence and  appearance,  of  a dirty  yellow  color,  dense  feel,  smooth  section,  presenting 
semi-translucent  edges.  The  spleen  weiglied  7 oz.  5 dr.,  and  was  healthy.  The 
mucous  membrane  of  the  csecum  was  of  a black  tint,  which  extended  up  the  ascending 
and  half  way  across  the  transverse  colon,  gradually  diminishing  in  intensity.  This  dis- 
colored portion  of  the  membrane  was  studded  over  w ith  chronic  tubercular  ulcers  in 
various  stages  of  healing,  mingled  with  numerous  cicatrices  and  puckerings.  The 
largest  of  the  open  ulcers  were  the  size  of  a shilling,  with  irregular  raised  edges,  and 
dirty  yellowdsh  base.  Mesenteric  glands  everywhere  enlarged,  of  a white  color  and  in- 
durated ; some  contained  tubercular  deposits.  Both  kidneys  waxy ; externally  pale, 
indurated,  and  rough  ; internally,  cortical  substance  atrophied,  pale,  and  on  section 
having  translucent  edges.  The  uterus  contained  in  its  inferior  wall  a fibrous  tumor 
the  size  of  a walnut.  Three  others  the  size  of  peas  were  on  its  anterior  surface ; 
ovaries  contracted,  rugose,  and  of  semi-cartilaginous  consistence.  Other  organs 
healthy. 

Microscopic  Examination. — The  tubercle  everywhere  presented  its  usual  charac- 
ters. The  cells  of  the  liver  had  undergone  a remarkable  change,  being  colorless,  re- 
refracting light,  deprived  of  nuclei,  and  forming,  when  compressed  together,  a trans- 
lucent, amorphous  mass.  The  black  matter  in  the  CEecum  was  composed  of  molecules 
and  irregular  masses  of  black  pigment. 

Commentary. — This  case  of  chronic  phthisis,  which  we  watched  for 
nine  months,  appeared  to  be  on  the  point  of  death  when  she  entered  the 
Infirmary.  The  prostration  was  extreme,  an  enormous  excavation  even 
then  existed  in  the  left,  with  smaller  ones  in  the  right  lung.  Careful 
treatment  directed  to  restore  the  tone  of  the  stomach,  nutrients  adminis- 
tered in  small  quantities,  with  wine  and  cod-liver  oil,  caused  a gradual 
restoration,  and  my  opinion  is,  that  from  that  time  the  pulmonary  dis- 
ease continued  to  diminish.  The  cavities  on  the  right  side  became  dry, 
cicatrices  and  cretaceous  transformations  of  tbe  tubercular  matter  pro- 
ceeded, and  the  large  excavation  on  the  left  side  became  smaller  and 
more  circumscribed.  The  liver  first,  and  then  the  kidneys,  underwent 
tlic  waxy  transformation;  oedema  came  on,  and  she  sunk.  I have 
already  alluded  to  the  peculiar  character  of  this  degeneration  of  the  liver 


PHTHISIS  PULMONALIS. 


733 


and  kidney  (p.  249).  It  is  exceedingly  common  in  phthisical  cases,  and 
in  this  instance  was  recognised  and  examined  histologically  with  great 
care  m 1815.  Formerly  it  was  confounded  with  fatty  degeneration,  and 
it  has  been  supposed  that  cod-liver  oil  tends  to  its  production.  But  a 
knowledge  of  the  true  nature  of  the  waxy  degeneration  must  negative 
such  a supposition,  as  the  liver  is  altogether  free  from  fat.  The  inter- 
ruption to  the  portal  and  renal  circulations,  and  the  diminished  flow  of 
urine,  produced  more  or  less  anasarca,  a complication  which  sooner  or 
later  is  uniformly  fatal. 

The  previous  cases  illustrate  tolerably  well  the  advantages  which 
attend  what  may  be  denominated  a curative,  as  distinguished  from  a 
palliative,  treatment  of  phthisis.  It  is  exceedingly  rare,  however,  that 
we  can  demonstrate  among  hospital  cases  a complete  cure  of  the  disease 
in  its  advanced  stage,  such  as  took  place  in  Barclay.  (Case  CLYIIL) 
In  the  majority  of  instances,  no  sooner  is  amendment  effected,  than  they 
insist  on  going  out.  A few  return  with  the  disease  advanced,  again  get 
better,  and  so  on,  until  at  length  they  die.  Many  others  I am  satisfied 
get  perfectly  well.  In  private  cases,  however,  recovery  is  much  more 
frequently  observed  ; and  now  that  physical  diagnosis  has  enabled  us 
with  great  certainty  to  recognise  the  disease  and  follow  its  progress,  we 
can  have  no  doubt  of  the  superior  advantages  of  a curative  over  a pal- 
liative practice.  To  carry  out  the  former,  however,  upon  correct  prin- 
ciples, it  is  proper  to  have  a knowledge — 1st,  Of  the  natural  progress  of 
the  disease;  2d,  Of  its  pathology  and  general  treatment;  and  3d,  Of 
the  special  treatment,. in  reference  to  symptoms  and  complications.  It 
may  be  well  to  make  a few  observations  on  each  of  these  heads. 

I. — On  the  Natural  Progress  of  Phthisis  Pulmonalis — The  Tendency  to 
Ulceration — The  modes  of  Arrestment, 

At  first  tubercle  is  deposited  in  the  state  of  a fluid  exudation  from 
the  capillaries  in  the  same  manner  that  lymph  is,  In  this  condition  it 
insinuates  itself  into  the  interstices  of  the  pulmonary  parenchyma,  passes 
through  the  lining  membrane  of  the  air  vesicles,  and  Alls  their  interior. 
Numerous  successful  injections  of  pneumonic,  tubercular,  and  cancerous 
lungs,  in  my  possession,  demonstrate  that  the  exudation  in  all  is  poured 
out  in  the  same  manner,  and  occupies  the  same  position  in  the  pulmo- 
nary texture.  A miliary  tubercle  may,  in  this  manner,  block  up  from 
three  to  twenty  of  these  air  vesicles  (Figs.  160, 161).  It  now  coagulates 
and  constitutes  a foreign  solid  body,  which  can  only  be  removed  by 
being  again  broken  down  and  rendered  capable  of  being  either  absorbed 
or  excreted.  Thus  the  miliary  or  infiltrated  forms,  whether  gray  or 
yellow,  after  a time  soften, — a process  which  may  commence  at  any 
part  of  the  mass  and  gradually  affect  the  whole.  This  softening  is  a 
disintegration  or  slow  death  of  the  tubercular  exudation,  constituting 
true  ulceration,  which  is  more  or  less  extensive  according  to  the 
amount  and  extent  of  the  morbid  deposit.  (Figs.  157,  158,  and  159.) 
When  recent,  the  pulmonary  parenchyma  in  the  immediate  neighbor- 
hood is  more  or  less  congested ; and  when  chronic,  it  is  thickened  and 


734 


DISEASES  OF  THE  KESPIEATORY  SYSTEM. 


indurated,  often  forming  a capsule  which  surrounds  the  tubercular  de- 
posit. The  pleura  also  is  very  liable  to  be  aflected ; when  recently  so, 
presenting  soft  fibrinous  exudations  with  more  or  less  adhesion ; where- 
as when  chronic,  these  become  fibrous,  and  reach  a thickness  and  den- 
sity seldom  seen  in  other  diseases.  The  bronchi  are  necessarily  in- 


Tig.  457. 

vclved ; their  extremities  are  among  the  first  structures  affected ; and 
as  the  tuberculosis  proceeds,  all  the  appearances  characteristic  of  chronic 

Fig.  457.  Section  of  a lung  in  the  first  stage  of  Phthisis  Puhnonalis.  Ulcerative 
softening  is  commencing  at  the  apex.  Two-thirds  the  real  size. 


PHTHISIS  PULMONALIS. 


V35 


bronchitis  are  produced.  As  the  ulcerative  process  extends,  the  lung  is 
more,  and  more  destroyed,  the  excavations  become  larger  and  more 
numerous  (Figs.  458,  459),  until  at  length  it  can  no  longer  carry  on  its 
important  functions,  and  the  patient  dies,  or  the  fatal  result,  as  very 
commonly  happens,  is  hastened  by  disease  in  other  organs. 

The  ulcerative  or  destructive  tendency  of  the  tubercular  exudation 


Fig.  458.  ' 

has  generally  been  supposed  to  be  its  chief  characteristic ; but  there  are 

_ Fig.  458.  Section  of  a lung  in  the  second  stage  of  Phthisis  Pulmonalis.  Tubercle 
is  extensively  infiltrated  in  the  upper  lobe,  and  a considerable  cavity  has  formed. 

Ttoo-thirds  the  real  size. 


736 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


very  few  cases  in  which  its  progress  is  uniform.  It  is  continually 
checked,  and  for  a time  slumbers;  and  all  morbid  anatomists  have 
recognised,  even  in  the  worst  specimens  of  tubercular  lungs,  numerous 
cicatrices  and  evidences  of  attempts  to  heal.  These  attempts  are  more  or 
less  perfect,  and  when  ineffectual,  it  is  owing  to  the  circumstance  that  as 
one  portion  of  lung  cicatrizes,  another  becomes  the  seat  of  recent  tubercle. 


Fig.  459. 

Cicatrices  present  different  appearances,  according  as  the  cavities 
Fi".  459.  Section  of  a lun"  in  the  third  stage  of  Phthisis  Pulmonalis.  A cavity 
occupies  the  superior  half  of  the  organ,  and  another  smaller  one  has  formed  in  the 
inferior  lobe.  Two-thirds  the  real  size. 


PHTHISIS  PULMONALIS. 


V37 


from  which  they  were  formed  have  been  superficial  or  deep  seated. 
In  the  first  case  it  will  generally  be  observed  that  the  pleurae  are  more 
or  less  adherent  and  thickened,  and  this  frequently  forms  an  external 
boundary  to  the  tubercular  cavity.  As  the  matters  which  the  cavity  con- 
tains are  expectorated  or  transformed,  the  lymph  gradually  contracts, 
draws  the  lung  closely  to  the  thoracic  walls,  from  which  it  cannot  be 
separated  without  great  violence.  Sometimes,  however,  it  is  deeper,  and 
the  adhesion  is  very  slight  or  does  not  exist.  In  this  case,  when  the 
walls  of  the  cavern  contract,  the  pleural  surface  of  the  lung  is  drawn  in- 
wards, and  in  this  way  the  irregular  puckerings  visible  on  the  surface 
are  produced. 

Occasionally  no  traces  of  tubercular  matter  are  discovered  either 
within  or  in  the  vicinity  of  these  cicatrices.  Under  such  circumstances 
they  appear  to  be  formed  of  dense  fibrous  tissue,  and  the  parenchymatous 
substance  in  their  vicinity  is  of  a bluish-black  color,  from  increased  pig- 
mentary deposit,  and  of  peculiar  induration  and  density,  owing  to 
chronic  exudatfion.  More  generally,  however,  the  contraction  and 
puckering  will  be  found  to  have  occurred  around  tubercle  which  has 
undergone  various  transformations.  Occasionally  there  are  round 
masses  of  crude  tubercle  surrounded  by  a cyst.  They  are  of  unusual 
density,  still  of  a yellowish  color;  but  contain  granules  of  earthy  salts 
more  or  less  numerous.  Often  they  are  white  and  friable,  resembling 
chalky  matter.  In  this  state  the  soft  portions  have  been  apparently 
absorbed,  and  the  whole  consists,  under  the  microscope,  of  irregular 
masses  of  earthy  matter,  mixed  with  numerous  granules  and  crystals  of 
cholesterine  (Figs.  162,  367).  At  other  times  the  whole  has  been  con- 
verted into  a solid  calcareous  mass,  frequently  round,  or  occasionally 
with  numerous  prolongations  and  irregularities,  which  accurately  fit  the 
surface  and  bronchi  with  which  they  are  in  contact.  These  cretaceous 
and  calcareous  concretions  may  remain  an  indefinite  time  in  the  paren- 
chymatous substance  of  the  lungs,  or  they  may  be  evacuated  through  the 
bronchi  with  the  sputa.  The  cyst  which  incloses  them  then  forms  a 
dense  linear  cicatrix. 

Such  appear  to  be  the  usual  modes  in  which  tubercular  ulcers  heal. 
They  occur  in  exactly  the  same  manner  as  abscesses  in  other  parenchy- 
matous tissues,  the  result  of  simple  exudation ; and  that  the  process  in 
both  is  identical,  is  proved  by  the  frequency  with  which  in  the  latter 
calcareous  deposits  also  take  place.  If,  then,  the  further  deposition  of 
tubercle  could  be  arrested,  there  seems  no  reason  why  cavities  in  the 
lung  should  not  heal  with  the  same  frequency  as  ulcerations  or  abscesses 
in  other  internal  organs.  Indeed,  the  careful  dissections  of  morbid 
anatomists  have  recently  shown  that  this  arrestment,  instead  of  being  a 
rare  or  occasional  occurrence,  really  happens  with  extreme  frequency. 
In  1845,  I made  a series  of  observations  with  reference  to  the  cretace- 
ous masses  and  puckerings  so  frequently  observed  at  the  apices  of  the 
lungs  in  persons  advanced  in  life.  The  conclusion  arrived  at  was,  that 
the  spontaneous  arrestment  of  tubercle  in  its  early  stage  occurred  in  the 
proportion  of  from  one-third  to  one-half  of  all  the  individuals  who  die 
after  the  age  of  forty.  The  observations  of  Rogee  and  Boudet,  made  at 
the  Salpetriere  and  Bicetre  Hospitals  in  Paris,  amongst  individuals 
47 


738 


DISEASES  OF  THE  EESPIRATOBY  SYSTEM. 


generally  above  the  age  of  seventy,  showed  the  proportion  in  such  per- 
sons to  be  respectively  one-half  and  four-fifths. 

That  the  cretaceous  and  calcareous  concretions,  accompanied  with 
puckerings,  are  really  evidences  of  abortive  tubercles,  is  established  by 
the  following  facts  : — 

1.  A form  of  indurated  and  circumscribed  tubercle  is  frequently  met 
with,  gritty  to  the  feel,  which,  on  being  dried,  closely  resembles  cretaceous 
concretions. 

2.  These  concretions  are  found  exactly  in  the  same  situations  as 


Fig.  460. 


tubercle.  Thus  they  are  most  common  in  the  apex,  and  in  both  lungs. 
They  frequently  occur  in  the  bronchial,  mesenteric,  and  other  lymphatic 
glands,  and  in  the  psoas  muscles,  or  other  textures  which  have  been  the 
seat  of  tubercular  depositions,  or  scrofulous  abscesses. 

3.  When  the  lung  is  the  seat  of  tubercular  infiltration  throughout, 
whilst  recent  tubercle  occupies  the  inferior  portion,  and  older  tubercle, 
and  perhaps  caverns,  the  superior,  the  cretaceous  and  calcareous  concre- 
tions will  be  found  at  the  apex. 

4.  A comparison  of  the  opposite  lungs  will  frequently  show,  that 
whilst  on  one  side  there  is  firm  encysted  tubercle,  partly  transformed 
into  cretaceous  matter,  on  the  other  the  transformation  is  perfect,  and 
has  occasionally  even  passed  into  a calcareous  substance  of  stony 
hardness. 

5.  The  seat  of  cicatrices  admits  of  the  same  exceptions  as  the  seat 
of  tubercles.  In  one  case,  I have  found  the  puckering  and  cicatrix  in 

Fig.  460.  Section  of  the  summit  of  the  right  lung,  exhibiting  the  cretaceous  masses, 
more  or  less  loaded  with  and  surrounded  by  carbonaceous  deposit.  Many  air  vesicles 
are  enlarged,  constituting  incipient  emphysema.  The  preparation  now  in  my  posses- 
sion exhibits  a,  characteristic  specimen  of  the  mode  in  which  a considerable  amount  of 
tubercular  exudation  is  arrested  by  calcareous  degeneration.  Natural  size. 


PHTHISIS  PULMONALIS. 


^39 


tlie  inferior  lobe  only ; and  have  met  with  three  cases  where  the  inferior 
Ijbe  was  throughout  densely  infiltrated  with  tubercle,  whilst  the  superi- 
or was  only  slightly  afiected. 

It  has  indeed  been  argued,  that  occasionally  these  cretaceous  masses 
may  be  the  result  of  a simple  exudation.  When  they  are  found  isolated 
in  the  middle  or  base  of  the  organ  such  certainly  may  be  the  case,  and 
consequently  the  fifth  argument  may  be  alfected.  But  this  is  rare,  and 
can  scarcely  make  any  alteration  in  the  vast  proportion  of  those  concre- 
tion-5  and  puckerings  which  are  undoubtedly  the  result  of  abortive 
tubercles.  With  these  facts  before  us,  and  with  the  knowledge  that 
there  is  nothing  in  the  nature  of  tubercle  itself  which  is  opposed  to  the 
evidence  of  these  anatomicl  faacts,  the  frequent  spontaneous  cure  of 
tubercle  may  now  be  considered  established. 

Since  these  observations,  however,  have  become  known,  it  has  been 
stated  that  after  all,  practically  speaking,  phthisis  pulmonalis  does  not 
mean  the  existence  of  a few  isolated  tubercles  scattered  through  the 
lung,  and  that  what  is  really  meant,  is  that  advanced  stage  in  which  the 
lung  is  affected  with  ulceration,  and  in  which  the  bodily  powers  are  so 
lowered  that  perfecet  rcovery  seldom  or  never  takes  place.  But  here 
again  a careful  examination  of  the  records  of  medicine  will  show  that 
many  even  of  these  advanced  cases  have  recovered.  Laennec,  Andral, 
Cruveilhier,  Kingston,  Pressat,  Bogee,  Boudet,  and  others,  have  pub- 
lished cases,  where  all  the  functional  symptoms  and  physical  signs  of  the 
disease,  even  in  its  most  advanced  stage,  were  present,  and  yet  where  the 
individual  survived  many  years,  ultimately  died  of  some  other  disorder, 
and  on  dissection  cicatrices  and  concretions  were  found  in  the  lungs. 

I here  show  you  a preparation,  exhibiting  a remarkable  cicatrix  in 
the  lung,  which  I described  and  figured  in  the  “ Monthly  Journal  ” for 
March  1850.  It  occurred  in  the  following  case  : — 

Case  CLXII. — Advanced  Phthisis — Restoration  to  Health — Death 
many  years  afterwards  from  Delirium  Tremens  — On  Dissection^ 
a Cicatrix^  three  inches  long^  in  Apex  of  Right  Lung^  and  Cre- 
taceous Concretions^  with  puckering  at  the  Summit  of  Left  Lung. 

“ John  Keith,  set.  60,  a teacher  of  languages,  was  admitted  into  the  Royal 
Infirmary,  February  8th,  1844,  in  a state  of  coma,  and  died  an  hour  afterwards.  On 
examination,  the  membranes  of  the  brain,  at  the  base,  were  unusually  congested,  and 
covered  with  a considerable  exudation  of  recently  coagulated  lymph,  hero  and  there 
mingled  with  bloody  extravasation.  The  apex  of  the  right  lung  presented  a remark- 
able cicatrix,  consisting  of  a dense  white  fibrous  tissue,  varying  in  breadth  from  one- 
fourth  to  three-fourths  of  an  inch,  and  measuring  about  three  inches  in  length.  The 
pleural  surface  in  its  neighborhood  was  considerably  puckered.  On  making  a 
section  through  the  lung,  parallel  with  the  external  cicatrix,  the  substance  immediate- 
ly below  presented  linear  indurations,  of  a black  color,  together  with  five  cretaceous 
concretions,  varying  in  size  from  a pin’s  head  to  that  of  a large  pea.  The  surrounding 
pulmonary  substance  was  healthy  (Fig.  461).  The  apex  of  the  left  lung  was  also 
strongly  puckered,  and  contained  six  or  seven  cretaceous  concretions,  each  surrounded 
by  a black,  dense,  fibrous  cyst. 

“ A very  respectable-looking  and  intelligent  man,  who  attended  the  post-mortem 
examination,  informed  me  that  Keith,  in  early  life,  was  in  very  indifferent  circum- 
stances, and  had  supported  himself  as  a writer’s  clerk.  At  the  age  of  two-and- 
twenty  or  three-and-twenty,  he  labored  under  all  the  symptoms  of  a deep  decline, 
and  his  life  was  despaired  of.  About  this  time,  however,  he  was  lost  sight  of  by 
his  friends ; but  it  was  afterwards  ascertained  that  he  had  become  a parish  school- 
master in  the  west  of  Scotland,  and  that  his  health  had  been  re-established.  He 


V40 


DISEASES  OP  THE  EESPIRATOKY  SYSTEM. 


returned  to  Edinburgh  six  years  before  his  death,  and  endeavored  to  gain  a liveli- 
hood by  teaching  Latin  and  French.  He  succeeded  but  very  imperfectly,  and  fell 
into  dissipated  habits.  Latterly  he  had  become  subject  to  attacks  of  mania,  appa- 
rently the  result  of  drink.  It  was  after  an  unusually  severe  attack  of  this  kind 
that  he  was  brought  into  the  Infirmary,  where  he  died  in  the  manner  previously 
described.” 

This  case  points  out  the  following  important  facts, — 1st,  That,  at  the 
age  of  twenty-two  or  twenty  three,  the  patient  had  had  a tubercular 
ulcer  in  the  right  lung,  the  size  of  which  must  have  been  very  consider- 
able when  the  contracted  cicatrix  alone  was  three  inches  long.  2d,  That 
tubercular  exudation  existed  in  the  apex  of  the  left  lung.  It  is,  there- 


Fig.  461. 


fore,  very  probable  that  the  statement  made  by  his  friend  at  the  exami- 
nation was  correct — namely,  that  when  young,  he  labored  under  all  the 
symptoms  of  advanced  phthisis  pulmonalis.  It  is  shown,  3 dly,  That  af- 

Fig.  461.  The  section  of  the  upper  portion  of  lung  in  Keith’s  case  seen  from  with- 
in, the  apex  having  been  left  entire  to  show  the  deep  puckerings  which  covered  its  sur- 
face. The  line  of  the  healed  cavity  is  densely  loaded  with  black  carbonaceous  deposit, 
in  which  are  seen  five  cretaceous  concretions,  three  of  them  encysted.  This  preparation, 
now  in  my  possession,  is  perhaps  a unique  specimen,  proving  the  healing,  by  cicatriza- 
tion, of  an  enormous  tubercular  excavation  in  the  lung.  Natural  size. 


PHTHISIS  PULMONALIS. 


741 


ter  receiving  the  appointment  of  a parish  schoolmaster,  after  changing  his 
residence  and  occupation,  while  his  social  condition  was  greatly  improved, 
these  symptoms  disappeared.  We  may  consequently  infer  that  it  was 
about  this  period  that  the  excavation  on  the  right  side  healed  and  cica- 
trized, while  the  tubercular  exudations  on  the  left  side  were  converted 
into  cretaceous  masses,  and  so  rendered  abortive.  It  demonstrates, 
4thly,  That  when,  at  a more  advanced  age,  he  again  fell  into  bad  cir- 
cumstances, and  even  became  a drunkard,  tubercular  exudations  did  not 
return,  but  that  delirium  tremens  was  induced,  with  simple  exudation 
on  the  membranes  of  the  brain,  of  which  he  died. 

Although  the  curability  of  phthisis  pulmonalis,  even  in  its  most 
advanced  stage,  can  now  no  longer  be  denied,  it  has  been  argued  that 
this  is  entirely  owing  to  the  operations  of  nature,  and  that  the  physician 
can  lay  little  claim  to  the  result.  Andral,  who  early  admitted  the  occa- 
sional cicatrization  of  caverns,  states  this  in  the  following  words  : — “ No 
fact,”  he  says,  “ demonstrates  that  phthisis  has  been  ever  cured,  for  it  is 
not  art  which  operates  in  the  cicatrization  of  caverns ; it  can  at  most 
only  favor  this,  by  not  opposing  the  operations  of  nature.  For  ages 
remedies  have  been  sought  either  to  combat  the  disposTion  to  tubercles, 
or  to  destroy  them  when  formed,  and  thus  innumerable  specifics  have- 
been  employed  and  abandoned  in  turn,  and  chosen  from  every  class  of 
medicaments.”^  But  if  it  be  true,  according  to  Hoffman,  that  ^^Medicus 
natwrcB  minister  non  magister  it  follows  that  by  carefully  observ- 
ing the  operations  of  nature,  learning  her  methods  of  cure,  imitating  it 
as  closely  as  possible,  avoiding  what  she  points  out  to  be  injurious,  and 
furnishing  what  she  evidently  requires,  we  may  at  length  arrive  at 
rational  indications  of  treatment.  The  cases  both  of  Keith  and  Bar- 
clay, in  my  opinion,  furnish  evidence  that  we  have  in  a great  measure 
attained  this  end ; and  this  leads  me  to  speak,  in  the  second  place,  of 

II. — The  Pathology  and  General  Treatment  of  Phthisis  Pidmonalis. 

Many  observant  physicians  have  not  failed  to  notice,  that  phthisis 
pulmonalis  is  ushered  in  with  a bad  and  capricious  appetite,  a furred  or 
morbidly  clean  tongue,  unusual  acidity  of  the  stomach  and  alimentary 
canal,  anorexia,  constipation  alternating  with  diarrhoea,  and  a variety  of 
symptoms  denominated  dyspeptic,  or  referable  to  a deranged  state  of  the 
primae  viae.  Moreover,  it  can  scarcely  be  denied  that,  in  the  great  major- 
ity of  cases,  these  are  the  symptoms  which  accompany  phthisis  throughout 
its  progress,  becoming  more  and  more  violent  towards  its  termination. 
Now,  as  the  nutritive  properties  of  the  blood  are  entirely  dependent  on 
a proper  assimilation  of  food,  and  as  this  assimilation  must  be  interfered 
with  in  the  morbid  conditions  of  the  alimentary  canal,  the  continuance 
of  such  conditions  necessarily  induces  an  impoverished  state  of  that  fluid, 
and  imperfect  growth  of  the  tissues.  Moreover,  when,  under  such  cir- 
cumstances, exudations  occur,  it  has  been  shown  by  the  histologist  that 
they  do  not  exhibit  any  tendency  to  perfect  cell  formations,  Wt  that 
corpuscles  are  produced,  which  form  slowly,  and  slowly  breaking  down, 
cause  softening  and  ulceration,  which  becomes  more  and  more  extensive 
as  the  amount  of  the  exudation  increases. 

An  observation  of  the  circumstances  which  precede  the  disease,  or 
* Diet,  de  Med.  1st  Edit.  Phthisie. 


742  DISEASES  OF  THE  EESPIEATORY  SYSTEM. 

its  so-called  causes,  clearly  indicates  imperfect  digestion  and  assimila- 
tion as  its  true  origin.  Thus  phthisis  is  essentially  a disorder  of  child- 
hood and  youth — that  is,  the  period  of  life  when  nutrition  is  directed  to 
building  up  the  tissues  of  the  body.  Diminish  the  proper  quantity  of 
food  taken  by  a healthy  adult,  and  tubercular  diseases  are  not  induced ; 
but  if  this  be  attempted  with  children  or  young  persons,  they  are  a most 
common  result.  It  has  been  supposed  that  hereditary  predisposition,  a 
vitiated  atmosphere,  changeable  temperature,  certain  unhealthy  occupa- 
tions, humidity,  particular  localities,  absence  of  light,  and  so  on,  predis- 
pose to  phthisis.  Very  frequently  several  of  these  are  found  united,  so 
that  it  is  difficult  to  ascertain  the  influence  of  each.  When  they  so  ope- 
rate, however,  they  invariably  produce,  in  the  first  place,  more  or  less 
disorder  of  the  nutritive  functions,  and  are  associated  with  dyspepsia  or 
other  signs  of  mal-assimilation  of  food. 

From  a study  of  the  symptoms,  causes,  morbid  anatomy,  and  histo- 
logy of  phthisis  pulraonalis,  we  are  therefore  led  to  the  conclusion,  that 
it  is  a disease  of  the  primary  digestion,  causing, — 1st,  Impoverishment 
of  the  blood ; 2d,  Local  exudations  into  the  lung,  which  present  the 
characters  of  tubercular  exudation ; and  3d,  Owing  to  the  successive 
formation  and  softening  of  these,  and  the  ulceration  which  follows  in  the 
pulmonary  or  other  tissues,  the  destructive  results  which  distinguish  the 
disease.  Further  observation  shows,  that  circumstances  which  remove 
the  mal-assimilation  of  food  frequently  check  further  tubercular  exuda- 
tions, while  those  which  previously  existed  become  abortive,  and  that 
occasionally  very  extensive  excavations  in  the  pulmonary  tissue  may, 
owing  to  like  circumstances,  heal  up  and  cicatrize.  The  curative  treat- 
ment of  this  disease  must  therefore  be  directed, — 1st,  To  restoring  the 
healthy  nutrition  of  the  economy ; 2d,  To  subduing  local  irritation  ; and 
3d,  To  the  avoidance  of  those  circumstances  which  are  likely  to  deterio- 
rate the  constitution  on  the  one  hand,  or  induce  pulmonary  symptoms  on 
the  other. 

1.  A healthy  nutrition  of  the  body  cannot  proceed  without  a proper 
admixture  of  mineral,  albuminous,  and  oleaginous  elements.  This  may 
be  inferred  from  the  physiological  experiments  of  Tiedemann  and  Gmelin, 
Leuret  and  Lassaigne,  Mageiidie,  and  others ; from  an  observation  of  the 
constituents  of  milk,  the  natural  food  of  young  mammiferous  animals ; 
from  a knowledge  of  the  contents  of  the  egg,  which  constitute  the  source 
from  which  the  tissues  of  oviparous  animals  are  formed  before  the  shell 
is  broken ; and  from  all  that  we  know  of  the  principles  contained  in  the 
food  of  adult  animals.  The  researches  of  chemists,  as  of  Prout,  Liebig, 
and  others,  point  to  the  same  generalisation,  when  they  assert  that  car- 
bonised and  nitrogenised,  or,  as  they  have  been  called,  respiratory  and 
sanguigenous  food,  are  necessary  to  carry  on  nutrition,  inasmuch  as  oil 
is  a type  of  the  one,  and  albumen  of  the  other.  The  chemical  theory  is 
imperfect,  however,  because  it  does  not  point  out  how  these  elements 
form  the  tissues ; for  it  is  not  every  form  of  carbonised  or  of  albuminous 
food  that  is  nutritious,  but  only  such  kinds  of  them  as  are  convertible 
into  oil  and  albumen. 

The  reason  of  this  was  first  pointed  out  by  Dr.  Ascherson  of  Berlin, 
in  1840,  and  made  known  by  me  to  the  profession  in  this  country  in 


PHTHISIS  PIJLMOXALIS. 


Y43 


1841.  I have  since  endeavored  to  show,  that  the  elementary  molecules 
formed  of  a particle  of  oil,  surrounded  hy  a layer  of  albumen,  which  are 
produced,  as  he  described,  by  rubbing  oil  and  albumen  together,  are  not 
developed  directly  into  blood-globules  and  other  tissues,  as  he  supposed, 
but  must  first  pass  through  a series  of  transformations — a knowledge 
of  which  is  highly  important,  not  only  to  a comprehension  of  nutrition 
generally,  but  especially  to  that  abnormal  condition  of  it  which  occurs  in 
phthisis.  Thus  the  successive  changes  which  occur  for  the  purposes  of 
assimilation  in  the  healthy  economy  may  be  shortly  enumerated  as  fol- 
lows: — 1st,  Introduction  into  the  stomach  and  alimentary  canal  of 
organic  matter.  2d,  Its  transformation  by  the  process  of  digestion  into 
alb^uminous  and  oily  compounds : this  process  is  chemical.  3d,  The 
imbibition  of  these  through  the  mucous  membrane  in  a fluid  state,  and 
their  union  in  the  termini  of  the  villi  and  lacteals  to  form  elementary  gran- 
ules and  nuclei ; this  process  is  physical.  4th,  The  transformation  of  these, 
first,  into  chyle  corpuscles,  and  secondly,  into  those  of  blood:  which  is  a 
vital  process.  It  is  from  this  fluid,  still  further  elaborated  in  numerous 
ways,  that  the  nutritive  materials  of  the  tissues  are  derived,  so  that  it  must 
be  evident,  if  the  first  steps  of  the  process  are  improperly  performed,  the 
subsequent  ones  must  also  be  interfered  with.  Hence  we  can  readily 
comprehend  how  an  improper  quantity  or  quality  of  food,  by  diminishing 
the  number  of  the  elementary  nutritive  molecules,  must  impede  nutrition. 

AVhen  we  examine  with  a magnifying  power  of  250  diameters  a drop 
of  chyle  taken  from  the  thoracic  duct  of  an  animal,  three  hours  after  it 
has  eaten  a meal,  we  observe  that  it  contains,  first,  a molecular  basis 
(Grulliver)  of  incalculably  minute  particles ; and  secondly,  numerous 
corpuscles  in  different  stages  of  development  into  blood  globules.  • This 
molecular  basis  has  been  proved  by  numerous  chemical  analyses  to  con- 
sist principally  of  fat,  eraulsionised  by  its  admixture  with  albumen.  In 
short,  these  two  important  principles,  fat  and  albumen,  constitute  essen- 
tial elements  of  the  nutritive  cli3mie ; and 
the  former  divided  into  exceedingly  minute 
particles  by  the  latter,  pass  through  the  villi 
and  form  the  milky  fluid  called  chyle.  It 
is  unnecessary  for  me  to  trace  the  subse- 
quent changes  this  chyle  undergoes  by  its 
passage  through  the  mesenteric  glands,  and 
the  successive  stages  of  elaboration  produced 
in  it  by  the  operation  of  the  blood  glands 
and  the  lungs.  No  one  can  doubt  that  the 
oil  and  the  albumen  so  derived  from  the 
food,  and  so  altered  chemically  and  mechanically  in  the  body,  constitute 
the  material  from  which  blood  is  formed ; neither  can  there  be  any 
question  that  the  presence  and  emulsionising  of  these  elements  in  proper 
proportions,  are  absolutely  necessary  to  supply  and  keep  up  the  vital 
properties  of  the  blood. 

Fig.  462.  Chyle  from  the  thoracic  duct  of  a dog,  three  hours  after  eating  a meal. 
«,  Fluid  chyle  showing  its  molecular  basis,  and  corpuscles  in  various  stages  of  devel- 
opment into  those  of  blood.  6,  Corpuscles  of  chyle  embedded  in  fibrillated  fibrin. 
They  are  round  in  the  centre,  but  more  or  less  compressed  and  elongated  towards  the 
margin.  250  diam. 


Fig.  462. 


744 


DISEASES  OP  THE  EESPIRATORY  SYSTEM. 


The  peculiarity  of  phthisis,  however,  is,  that  an  excess  of  acidity 
exists  in  the  alimentary  canal,  whereby  the  albuminous  constituents  of 
the  food  are  rendered  easily  soluble,  whilst  the  alkaline  secretions  of 
the  saliva  and  of  the  pancreatic  juice  are  more  than  neutralized,  and 
rendered  incapable  either  of  transforming  the  carbonaceous  constituents 
of  vegetable  food  into  oil,  or  of  so  preparing  fatty  matters  introduced 
into  the  system,  as  will  render  them  easily  assimilable.  Hence  an  in- 
creased amount  of  albumen  enters  the  blood,  and  has  been  found  to  exist 
there  by  all  chemical  analysis,  while  fat  is  largely  supplied  by  the  ab- 
sorption of  the  adipose  tissues  of  the  body,  causing  the  emaciation  which 
characterises  the  disease.  In  the  meanwhile,  the  lungs  become  especially 
liable  to  local  congestions,  leading  to  exudation  of  an  albuminous  kind  : 
which  is  tubercle.  This,  in  its  turn,  being  deficient  in  the  necessary 
proportion  of  fatty  matter,  elementary  molecules  are  not  formed  so  as 
to  constitute  nuclei  capable  of  further  development  into  cells ; they 
therefore  remain  abortive,  and  constitute  tubercle  corpuscles.  .Thus  a 
local  disease  is  added  to  the  constitutional  disorder,  and  that  compound 
affection  is  induced  which  we  call  phthisis  pulmonalis,  consisting  of 
symptoms  attributable  partly  to  the  alimentary  canal,  and  partly  to  the 
pulmonary  organs. 

To  improve  the  faulty  nutrition  which  originates  and  keeps  up  the 
disease,  it  is  of  all  things  important,  therefore  to  cause  a larger  quantity 
of  fatty  matter  to  be  assimilated.  A mere  increase  in  the  amount,  or 
even  quality,  of  the  food,  will  often  accomplish  this,  as  in  the  case  of 
Keith.  The  treatment  practised  some  years  ago  by  Dr.  Stewart  of 
Erskine,  which  consisted  in  freely  administering  beef-steaks  and  porter, 
and  causing  exercise  to  be  taken  in  the  open  air,  excited  considerable 
attention  from  its  success.  I have  been  informed,  that  in  some  parts  of 
America  the  cure  consists  in  living  on  the  bone  marrow  of  the  buffalo, 
and  that  the  consumptive  patient  gets  so  strong  in  this  way,  that  he  is 
at  length  able  to  bunt  down  the  animal  in  the  prairies.  All  kinds  ( 
food  rich  in  fat  will  not  unfrequently  produce  the  same  effects,  and  hence 
the  value  long  attributed  to  milk,  especially  ass’s  milk,  the  produce  of 
the  dairy,  as  cream  and  butter,  fat  bacon,  caviar,  etc. 

But  in  order  that  such  substances  should  be  digested  and  assimilated, 
the  powers  of  the  stomach  and  alimentary  canal  must  not  have  under- 
gone any  great  diminution.  In  most  cases  it  will  be  found  that  the 
patient  is  unable  to  tolerate  such  kind  of  food,  and  that  it  either  lies  un- 
digested in  the  stomach,  or  is  sooner  or  later  vomited.  Under  these 
circumstances,  the  animal  oils  themselves  are  directly  indicated,  by 
giving  which,  we  save  the  digestive  apparatus,  as  it  were,  the  trouble  of 
manufacturing  or  separating  them  from  the  food.  By  giving  consider- 
able quantities  of  oil  directly,  a large  proportion  of  it  is  at  once  assimi- 
lated, and  is  rendered  capable  of  entering  into  combination  with  the 
albumen,  and  thereby  forming  those  elementary  molecules  so  necessary 
for  the  formation  of  a healthy  chyle.  Such,  it  appears  to  me,  is  the 
rationale  of  the  good  effects  of  cod-liver  oil. 

Since  I introduced  this  substance  to  the  notice  of  the  profession  in 
this  country  as  a remedy  for  phthisis,  in  1841,  I have  continually  pre- 
scribed it  in  hospital,  dispensary,  and  private  practice.  I need  not  per- 


PHTHISIS  PULMOXALIS. 


745 


haps  say,  that  I have  given  it  in  a very  large  number  of  cases,  and  have 
observed  its  effects  in  all  the  stages  of  the  disease,  and  under  almost 
every  circumstance  of  age,  sex,  and  condition.  I have  had  the  most  ex- 
tensive opportunities  of  examining  the  bodies  of  those  who  have  died 
after  taking  it  in  considerable  quantities,  and  am  still  observing  the  cases 
of  many  persons  who  may  be  said  to  have  owed  their  lives  to  its  employ- 
ment. Further,  I have  carefully  watched  the  progress  it  has  made  in 
the  good  opinion  of  the  professional  public,  and  perused  all  that  has  been 
published  regarding  it  in  the  literature  of  this  and  other  countries.  It 
were  certainly  easy  for  me,  therefore,  to  write  at  great  length  on  this 
subject ; but  I do  not  see  that  anything  of  utility  could  be  added  to 
what  I have  already  published.  The  following  is  a summary  of  my  views 
regarding  cod-liver  oil  as  a remedy  for  phthisis  : — 

1.  Cod-liver  oil  is,  as  M.  Taufflied  pointed  out,  an  analeptic 
(di/aXa/x/5di/co,  to  repair),  and  is  indicated  in  all  cases  of  abnormal 
nutrition  dependent  on  want  of  assimilation  of  fatty  matter. 

2.  It  is  readily  digestible  under  circumstances  where  no  other  kind 
of  animal  food  can  be  taken  in  sufficient  quantity  to  furnish  the  tissues 
with  a proper  amount  of  fatty  material. 

3.  It  operates  by  combining  with  the  excess  of  albuminous  consti- 
tuents of  the  chyme,  and  forming  in  the  villi  and  terminal  lacteals  those 
elementary  molecules  of  which  the  chyle  is  originally  composed. 

4.  Its  effects  in  phthisis  are  to  nourish  the  body,  which  increases  in 
bulk  and  in  vigor;  to  check  fresh  exudations  of  tubercular  matter,  and 
to  diminish  the  cough,  expectoration,  and  perspiration. 

5.  The  common  dose  for  an  adult  is  a table-spoonful  three  times  a 
day,  which  may  be  often  increased  to  four,  or  even  six,  with  advantage. 
When  the  stomach  is  irritable,  however,  the  dose  to  commence  with 
should  be  a tea  or  dessert-spoonful. 

6.  The  kind  of  oil  is  of  little  importance  thernpeutically.  The  pure 
kinds  are  most  agreeable  to  the  palate ; but  the  brown  coarser  kinds 
have  long  been  used  with  advantage,  and  may  still  be  employed  with 
confidence  whenever  cheapness  is  an  object. 

7.  I have  never  observed  its  employment  to  induce  pneumonia,  or 
fatty  disease  of  the  liver  or  kidney,  however  long  continued,  although 
such  complications  of  phthisis  are  also  exceedingly  frequent. 

But  in  some  rare  cases  the  oil  cannot,  even  under  the  best  manage- 
ment, be  retained  on  the  stomach,  and  efforts  have  been  made  to  intro- 
duce fat  into  the  economy  by  some  other  channel,  such  as  by  the  skin 
and  rectum.  The  former  plan  was  first  tried  by  I)r.  Baur  of  Tubingen, 
who  rubbed  various  kinds  of  oil  into  the  skin,  and  even  recommended  oil 
baths.  Persons  occasionally  got  better  under  this  as  they  do  under  every 
other  kind  of  treatment,  but  the  excessive  trouble,  and  sense  of  unclean* 
liness  which  greasy  frictions  occasion,  are  strong  objections  to  its  use. 
Its  costliness  also  renders  it  inapplicable  to  the  poor.  Oily  enemata 
were  recommended  by  Dr.  Buist  of  Aberdeen.  But  it  must  be  evident 
that  as  nature  never  intended  mankind  to  be  permanently  nourished 
either  by  the  skin  or  by  the  rectum,  so,  in  imitation  of  her  processes,  the 
object  of  an  analeptic  treatment  in  pulmonary  tuberculosis  must  be  to 
cause  the  elements  of  the  food  to  be  taken  by  the  mouth ; to  diminish 


746 


DISEASES  OF  THE  KESPIEATOEY  SYSTEM. 


the  dyspeptic  symptoms,  and  induce  assimilation  by  the  lacteal  rather 
than  by  the  lymphatic  vessels. 

2.  The  second  indication — namely,  to  subdue  local  irritation — is  only 
to  be  followed  out  in  acute  cases  by  much  the  same  practice  as  guides  us 
in  the  treatment  of  pneumonia,  which  is  the  general  cause  of  such  irrita- 
tion. From  what  has  been  previously  said  on  that  subject,  it  must  be 
evident  that,  however  practitioners  may  flatter  themselves  that  by  bleed- 
ing or  mercury  they  have  checked  inflammation,  these  remedies  in 
phthisis,  so  far  from  arresting  the  local  lesion,  have  only  accelerated  it. 

In  the  chronic  forms  of  the  disease  this  indication  is  only  to  be  met 
by  topical  counter-irritation.  Hence  a seton  or  issue,  a succession  of 
blisters,  tartar  emetic  ointment,  and  croton  oil,  are  all  beneflcial,  and  may 
be  used  according  to  circumstances.  Cold  sponging,  employed  with 
great  precaution,  so  as  not  to  produce  a chill,  but  rather  a glow  of  heat 
afterwards,  is  also  beneficial.  Such  are  the  only  means  in  our  power  to 
meet  this  important  indication,  because,  combined  with  this  local  lower- 
ing treatment,  the  general  system  must  be  invigorated  to  the  utmost. 
This  is  the  difficult  problem  to  be  worked  out  in  the  treatment  of 
phthisis,  and  in  doing  so  we  shall  be  much  assisted  by  paying  particular 
attention  to  the  third  indication. 

3.  The  avoidance  of  those  circumstances  likely  to  deteriorate  the 
constitution  on  the  one  hand,  or  induce  pulmonary  symptoms  on  the 
other,  offers  a wide  field  for  the  judieious  practitioner,  especially  in  his 
character  as  a watchful  guardian  over  his  patient’s  health.  One  of  the 
great  difficulties  we  have  to  overcome  in  this  climate,  is  the  frequent 
variations  of  temperature,  and  the  sudden  changes  from  fervent  heat  to 
chilling  cold.  Supposing  that  you  have  the  means  of  supporting  nutri- 
tion and  keeping  down  local  irritation,  it  is  by  no  means  certain  that 
good  will  be  accomplished,  from  the  impossibility  of  securing  those 
hygienic  regulations  and  that  equable  climate,  which  are  necessary  to 
carry  out  the  third  indication.  In  the  first  place,  nutrition  itself  is 
more  connected  with  proper  exercise  and  breathing  fresh  air  than  many 
people  imagine.  It  does  not  merely  consist  in  stimulating  the  appetite 
and  giving  good  things  to  eat.  It  requires — 1st,  Food  in  proper  quan- 
tity and  quality ; 2d,  Proper  digestion  ; 3d,  Healthy  formation  of  blood ; 
4th,  A certain  exchange  between  the  blood  and  the  external  air  on  the 
one  hand,  and  between  the  blood  and  the  tissues  on  the  other ; and 
5th,  It  requires  that  there  should  be  proper  excretion,  that  is,  separation 
of  what  has  performed  its  allotted  function  and  become  useless.  All 
these  processes  are  necessary  for  nutrition,  and  not  merely  one  or  two 
of  them,  for  they  are  all  essentially  connected  with,  and  dependent  on, 
one  another.  Hence  the  means  of  prevention  consist  in  carrying  out 
those  hygienic  regulations  which  secure  the  performance  of  these  difier- 
ent  nutritive  acts,  the  most  important  of  which  are  attention  to  climate, 
exercise,  and  diet. 

Much  has  been  written  on  climate,  but  the  one  which  appears  to  me 
best  is  that  which  will  enable  the  phthisical  patient  to  pass  a few  hours 
every  day  in  the  open  air,  without  exposure  to  cold  or  vicissitudes  of 


PHTHISIS  PULMONALIS. 


747 


temperature  on  the  one  hand,  or  excessive  heat  on  the  other.  Whenever 
such  a favored  locality  may  be  found  during  the  winter  and  spring 
months,  its  advantages  should  be  considered  as  dependent  on  exercise, 
and  on  the  stimulus  given  to  the  nutritive  functions,  rather  than  to  its 
influence  on  the  lungs  directly. 

The  great  mass  of  those  affected  with  phthisis,  however,  have  not 
the  means  of  searching  out  a favorable  climate  on  the  Continent,  or  even 
of  maintaining  themselves  in  a sheltered  nook  on  the  western  or  south- 
western coasts  of  this  country.  It  has,  therefore,  been  proposed  that 
such  buildings  as  the  Crystal  Palace  should  be  converted  into  winter 
gardens  and  public  promenades.  Not  to  speak  of  the  intellectual  and 
recreative  purposes  that-such  a plan  would  subserve,  it  is  worthy  of  our 
consideration  how  far  it  would  tender  to  promote  health  in  general,  but 
especially,  how  it  would  conduce  to  the  cure  of  phthisis.  Its  great  ad- 
vantage would  be  offering  the  means  of  exercise  in  a pure  atmosphere, 
at  an  eq[uable  temperature.  It  is  easy  for  us,  by  confining  patients  in 
a suite  of  rooms  in  which  the  heat  is  regulated,  to  secure  immunity  from 
cold  and  change  of  air  ; but  such  a contrivance  is  most  intolerable  to 
the  patient;  the  mind  becomes  peevish,  which  in  itself  is  a powerful 
obstacle  to  the  proper  performance  of  the  digestive  functions.  But  above 
all,  the  body  is  deprived  of  exercise — that  necessary  stimulus  to  the 
appetite,  respiration,  and  other  functions.  Some  years  ago,  I succeeded 
in  confining  a consumptive  patient  to  his  room  for  an  entire  winter.  His 
spirits  suffered  greatly ; but  on  the  whole  he  supported  the  imprison- 
ment with  resolution.  Next  winter,  however,  nothing  could  induce  him 
to  remain  at  home,  and  one  day  he  rushed  out  of  the  house,  ascended 
Arthur’s  Seat,  and  w«\s  much  better  in  consequence.  Since  then  I have 
been  convinced  that,  although  by  confinement  you  may  gain  some  ad- 
vantages, on  the  whole  it  is  a prejudicial  practice  if  rigorously  carried 
out. 

What  is  required  in  these  cases  is  the  means  of  exercise,  whether  on 
foot,  on  horseback,  or  in  a carriage,  where  the  patient  is  protected  from 
cold  winds,  and  where  the  mind  can  be  amused  by  pleasant  sights  and 
cheerful  conversation.  Such  is  the  case  in  all  those  favored  localities 
considered  best  for  consumptive  people,  and  such  would  be  the  advan- 
tages derived  from  resorting  to  the  Crystal  Palace  as  a winter  garden 
and  promenade.  Delicate  individuals  could  be  transported  there  by 
means  of  a close  carriage,  in  the  worst  seasons,  without  difficulty,  and  on 
entering  it  could  breathe  for  hours  a pure,  balmy  air,  meet  their  friends, 
take  exercise  in  various  ways,  read,  work,  or  otherwise  amuse  themselves. 
Such  an  out-door  means  of  recreation,  combined  with  careful  hygienic 
regulations  at  home,  would  go  far  to  remove  many  of  the  difficulties  which 
we  have  to  encounter  in  the  ordinary  treatment  of  consumption. 

With  regard  to  diet,  it  may  be  said,  in  general  terms,  that  one  of  a 
nutritious  kind,  consisting  of  a good  proportion  of  animal  food  abound- 
ing in  fat,  is  best  adapted  for  phthisical  cases,  whilst  everything  that  in- 
duces acidity  should  be  avoided.  But,  as  previously  stated,  the  difficulty 
consists  in  causing  such  diet  to  be  taken,  on  account  of  the  bad  appetite 
and  dyspeptic  or  febrile  symptoms  which  prevail.  No  effort,  therefore, 
should  be  spared  to  overcome  the  obstacles  which  prevent  food  of  suffi- 


•748 


DISEASES  OF  THE  RESPIEATORY  SYSTEM. 


cient  quality  and  quantity  from  being  digested,  the  appropriate  means 
for  doing  which  must  vary  according  to  the  circumstances  of  the  case, 
and  will  be  treated  of  immediately.  The  strongest  stimulus  to  the  appe- 
tite, however,  is  exercise,  and  hence  the  importance  of  the  considerations 
already  entered  into,  with  reference  to  securing  what  is  essential  in  the 
treatment  of  the  disease,  namely,  good  digestion  and  proper  assimilation. 

If  the  pathology  of  pulmonary  tuberculosis  formerly  described  be 
correct,  it  indicates  what  are  the  means  best  adapted  for  preventing  as 
well  as  arresting  the  disease  when  it  has  already  commenced.  These  are, 
for  the  infant,  a healthy  nurse,  cleanliness,  and  careful  attention  to  all 
those  circumstances  which  tend  to  increase  the  bodily  vigor  and  to 
secure  good  digestion.  At  the  time  of  weaning  and  of  teething,  the 
most  watchful  care  becomes  necessary,  so  that  local  irritation  and  its 
effects  may  be  prevented  as  much  as  possible,  and  a proper  diet,  contain- 
ing a sufficient  amount  of  the  fatty  principles,  be  taken.  During  ado- 
lescence, indulgence  in  indigestible  articles  of  food  should  be  avoided, 
especially  pastry,  unripe  fruit,  salted  provisions,  and  acid  drinks,  while 
the  habit  of  eating  a certain  quant',  ty  of  fat  should  be  encouraged,  and,  if 
necessary,  rendered  imperative.  The  same  precautions,  conjoined  with 
proper  bodily  and  mental  exercise,  avoiding  exhausting  and  too  fatigu- 
ing occupations,  should  subsequently  be  maintained  until  the  predisposi- 
tion to  tubercular  disease  has  been  completely  overcome.  In  short,  every- 
thing that  can  support  and  invigorate  should  be  adopted,  and  everything 
that  can  exhaust  and  depress  should  be  shunned.  As  vitiation  of  the 
chyle  and  blood  precedes  the  local  deposition  of  a tubercular  exudation, 
it  necessarily  follows  that  the  numerous  class  of  delicate  invalids  whose 
chief  complaint  is  derangement  of  the  digestive  process,  with  languor  and 
debility,  may,  by  the  hygienic  means  now  indicated,  and  proper  treat- 
ment of  the  dyspepsia,  be  restored  to  health. 

"V\^ere  it  possible  in  all  cases  for  these  three  indications  to  be  carried 
out,  I feel  satisfied  the  cure  of  phthisis  would  be  more  frequent ; but  in 
the  treatment  of  this  disease,  the  physician  has  to  struggle  not  only  with 
the  deadly  nature  of  the  disorder,  but  with  numerous  difficulties  over 
which  he  has  no  control,  such  as,  among  the  poorer  classes,  the  impossi- 
bility of  procuring  good  diet,  and  the  thousand  imprudences  not  only 
they,  but  the  majority  of  invalids,  are  continually  committing.  Then 
another  great  difficulty  is,  to  convince  the  patient  that,  notwithstanding 
the  removal  of  his  urgent  symptoms,  the  disease  is  not  cured,  and  that 
these  will  return,  if  the  causes  which  originally  produced  them  are 
again  allowed  to  operate.  Sometimes  I have  found  it  difficult  to  keep 
hospital  patients  in  the  house  when  they  are  doing  well,  at  other  times 
they  are  sent  out  in  accordance  with  certain  regulations,  which  oblige 
the  admission  of  more  acute  cases.  This  was  the  case  with  Barclay. 
(Case  CLVIII.)  So  long  as  he  was  under  treatment,  or  rather  enjoyed 
the  comforts  and  good  diet  of  the  Infirmary,  so  long  was  he  well.  But 
sent  out,  exposed  to  misery,  to  insufficient  food,  and  work,  he  became 
worse.  Lastly,  the  attempt  to  relieve  distressing  symptoms  interferes 
much  more  than  is  generally  supposed  with  the  curative  treatment.  This 
leads  me  to  speak  of  the 


PHTHISIS  PULMONALIS. 


749 


III. — Special  Treatment  of  Phthisis  Puhnonalis. 

Under  the  head  of  General  Treatment  of  Phthisis  Pulnionalis,  I 
have  pointed  out  the  means  of  meeting  the  three  indications  which  should 
never  be  lost  sight  of  in  this  disease.  But  every  case  requires  a special 
treatment  in  addition,  which  will  depend  on  the  unusual  severity  of  this 
or  that  symptom,  or  the  existence  of  peculiar  complications.  It  is  to 
the  undue  importance  given  to  this  special,  as  distinguished  from  the 
general  treatment,  that  I attribute  much  of  that  want  of  success  experi- 
enced by  practitioners.  Thus  it  is  by  no  means  uncommon  to  meet  with 
patients  who  are  taking  at  the  same  time  a mixture  containing  squills 
and  ipecacuanha  to  relieve  the  cough;  an  anodyne  draught  to  cause 
sleep  and  diminish  irritability ; a mixture  containing  catechu,  gallic 
acid,  tannin,  or  other  astringents,  to  check  diarrhoea;  acetate  of  lead  and 
opium  pills  to  diminish  haemoptysis ; sulphuric  acid  drops  to  relieve  the 
sweating ; and  cod-liver  oil  in  addition.  I have  seen  many  persons  tak- 
ing all  these  medicines  and  several  others  at  one  time,  with  a mass  of 
bottles  and  boxes  at  the  bedside  sufficient  to  furnish  an  apothecary’s 
shop,  without  its  ever  suggesting  itself  apparently  to  the  practitioner,  that 
the  stomach  drenched  with  so  many  nauseating  things  is  thereby  pre- 
vented from  performing  its  healthy  functions.  In  many  cases  there  can 
be  little  doubt  that  this  treaGment  of  symptoms,  with  a view  to  their 
palliation,  whilst  it  destroys  all  hope  of  cure,  ultimately  fails  even  to 
relieve  the  particular  functional  derangement  to  which  it  is  directed. 
Still  these  symptoms  require  attention;  but  their  causes,  and  the  means 
required  for  their  relief,  will  be  best  understood  by  speaking  of  each  in 
succession. 

Cough  and  Expectoration. — At  first  the  cough  in  phthisis  is  dry  and 
hacking.  When  tubercle  softens  or  bronchitis  is  present,  it  becomes 
moist  and  more  prolonged.  When  excavations  exist,  it  is  hollow  and 
reverberating.  In  every  case  cough  is  a spasmodic  action,  occasioned  by 
exciting  the  branches  of  the  pneumogastric  nerves,  and  causing  simulta- 
neous reflex  movements  in  the  bronchial  tubes  and  muscles  of  the  chest. 
The  expectoration  following  dry  cough  is  at  first  scanty  and  muco- 
purulent, and  afterwards  copious  and  purulent.  When  it  assumes  the 
nummular  form — that  is,  occurs  in  viscid  rounded  masses,  swimming  in 
a fluid  clear  mucus — it  is  generally  brought  up  from  pulmonary  exca- 
vations. The  accumulation  of  the  sputum  in  the  bronchial  tubes  is  an 
exciter  of  cough  ; and  hence  the  latter  symptom  is  often  best  combated 
by  those  means  which  diminish  the  amount  of  sputum.  When,  on  the 
other  hand,  the  cough  is  dry,  those  remedies  should  be  used  which 
diminish  the  sensibility  of  the  nerves.  In  the  first  case,  the  amount  of 
mucus  and  pus  formed  will  materially  depend  on  the  weakness  of  the 
body,  and  the  onward  progress  of  the  tubercle.  Hence  good  nourish- 
ment and  attention  to  the  digestive  functions  are  the  best  means  of  check- 
ing bith  the  cough  and  the  expectoration;  whereas  giving  nauseating 
mixtures  of  ipecacuanha  and  squills  is  perhaps  the  worst  treatment  that 
can  be  employed.  There  is  no  point  which  experience  has  rendered  me 
more  certain  of  than  that,  however  these  symptoms  may  be  palliated  by 
cough  and  anodyne  remedies,  the  stomach  is  thereby  rendered  intolerant 


750 


DISEASES  OF  THE  EESPIEATORY  SYSTEM. 


of  food,  and  the  curative  tendency  of  the  disease  is  impeded.  On  the 
other  hand,  nothing  is  more  remarkable  than  the  spontaneous  cessation 
of  the  cough  and  expectoration  on  the  restoration  of  the  digestive  func- 
tions and  improvement  in  nutrition.  When  the  cough  is  dry,  as  may 
occur  in  the  first  stage,  with  crude  tubercle,  and  in  the  last  stage,  with 
dry  cavities,  counter-irritation  is  the  best  remedy,  employed  in  various 
forms.  Opium  may  relieve,  but  it  never  cures.  The  occasional  use  of 
the  sponge  saturated  in  a solution  of  nitrate  of  silver,  is  frequently  of 
the  greatest  service.  (See  Laryngitis.) 

Loss  of  Appetite. — This  is  the  most  constant  and  important  symptom 
of  phthisis,  inasmuch  as  it  interferes  more  than  any  other  with  the 
nutritive  processes.  If  food,  or  the  analeptic,  cod-liver  oil,  cannot  be 
taken  and  digested,  it  is  vain  to  hope  for  amelioration  in  any  of  the 
essential  symptoms  of  the  disease.  Hence  we  should  avoid  a mistake 
into  which  the  inexperienced  are  very  liable  to  fall.  Nothing  is  more 
common  than  for  phthisical  patients  to  tell  their  medical  attendams 
that  their  appetite  is  good,  and  that  they  eat  plentifully,  when  more 
careful  inquiry  proves  that  the  consumption  of  food  is  altogether  inade- 
quate, and  that  they  loathe  every  kind  of  animal  diet.  In  the  same 
manner,  they  say  they  are  quite  well,  or  better,  when  they  are  evidently 
sinking.  We  should  never  be  satisfied  with  general  statements,  but 
determine  the  kind  and  amount  of  food  taken,  when  sufficient  proof 
will  be  discovered,  in  the  vast  majority  of  cases,  of  the  derangement, 
formerly  alluded  to,  of  the  appetite  and  digestive  powders.  V ery  com- 
monly also,  there  will  be  acid  and  other  unpleasant  tastes  in  the  mouth. 
In  all  such  cases,  especially  if  too  much  medicine  has  been  already  given, 
the  stomach  should  be  allowed  to  repose  itself  before  anything  be  ad- 
ministered, even  cod-liver  oil.  Sweet  milk,  with  toasted  bread,  and 
small  portions  of  meat  nicely  cooked,  so  as  to  tempt  the  capricious  ap- 
petite, should  be  tried.  Then  ten  drops  of  the  Sp.  Ammon.  Aromat., 
given  every  four  hours  in  a wine-glassful  of  some  bitter  infusion,  such  as 
that  of  Calumba  or  Gentian,  with  a little  Tr.  Aurantii,  Tr.  Cardamomi, 
or  other  carminative.  In  this  way  the  stomach  often  regains  its  tone, 
food  is  taken  better,  and  then  cod-liver  oil  may  be  tried,  first  in  tea- 
spoonful doses,  cautiously  incre.ased.  Sh-.uld  this  plan  succeed,  amelio- 
ration in  the  symptoms  will  be  almost  certainly  observed. 

Nausea  ayid  Vomiting. — Not  untrequently  the  stomach  is  still  more 
deranged  ; there  is  a feeling  of  nausea  and  even  vomiting  on  taking  food. 
In  the  latter  stages  of  phthisis,  vomiting  is  also  sometimes  occasioned 
by  violence  of  the  cough,  and  the  propagation  of  reflex  actions,  by 
means  of  the  par  vagum,  to  the  stomach.  In  the  former  case,  the 
sickness  is  to  be  alleviated  by  carefully  avoiding  all  those  substances 
wdiich  are  likely  to  occasion  a nauseating  eficct,  by  not  overloading  the 
stomach,  but  allowing  it  to  have  repo-se.  In  cases  where  too  much 
medicine  has  been  administered,  a suspension  of  all  medicaments  for  a 
few  days  will  frequently  enable  the  practitioner  to  introduce  nourish- 
ment cautiously  with  the  best  effect.  I have  found  tie  following 
mixture  very  effectual  in  checking  the  vomiting  in  phthisis:  NaphtluB 

J^fedicinalis  3j>;  Tr.  Cardamomi  comp  3j;  Mist.  CamphorcE  1 vij. 
M.  ft.  mist.  Of  which  a sixth  part  may  be  taken  every  four  hours. 


PHTHISIS  PULMONALIS. 


151 


When  it  depends  on  the  cough,  those  remedies  advised  for  that  symptom 
should  be  given.  I have  tried  emetics  for  the  relief  of  nausea  and 
vomiting,  but  with  no  good  result. 

Dlarrhcea. — This  is  a very  common  symptom  throughout  the  whole 
progress  of  phthisis,  at  first  depending  on  the  excess  of  acidity  in  the 
alimentary  canal,  to  which  we  have  alluded,  but  in  advanced  cases  con- 
nected with  tubercular  deposits  and  ulceration  in  the  intestinal  gland. 
The  best  method  of  checking  this  troublesome  symptom  is  by  improving 
the  quality  and  amount  of  the  food.  The  moment  the  digestive  pro- 
cesses are  renovated,  this,  with  the  other  functional  derangements  of 
the  alimentary  canal,  will  disappear.  Hence  at  an  early  period  we  should 
avoid  large  doses  of  opium,  gallic  acid,  tannin,  and  other  powerful 
astringents,  and  depend  upon  the  mildest  remedies  of  this  class,  such  as 
chalk  with  aromatic  confection,  or  an  antacid,  such  as  a few  grains 
of  carbonate  of  potash.  When,  on  the  other  hand,  in  advanced 
phthisis,  continued  diarrhoea  appears,  and  is  obstinate  under  such  treat- 
ment, then  it  may  be  presumed  that  tubercular  disease  of  the  intestine 
is  present,  and  the  stronger  astringents  with  opium  may  be  given  as 
palliatives. 

Ucemoptysis. — This  symptom  sometimes  appears  suddenly  in  indivi- 
duals in  whom  there  has  been  no  previous  suspicion  of  phthisis,  and  in 
whom,  on  careful  examination,  no  physical  signs  of  the  disease  can  be 
detected.  On  other  occasions,  the  sputum  may  be  more  or  less  streaked 
with  blood ; and  lastly,  it  may  occur  in  the  advanced  stage  of  the  dis- 
ease, apparently  from  ulceration  of  a tolerably  large  vessel.  In  all  these 
cases  the  best  remedy  is  perfect  quietude,  and  avoidance  of  every  kind  of 
excitement,  bodily  and  mental.  Astringents  have  been  recommended, 
especially  acetate  of  lead  and  opium ; but  how  these  remedies  can 
operate,  I am  at  a loss  to  understand ; and  I have  never  seen  a case  in 
which  their  administration  was  unequivocally  useful.  I have  now  met 
with  several  cases  where  supposed  pulmonary  haemorrhage  really  origi- 
nated in  follicular  disease  of  the  pharynx  or  larynx,  and  with  the  sup- 
posed phthisical  symptoms,  was  removed  by  the  use  of  the  probang  and 
nitrate  of  silver  solution. 

Sweating  I regard  as  a symptom  of  weakness,  and  therefore  as  a com- 
mon, though  by  no  means  a special  one  in  phthisis.  Here,  again,  the 
truly  curative  treatment  will  consist  in  renovating  the  nutritive  pro- 
cesses, and  adding  strength  to  the  economy.  It  will  always  be  observed 
that,  if  cod-liver  oil  and  good  diet  produce  their  beneficial  efiect,  the 
sweating,  together  with  the  cough  and  expectoration,  ceases.  On  the 
other  hand,  giving  acid  drops  to  relieve  this  symptom,  as  is  the  common 
practice,  by  adding  to  the  already  acid  state  of  the  alimentary  canal,  is 
directly  opposed  to  the  digestion  of  the  fatty  principles,  which  require 
assimilation. 

It  should  not  be  forgotten  that  consumptive  patients,  and  all  those 
suffering  from  pulmonary  diseases,  are  especially  sensitive  to  cold.  The 
impeded  transpiration  from  the  lungs  in  such  cases,  is  counterbalanced 
by  increased  action  of  the  skin,  which  becomes  unusually  liable  to  the 
influence  of  diminished  temperature.  Again,  cold  applied  to  the  surface 
immediately  produces,  by  reflex  action,  spasmodic  cough  and  excitation 


V52 


DISEASES  OF  THE  KESPIKATORT  SYSTEM. 


of  the  lungs.  Every  observant  person  must  have  noticed  how  cough  is 
induced  by  crossing  a lobby,  going  out  into  the  open  air,  a draught  of 
wind  entering  the  room,  getting  into  a cold  bed,  etc.  etc.  The  mere 
exposure  of  the  face  to  the  air  on  a cold  day,  takes  away  the  breath, 
induces  cough,  and  obliges  the  patient  instinctively  to  muffle  up  the 
mouth.  The  numerous  precautions,  therefore,  that  ought  to  be  taken  by 
the  phthisical  individual,  should  be  pointed  out,  especially  the  necessity 
of  warm  clothing,  to  which  large  additions  should  be  made  on  going 
out  into  the  air.  Thus,  covering  the  lower  part  of  the  face  is  important 
as  a means  of  extra  clothing,  and  not  as  a means  of  breathing  warm  air, 
as  the  favorers  of  respirators  imagine.  The  patient  should  always  sit 
with  his  back  to  the  horse  or  to  a steam-engine,  and  if  by  accident  his 
shoes  or  clothes  become  wet,  they  should  be  changed  as  soon  as  possible. 
In  the  house,  ladies  should  have  a shawl  near  them,  to  put  on  in  going 
from  one  room  to  another,  in  descending  a stair  to  dinner,  etc.  By  at- 
tention to  these  minutiae,  much  suffering  and  cough  may  be  avoided. 

Febrile  Symptoms. — The  quick  pulse,  general  excitement,  loss  of 
appetite,  and  thirst,  which  are  so  common  in  the  progress  of  phthisical 
cases,  are' dependent  on  the  same  causes  as  those  which  induce  sympto- 
matic fever  in  general.  Vascular  distention,  resulting  in  exudation  and 
its  absorption,  is  proceeding  with  greater  or  less  intensity  in  the  lungs, 
and  frequently  in  other  organs.  This  leads  to  nervous  irritation  and 
increase  of  fibrin  in  the  blood,  accompanied  by  febrile  phenomena.  The 
intensity  of  these  is  always  in  proportion  to  the  activity  ot  local  disease, 
or  to  the  amount  of  secondary  absorption  going  on  from  the  tissues,  or 
from  morbid  deposits.  Nothing  is  more  common  than  attacks  of  so- 
called  local  inflammations  in  phthisis,  and  the  careful  physician  may 
often  determine  by  physical  signs  the  supervention  of  pleurisy,  pneu- 
monia, or  bronchitis,  on  the  previously  observed  lesion,  and  not  unfre- 
quently  laryngitis,  enteritis,  or  other  disorders.  In  such  cases,  nature 
herself  dictates  that  the  analeptic  treatment,  otherwise  appropriate,  is  no 
longer  applicable — food  disgusts,  and  fluids  are  eagerly  demanded. 
Under  these  circumstances,  it  has  been  common  to  apply  leeches  to  the 
inflamed  part,  and  extract  blood  by  cupping,  measures  which  undoubtedly 
cause  temporary  relief,  but  which  are  wholly  opposed  to  the  plan  of  gen- 
eral treatment  formerly  recommended,  and  to  what  we  know  of  the  patho- 
logy of  the  disease.  Every  attack  of  febrile  excitement  is  followed  by 
a corresponding  collapse,  and  it  should  never  be  forgotten  that,  in  a dis- 
ease which  is  essentially  one  of  weakness,  the  patient’s  strength  should  be 
husbanded  as  much  as  possible.  Hence  the  treatment  I depend  on  in 
such  circumstances  consists  of  at  first  the  internal  administration  of  the 
neutral  salts,  especially  of  tartar  emetic  in  small  doses,  combined  with 
diuretics,  in  order  to  favor  crisis  by  the  urine.  Subsequently  quinine 
is  undoubtedly  advantageous.  I have  satisfied  myself  that  such 
attacks  are  not  to  be  cut  short  by  leeches  or  cupping,  and  although  in 
many  cases,  as  previously  stated,  temporary  relief  is  produced,  the  ex- 
posure of  the  person,  and  unpleasant  character  of  the  applications,  the 
trickling  of  blood,  and  wet  sponges,  as  often  irritate,  and  give  rise  to 
unnecessary  risk.  Still  there  are  cases  where  topical  blood-letting,  if  it 
cannot  be  shown  to  have  advanced  the  cure,  cannot  be  proved  to  have 


PHTHISIS  PULMONALIS. 


753 


done  harm ; but  these  cases,  as  far  as  my  observation  goes,  are  very  few 
in  number.  In  the  rapidly  febrile  cases,  or  the  so-called  instances  of 
acute  phthisis,  mercury  has  been  recommended  ; but  I have  never  seen 
it  produce  the  slightest  benefit. 

Debility. — This  is  a very  common  symptom  of  phthisis  from  the 
first,  and  frequently  leads  the  patient  into  indolence  both  ot  mind  and 
body,  a condition  very  unfavorable  for  the  nutritive  functions,  upon 
the  successful  accomplishment  of  which  its  remoral  depends.  It  is  to 
remove  the  weakness  that  tonics  have  been  administered,  but  I have 
never  seen  quinine,  bitter  infusions,  or  even  chalybeates,  of  much 
service  alone,  while  the  continual  use  of  nauseous  medicine  disgusts 
the  patient,  and  interferes  with  the  functions  of  the  stomach.  Here 
again  the  great  indication  is  to  remove  the  dyspeptic  symptoms,  give 
cod-liver  oil,  an  animal  diet,  and  improve  the  appetite  by  gentle  exercise 
and  change  of  scene.  Should  the  practitioner  succeed  in  renovating  the 
nutritive  functions,  it  is  often  surprising  how  the  strength  increases,  in 
itself  a sufficient  proof  as  to  what  ought  to  be  the  method  of  removing 
the  debility.  I have  frequently  seen  patients  who  have  been  so  weak 
that  they  could  not  sit  up  in  bed  without  assistance,  so  strengthened  by 
the  analeptic  treatment,  that  they  have  subsequently  walked  about  and 
taken  horse-exercise  without  fatigue,  and  this  after  all  the  vegetable, 
mineral,  and  acid  tonics  had  been  tried  in  vain. 

Despondency  and  Anxiety. — It  is  impossible  for  the  careful  practitioner 
to  avoid  noticing  the  injurious  influence  of  depressing  mental  emotions 
on  the  progress  of  phthisis.  Indeed  the  worst  cases  are  those  of  indi- 
viduals with  mild,  placid,  and  unimpassioned  characters,  who  give  way 
to  the  feelings  of  languor  and  debility  which  oppress  them.  Such  per- 
sons are  most  amiable  patients — they  give  no  trouble — anything  will  do 
for  them — they  resign  themselves  to  circumstances,  and  state  that  they 
are  eating  well  and  getting  better  up  to  the  last.  These  are  cases  of  bad 
augury,  for  it  is  exceedingly  difficult  to  inspire  them  with  sufficient 
energy  to  take  exercise,  or  to  carry  out  those  regulations  which  are  abso- 
lutely essential  to  renovate  the  appetite  and  the  nutritive  functions. 
Such  persons  are  benefited  by  slow  travelling,  cheerful  society,  and 
everything  that  can  elevate  the  spirits,  and,  insensibly  to  themselves, 
communicate  a stimulant  to  the  mental  and  bodily  powers.  Anxiety, 
on  the  other  hand,  though  it  may  sometimes  depress  and  interfere  with 
the  digestive  functions,  is  often  a most  useful  adjunct  to  the  physician. 
Those  who  experience  it  are  most  careful  of  their  health,  sometimes 
indeed  too  much  so,  but  if  once  satisfied  of  the  benefit  of  any  particular 
line  of  treatment,  they  pursue  it  with  energy.  These  are  cases  of  good 
augury,  and  most  of  the  permanent  cures  I have  witnessed  have  been  in 
such  persons — medical  men,  and  others  acquainted  with  the  nature  of 
their  disease,  who  have  exhibited  resolution,  and  a noble  fortitude,  and 
have  bravely  struggled  against  local  pain,  general  debility,  and  nervous 
fear.* 


* For  numerous  other  facta  and  observations  connected  with  the  pathology  and 
treatment  of  phthisis,  see  the  Author’s  work  on  Pulmonary  Consumption,  8vo,  2d 
edition.  Edinburgh. 

48 


754 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


CANCER  OF  THE  LUNG. 

Case  CLXIII.* — Cancer  of  the  Lung,  Thyroid  Body,  and  Lymphatic 
Glands  of  the  Nech — Bro7ichitis — Leucoeythemia. 

History. — Margaret  Stewart,  a cook,  aet.  60 — admitted  into  the  clinical  ward 
July  16,  1851.  For  some  years  back  she  has  been  subject  to  a short  dry  cough,  which 
has  never  been  troublesome  except  after  cooking  a larger  dinner  than  usual.  With 
the  exception  of  an  attack  of  diarrhoea  when  the  cholera  was  prevalent,  she  has  been 
more  or  less  constipated.  Has  never  suffered  from  epistaxis  or  other  form  of 
haemorrhage.  Four  weeks  ago  she  first  perceived  a swelling  in  the  neck,  wliich,  com- 
mencing in  front,  has  gradually  spread  towards  the  right  side.  Latterly  her  breathing 
has  become  short  and  hurried ; her  strength  has  decreased  ; and  the  cough  has  been 
accompanied  by  considerable  expectoration. 

Symptoms  on  Admission. — On  admission,  the  neck  presents  a prominent  indurated 
swelling  anteriorly,  measuring  about  four  inches  in  diameter,  evidently  owing  to  en- 
largement of  the  thyroid  body.  A chain  of  enlarged  glands  extends  from  the  anterior 
swelling  round  the  right  side  of  the  neck,  a little  beyond  the  ear.  She  complains  of 
great  weakness,  constant  sweating  at  night,  and  cough  with  copious  frothy  expectora- 
tion. The  chest  is  everywhere  resonant  on  percussion.  There  are  loud  sonorous 
and  moist  rales  heard  over  the  whole  chest,  especially  posteriorly  and  infei  iorly.  The 
vocal  resonance  is  also  unusually  loud,  but  equal  on  both  sides.  The  tongue  is  furred, 
dark  brown  in  the  centre ; deglutition  is  difficult,  apparently  from  pressure  of  the 
enlarged  cervical  glands.  The  appetite  is  bad,  with  an  acid  taste  in  the  mouth. 
Other  functions  properly  performed. 

Progress  of  the  Case. — She  continued  in  this  condition  for  several  days,  during 
M'hich  iodine  and  counter-irritants  were  applied  to  the  neck,  and  expectorants  and 
antispasmodics  taken  internally  to  relieve  the  cough.  The  dyspnoea,  however,  gradually 
increased;  deglutition  became  more  difficult,  and  her  strength  diminished.  On  the 
ZQth  of  July  the  urine  was  ascertained  to  contain  albumen,  which  had  previously  not 
existed.  She  died  without  a struggle,  August  ^th. 

Sectio  Cadaveris. — Forty  hours  after  Death. 

Neck. — On  dissecting  the  integuments  from  the  neck  on  the  right  side,  a con- 
siderable number  of  glands,  about  the  size  of  a barley-corn  and  small  pea,  were 
observed  in  clusters  between  the  platysma  myoides  and  sterno-mastoid  muscle.  A 
hard  tumor  existed  in  front  of  the  neck,  stretching  along  the  whole  front  of  the 
trachea,  and  over  the  great  vessels  on  either  side  beneath  the  sterno-mastoid  muscles, 
and  posteriorly  on  the  right  side,  as  far  back  as  the  transverse  processes  of  the  ver- 
tebrae, and  down  beneath  the  clavicle  to  the  anterior  surface  of  the  first  rib,  where 
it  was  firmly  adherent  to  the  periosteum.  A prolongation  of  the  tumor,  about  the 
size  of  two  walnuts,  passed  beneath  the  sternum  at  its  upper  end,  being  attached  to 
its  periosteum.  This  prolongation  on  section  presented  the  outline  of  a congeries  of 
enlarged  lymphatic  glands,  having  a white  appearance,  in  some  places  soft,  and  even 
diffluent,  and  yielding  on  pressure  a copious  milky  cancerous  juice. 

Thorax. — There  were  lax  adhesions  at  various  points  on  the  pleurte  on  both  sides. 
The  pleural  cavities  contained  a little  fluid  on  the  right  side,  amounting  to  about  five 
ounces.  At  the  lower  part  of  the  left  lung,  and  also  at  the  back  part  of  right  lung, 
there  was  a small  amount  of  recent  membranous  exudation.  A multitude  of  small 
cancerous  nodules  were  scattered  throughout  the  vdiole  of  both  lungs.  Some  were 
immediately  below  the  pleurae,  and  some  in  the  substance  of  the  organs.  For  the 
most  part  these  masses  were  scattered  pretty  equally,  being  as  numerous  at  the  base  as 
at  the  apex,  and  varying  from  the  size  of  a millet-seed  to  that  of  a small  walnut. 
Some  were  of  firm  consistence,  and  others  soft  and  friable,  presenting  various  degrees 
of  induration.  They  all  on  pressure  yielded  a copious  milky  juice.  The  mucous 
membrane  of  the  bronchi  was  of  a mahogany  color,  and  the  tubes  were  more  or  less 
filled  with  muco-purulont  matter. 

Abdomen. — Abdominal  organs  healthy. 

Microscopic  Examination. — The  cancerous  juice  squeezed  from  the  cervical 
glands,  and  the  nodules  scattered  throughout  the  lungs,  contained  numerous  cancer 
cells,  which  it  is  unnecessary  to  describe  minutely  here.  (See  p.  139.)  Associated 


* Reported  by  Mr.  D.  0.  Hoile,  Clinical  Clerk. 


CAXCER  OF  THE  LUNG. 


7o3 


s? 


with  these  were  a considerable  number  of  round  colorless  corpuscles,  varying  in 
diameter  from  the  150th  to  the  100th  of  a millimetre  in  diameter.  An  unusual 
number  of  these  cells  also  existed  » -o^ 

in  the  blood,  as  was  determined  f 
both  before  and  after  death  (See 
Leucocythemia).  ^ ""o* 

:l- :■  frp- 


-;(e 


•••  ^ 


Commentary. — In  tlio 

case  before  us,  the  che^'t 
was  frequently  examined 
with  great  care,  and  was 
ascertained  to  be  every- 
where resonant  on  per-  Figrics.  Fig.  464. 

cussion.  Loud  sonorous  and  moist  rales  were  heard  on  both  sides, 
especially  posteriorly  and  inferiorly.  Hence  there  were  all  the  signs  of 
bronchitis,  which  was  f)und  afterwards  to  exist;  but  there  was  associated 
with  them  unusually  loud  vocal  resonance,  equal  on  both  sides.  It 
occurred  to  me  at  the  time  that  this  latter  sign  was  merely  indicative  of 
diminished  volume  in  the  lungs,  but,  after  the  dissection,  it  became 
manifest  that  it  was  owing  to  increased  density  of  the  organs,  from  the 
disseminated  cancerous  nodules.  Whether  the  conjoined  signs  of  aug- 
mented or  unusual  resonance  of  the  lungs,  bronchitis  and  increased  vocal 
resonance,  will  prove  diagnostic  in  such  cases,  further  experience  only 
can  determine.  Doubtless  it  will  be  always  difficult  to  separate  such 
signs,  dependent  on  nodular  cancer,  from  those  connected  with  collapse 
of  the  lung,  which  is  so  common  a result  of  chronic  bronchitis.  In  the 
present  case  I was  in  great  doubt,  notwithstanding  my  acquaintance  with 
the  valuable  sign  of  tumor  in  the  neck,  as  pointed  out  by  Dr.  Kilgour 
of  Aberdeen.'^ 

The  treatment,  it  must  be  obvious,  could  only  be  palliative. 


Cancer  of  the  lung  may  occur  in  two  distinct  forms, — 1st,  That  of 
disseminated  nodules ; 2d,  That  of  infiltrated  masses.  In  the  former 
case  there  are  no  physical  signs,  or  functional  symptoms,  which  indicate 
the  presence  of  cancer ; in  tlie  latter  there  are  unusual  dulness,  and  re- 
sistance on  percussion,  increased  vocal  resonance  and  tubular  breathing, 
or  diminished  respiration,  according  to  the  density,  position,  and  extent 
of  the  cancerous  infiltration.  If  with  these  signs  there  be  indications  of 
the  existence  of  cancer  in  other  parts  of  the  body,  there  will  be  little 
difficulty  in  forming  the  diagnosis ; and  even  should  these  be  absent,  the 
history  of  the  case,  advanced  period  of  life,  and  the  non-existence  of 
moist  rattles  will  occasionally  be  sufficient.  It  must  be  confessed,  how- 
ever, that  notwithstanding  the  valuable  labors  of  Stokes,  Hughes, 
M‘Donnell,  Walshe,  and  Kilgour,  the  means  of  diagnosing  this  lesion 
with  certainty  are  very  defective.  In  the  present  work,  eight  other  cases 
are  recorded  in  which  cancer  of  the  lung  existed  (Case  XXX., 
* Monthly  Journal  of  Medical  Science,  June  1850. 

Fig.  463.  Corpuscles  in  cancerous  juice  squeezed  from  the  thyroid  body. 

Fig.  464.  The  same,  after  the  addition  of  acetic  acid,  showing  the  cancer  cells,  and 
those  peculiar  to  the  gland,  which  were  found  in  large  numbers  in  the  blood. 

260  diam. 


15Q 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


XXXIX.,  LIIL,  LXXIII.,  LXXIX.,  LXXXV.,  LXXXYL,  CXY.) 
lu  oue  of  these  the  pleurae  only  were  afl'ected  (Case  LXXXYI.)  With 
the  exception  of  Case  XXX IX.,  in  which  the  posterior  surface  of  the 
lungs  could  not  be  examined,  the  pulmonary  organs  were  carefully  per- 
cussed and  auscultated  in  all.  But  in  none  did  any  combination  or  suc^ 
cession  of  signs  exist  which  could  induce  any  one  to  pronounce  that 
pulmonary  cancer  was  present.  Case  LXXXY.  alone  presented  the 
gelatinous  sputum  ticged  with  blood,  or  the  currant  jelly  expectoration 
described  by  Stokes.  In  Case  LIII.  there  were  ulceration  and  gangrene 
of  the  fungoid  mass,  with  all  the  signs  of  pneumonia — and  pneumonic 
condensation  was  found  surrounding  the  epithelioma  of  the  lung  after 
death.  In  Case  LXXXIX.  there  was  thoracic  aneurism,  to  which  all 
the  physical  signs  were  attributable.  When  infiltrated  cancer  exists  to 
any  amount  in  the  apex  of  the  lungs,  associated  with  cancer  in  other  or- 
gans, or  with  an  evident  tumor  in  the  neck  or  mediastinum,  the  diagnosis 
is  comparatively  easy. 

Nothing  can  be  more  variable  than  the  minute  structure  of  cancer  in 
the  lung.  When  recent,  it  may  present  delicate  round  or  oval  cells 
(Fig.  287).  When  more  advanced  it  may  exhibit  large  compound  cells 
(Fig.  294),  as  in  case  LXXXY.  When  in  the  infiltrated  form  and 
softened  to  any  extent,  I have  seen  the  whole  reduced  to  a mass  of 
irregularly-formed  nuclei,  as  in  Fig.  348.  On  one  occasion  I found  a 
large  mass  of  bran-like  looking  cancer  of  the  lung,  somewhat  fibrous, 
and  principally  composed  of  elongated  fusiform  corpuscles. 

CARBONACEOUS  LUNGS. 

Case  CLXIY."^ — Carbonaceous  Lungs  with  Black  Expectoration. 

History. — Thomas  Wilson,  aet.  38,  collier,  from  the  Oakley  Mines,  near  Dunferm- 
line, was  admitted  into  the  clinical  ward  26th  July,  1851.  He  states  that  he  has  been 
employed  about  coal  mines  for  the  last  twenty-four  years,  during  the  principal  part  of 
which'time  he  has  been  occupied  in  blasting  rock  for  the  sinking  of  pits,  using  large 
quantities  of  gunpowder  daily.  He  is  much  exposed  to  cold  and  wet  in  this  occupa- 
tion, working  almost  constantly  with  wet  feet,  and  frequently  wdth  the  whole  of  his 
clothes  drenched.  During  the  laying  open  of  a new  surface  for  the  working  of  coal, 
he  has  often  worked  in  an  atmosphere  barely  capable  of  supporting  the  combustion  of 
the  miners’  lamps ; he  has  observed  this  particularly  when  working  iron-stone.  Not- 
withstanding, it  was  only  six  months  ago  that  he  began  to  be  troubled  with  short  dry 
cough,  and  difficulty  of  breathing.  He  continued  to  work  till  about  four  months  ago, 
when  the  cough  became  more  severe  ; he  had  much  dyspnoea,  and  frequent  profuse 
expectoration,  especially  at  night.  Two  weeks  after  this — that  is,  about  fourteen 
weeks  ago — he  was  laid  up  from  work  ; and  about  the  same  time,  while  under  treat- 
ment, he  began  to  spit  much,  and  observed  that  the  expectoration  was  of  a deep  black 
color.  The  change  was  so  sudden  as  to  alarm  him  considerably. 

Symptoms  on  Admission. — On  admission,  the  thorax  is  of  large  dimensions  and 
well  formed.  On  percussion,  there  is  slight  comparative  dulness  on  the  left  side  of 
the  chest  over  the  upper  half  in  front ; and  there  is  also  appreciable  dulness  over 
the  same  extent  on  the  same  side  posteriorly.  There  is  complete  resonance  on  the 
right  side  anteriorly  and  posteriorly.  On  auscultation,  for  some  inches  below  the  clavicle 
on  the  left  side,  the  inspiration  is  rough  and  harsh,  and  there  is  prolongation  of  the  ex- 
piration. Lower  down  on  the  same  side,  there  is  also  fine  moist  rale,  and  the 
vocal  resonance  is  somewhat  increased.  On  the  right  side  there  is  loud  pealing 

* Reported  by  Mr.  W.  Calder,  Clinical  Clerk. 


CARBONACEOUS  LUNGS. 


157 


vocal  resonance  both  anteriorly  and  posteriorly ; it  is  particularly  loud  in  front  imme- 
diately below  the  clavicle,  but  there  is  nothing  abnormal  to  be  detected  in  the  respira- 
tory sounds.  The  expansion  of  the  chest  is  equal  on  both  sides.  Breathing  is  equal 
and  unembarrassed  while  he  is  sitting  or  lying  in  bed,  but  on  using  much  exertion,  it 
becomes  short  and  difficult.  There  is  some  cough,  but  it  is  not  very  troublesome. 
States,  that  at  the  commencement  of  his  illness,  he  could  not  lie  on  his  left  side  ; but 
at  present  he  can  lie  in  any  position  without  uneasiness.  The  sputum  is  in  considera- 
ble quantity,  adheres  tenaciously  to  the  bottom  of  the  spit-box,  and  is  of  an  intense 
black  color.  On  being  placed  in  water,  a small  portion  of  a lighter  color  swims  on 
the  surface,  but  the  greater  part  sinks  immediately.  On  being  allowed  to  stand  for 
a little,  the  supernatant  water  becomes  nearly  clear,  the  dense  black  mass  remaining 
at  the  bottom  of  the  dish.  Acetic,  sulphuric,  and  nitric  acids  and  also  aq.  potassa?, 
though  boiled  with  the  sputum,  do  not  in  the  least  affect  its  color.  The  other  systems 
are  quite  normal.  Has  good  appetite  ; no  sour  or  unpleasant  taste  in  his  mouth.  Bow- 
els are  regular  at  present,  and  are  generally  so  ; has  never  had  diarrhoea.  Does  not 
sweat  at  night,  nor  unless  when  employed  at  his  work.  Pulse  during  examination  was 
88,  soft  and  full;  during  his  stay  in  the  house  has  averaged  about  76.  He  was  or- 
dered an  expectorant  mixture  ; and  during  the  last  fortnight  he  was  in  the  house,  he 
had  three  table-spoonfuls  of  cod-liver  oil  daily.  He  went  out  by  his  own  desire  in 
August,  the  symptoms  having  undergone  little  change. 

Microscopic  examination  op  the  Sputum. — On  placing  a small  portion  of  the 
sputum  below  the  microscope,  many  of  the  epithelial  cells  are  seen  loaded  with  the 
black  carbonaceous  matter.  In  some  of  them  the  nuclei  are  evident,  the  matter 
being  deposited  between  them  and  the  cell  walls  ; in  others,  the  nuclei  are  quite  con- 
cealed. In  other  parts  of  the  field  all  appearance  of  cells  is  lost,  and  nothing  but 
apparently  homogeneous  black  masses  are  visible.  Some  of  the  cells  may  also  be 
seen  ruptured,  and  the  black  contents  poured  out.  (See  Fig.  360.) 

Commentary. — The  physical  signs  existing  in  this  case  leave  us  in 
little  doubt  that  there  was  considerable  condensation  at  the  apex  of  both 
lungs.  This  was  indicated  on  one  side  by  considerable  dulness  on  per- 
cussion, and  on  the  other  by  a pealing  vocal  resonance.  It  is  true,  the 
resonance  in  this  place  was  unaccompanied  by  any  change  in  the  percus- 
sion note,  a circumstance  that  may  be  caused  by  the  existence  of  slight 
emphysema  counterbalancing  the  increased  density  of  the  pulmonary 
tissue.  The  history  of  the  man’s  case,  the  nature  of  his  employment, 
and  the  black  sputum,  at  once  indicated  to  us  that  this  condensation  was 
owing  to  accumulation  of  carbonaceous  matter  in  the  lungs,  a disease 
which  is  peculiarly  apt  to  occur  in  coal-miners,  the  moulders  in  iron  and 
copper,  and  a few  other  trades. 

Case  CLXV.* — Carhonaceous  Lungs  with  Black  Expectoration  in  a 

Female. 

History. — Christina  Nasmyth,  ast.  42,  the  wife  of  a coal-miner  residing  near  Mus" 
selburgh— admitted  21st  May,  1857.  For  nine  years  previous  to  marriage  she  worked 
in  a coal-pit,  being  engaged  in  pushing  the  trucks  along  the  tram-ways.  She  married 
at  sixteen  years  of  age,  and  has  never  since  worked  in  the  pit.  She  has  had  four  chil- 
dren, all  healthy.  Her  own  health  she  declares  to  have  been  excellent  till  January, 
1857.  About  this  time  she  noticed  a cough  accompanied  by  sputum  of  inky  lilack 
color,  and  by  sense  of  pain  over  the  breast  and  between  the  shoulders.  Her  appetite 
failed,  and  she  became  very  weak.  Latterly  her  voice  has  become  hoarse  and  broken. 
Medical  treatment  before  admission  had  not  been  effectual. 

Symptoms  on  Admission. — No  dyspnoea;  cough  is  unfrequent,  short,  and  rather 
dry ; sputum  scanty,  consisting  of  frothy  blood  with  tenacious  masses  of  bluish-l)lack 
mucus ; painful  sense  of  tightness  over  the  breast ; the  voice  is  harsh  and  broken. 
There  is  slight  dulness  under  right  clavicle,  with  creaking  sound  during  inspiration, 
prolonged  expiration,  and  some  increase  of  vocal  res  ince.  There  is  cracked-pot 
sound  under  left  clavicle,  bronchial  respiration  with  a few  moist  sounds  at  close  of  in- 

^ Keported  by  S.  de  Melho  Aserappa,  Clinical  Clerk. 


758 


DISEASES  OP  THE  EESPIKATOEY  SYSTEM. 


spiration,  and  increased  vocal  resonance;  posteriorly,  percussion  seems  unimpaired; 
no  moist  sounds  are  audible,  but  occasional  sibilant  and  snoring  sounds  during  expira- 
tion over  middle  of  both  lungs.  The  cardiac  organ  is  normal  in  position  and  size ; the 
first  sound  is  rough  at  apex  ; the  pulse  is  80,  and  of  good  strength.  Appetite  is  de- 
fective; occasional  thirst  in  the  mornings;  no  vomiting;  considerable  flatulence ; 
bowels  are  opened  generally  every  second  day  ; menstruation  regular  ; urine  1010  sp. 
gr,,  otherwise  normal. 

Progress  of  the  Case. — May  2Bd — No  trace  of  blood  in  the  sputum,  which 
consists  of  several  tenacious  masses  of  a bluish-black  color,  floating  in  a slightly  vis- 
cous mucus.  On  microscopic  examination,  there  are  seen  numerous  molecules  of  pig- 
ment occasionally  lying  free,  but  sometimes  contained  in  large  cells ; there  are  also 
visible  a few  bundles  of  fibrous  and  elastic  tissue.  Ordered  milk  and  steak  diet. 
2<6th — No  moist  sounds  are  now  audible  under  left  clavicle  ; respiration  continues  to  be 
loudly  bronchial  at  left  apex,  and  less  so,  but  still  unusually  loud  over  the  right ; 
hoarseness  of  voice  has  diminished.  27/'A. — Ordered  Emplastrum  Picis  (6  by  6)  to  he 
<i])plied  over  the  chest.  2%th. — No  change  in  respiratory  murmurs,  nor  in  sputum; 
some  dyspnoea,  and  considerable  debility.  Is  ordered  a mixture  of  sweet  spirits  of 
nitre  and  aromatic  spirits  of  ammonia.  20i?/n — The  black  masses  are  now  fewer  in 
number.  June  LsA — Hoarseness  of  voice  has  ceased  ; sputum  more  scanty,  with  fewer 
black  masses ; appetite  is  improved  ; patient  walks  daily  about  the  ward.  June  Uh. — 
Eas  continued  in  the  same  state  as  in  last  report ; is  anxious  now  to  return  to  her 
family,  and  is  accordingly  discharged  to-day  relieved. 

Commentary. — It  would  appear  from  the  account  of  this  woman, 
that  from  the  age  of  seven  to  that  of  sixteen  years,  she  worked  in  a 
coal-pit.  She  then  married,  ceased  to  work  in  the  pit,  and  continued 
healthy  for  twenty-six  years.  Then  for  the  first  time  cough  came  on 
accompanied  with  black  spit  and  disorganization  of  the  lung.  This 
circumstanee  proves  that  the  tendency  to  carbonaceous  formation  may 
be  formed  several  years  before  it  becomes  manifested  in  active  disease, 
which  may  be  induced  subsequently  by  any  of  the  ordinary  causes  which 
occasion  bronchitis  or  pneumonia.  Young  girls  are  not  now  so  much 
employed  in  coal  pits  as  formerly,  and  such  a case  as  the  above  must  be 
considered,  in  many  points  of  view,  as  one  of  great  rarity. 

From  the  circumstance  of  this  disease  being  very  common  among  the 
colliers  in  the  neigh boiFood  of  Edinburgh,  it  has  been  thoroughly 
studied  here.  In  the  first  case  that  was  recorded  by  Dr.  James  Gregory, 
the  black  matter  was  analysed  by  Dr.  Christison,  and  shown  by  him  to 
consist  of  pure  carbon  or  lamp  black,  a result  confirmed  by  every  sub- 
sequent writer.  The  papers  by  Dr.  William  Thomson,  inserted  in  the 
XX.  and  XXI.  Vols.  of  the  “ Transactions  of  the  Medico- Chirurgical 
Society  of  London,”  contain  a mass  of  important  information  concerning 
this  disease ; and  in  a series  of  communications  by  the  late  Dr.  Mac- 
kellar,  inserted  in  the  “Monthly  Journal”  for  1845,  you  will  find 
numerous  facts  and  opinions  regarding  it,  the  results  of  long  and  exten- 
sive practice  among  the  colliers  of  Haddingtonshire. 

On  examining  the  lungs  of  those  who  die  laboring  under  this 
disease,  they  are  found  to  present  a deep  black  color,  which  is  most 
intense  towards  their  apices.  On  section,  the  pulmonary  tissue  yields 
on  pressure  a copious  black  inky  juice,  which  stains  all  surrounding 
objects,  attaches  itself  to  the  inequalities  of  the  skin  of  the  hands,  and 
insinuates  itself  under  the  nails  like  fine  black  paint.  At  the  apices  of 
the  lungs,  the  pulmonary  tissue  is  generally  more  or  less  condensed,  and 
the  black  matter  thicker,  and  often  of  the  consistence  of  putty.  In 
advanced  cases,  ulcerations  and  cavities  exist,  exactly  resembling  in  all 


CARBONACEOUS  LUNGS. 


759 


their  characters  those  of  phthisis,  with  the  exception  that  no  tubercle 
can  be  discovered,  and  that  the  whole  is  of  an  intensely  black  color. 
Occasionally  black  indurated  and  gritty  masses  can  be  felt  and  dug  out, 
which  in  some  rare  cases  present  a slight  crystallized  structure,  like  coal 
or  crystallized  carbon.  The  morbid  anatomy  of  the  disease  will  be  best 
understood  by  carefully  examining  the  preparations  which  exist  in  the 
University  Museum. 

On  placing  some  of  the  black  fluid  squeezed  from  the  lung  under  a 
microscope,  and  examining  it  with  a power  of  250  diameters  linear,  it  is 
seen  to  consist  of  a multitude  of  black  molecules  of  extreme  minuteness 
floating  in  a liquid.  Here  and  there  may  be  observed  cells,  similar  to 
those  previously  described  as  existing  in  the  sputum,  more  or  less  loaded 
with  similar  molecules  of  black  matter,  on  which  the  strongest  chemical 
re-agents  produce  no  effect  whatever.  (See  Figs.  83,  84,  and  360.)  I 
have  frequently  examined  the  disease  in  all  its  stages,  and  never  found 
it  to  be  referable  to  the  changes  occurring  in  blood  after  hemorrhagic 
extravasations,  as  Virchow  supposes  to  be  the  case. 

When  we  endeavor  to  investigate  the  pathology  of  this  disorder,  we 
are  met  with  a host  of  difficulties.  Does  it  originate  from  the  inhala- 
tion of  carbonaceous  particles  floating  in  the  atmosphere,  or  is  it  the 
result  of  a secretion  of  carbon  in  the  pulmonary  system  itself? 

The  principal  fact  on  which  the  first  opinion  rests,  i§  the  frequency 
of  the  disease  in  colliers,  and  in  moulders  of  iron  and  copper.  Yet  it 
is  curious,  that  whilst  it  is  common  among  the  workmen  of  some  coal- 
pits, it  is  unknown  among  those  employed  in  others,  although  the  dust 
and  powder  is  as  finely  levigated  in  one  place  as  in  the  other. 

There  is  another  curious  fact  connected  with  the  disease  in  coal- 
miners, viz.,  that  those  engaged  in  working  at  what  is  called  the  coal 
wall,  and  in  shifting  or  transporting  the  coal,  are  little  aflected ; whilst 
those  who  work  at  the  stone  wall  are  peculiarly  liable.  This  working 
at  the  stone  wall,  consists  in  blasting  the  rock  by  means  of  gunpowder. 
Hence  the  prevalence  of  black  deposits  in  the  lungs  has  been  by  some 
not  so  much  attributed  to  the  dust  of  coal,  as  to  the  smoke  of  the  ex- 
plosions, or  of  the  lamps  carried  by  the  miners,  confined  as  it  is  in  nar- 
row passages,  where  little  ventilation  exists. 

Even  this  explanation  has  difficulties;  for  it  has  been  proved,  that 
in  some  mines,  where  blasting  is  carried  on  very  extensively,  and  where 
there  is  much  coal  dust,  it  does  not  exist  at  all ; and  hence  it  has  been 
supposed  that  there  are  some  kinds  of  stone  which  disengage  g-ases,  or 
the  working  among  which  is  much  more  deleterious  than  others.  Thus 
Mr.  Philp  of  Aberdour,  who  has  had  great  experience  in  this  disease,  in  a 
communication  he  made  to  Dr.  Thomson,  says,  “ In  workiog  at  stone 
work,  that  is,  in  sinking  pits  and  driving  mines  of  communication,  the 
workmen  are  exposed,  in  an  imminent  degree,  to  the  influence  of  the 
impure  air;  for,  besides  working  in  a confined  space,  and  in  a cul-de-sac^ 
where  the  ventilation  is  very  imperfect,  there  is  also  a considerable 
exudation  of  the  carbonic  acid  gas  from  the  fresh  cut  surfaces  of  the 
minerals.  In  this  impure  air  they  continue  to  work  for  many  hours 
daily  for  some  months,  their  operations  being  frequently  carried  on 
several  yards  in  advance  of  where  their  lamps  will  burn.”  In  another 


760 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


place,  he  says,  “ Those  pits  and  mines  which  have  been  noted  for  the 
impurity  of  the  air,  have  given  origin  to  the  greatest  number  of  cases.’’ 

Again,  Mr.  Steel  of  Craighall  says,  he  considers  the  disease  to  be 
caused  by  running  mines  in  stone,  and  working  in  impure  air.  He  also 
observes, — “ A principal  reason  is,  that  the  stone  contains  some  poison- 
ous matter,  which  is  probably  of  a metallic  nature,  as  the  workmen  com- 
plain of  it  exciting  a styptic  and  metallic  taste  in  the  mouth.  A mine 
was  carried  across  the  strata  in  the  Niddry  estate,  the  finishing  of  which 
required  a number  of  years.  Six  or  eight  of  the  miners  employed  in  it 
died;  several  were  obliged  to  leave  it,  and  only  one  of  those  who  com- 
menced it  was  able  to  work  in  it  throughout,  and  lived  to  see  it  com- 
pleted. There  was  a particular  stone  in  this  mine,  which  was  repeatedly 
met  with,  and  to  which  the  miners  gave  the  name  of  arsenic,  which  was 
found  highly  pestiferous.  Its  exact  nature  I am  not  acquainted  with. 
In  a stone  mine,  run  some  years  ago  in  the  Newbattle  field,  a great  many 
men  died, — the  average  length  of  time  each  of  the  miners  employed  in 
it  lived  being  about  two  years.  The  mortality  was  ascribed  to  the  na- 
ture of  the  stone.” 

The  facts  connected  with  this  peculiar  black  coloring  of  the  lung 
leave  it  therefore  undecided  whether  it  be  owing  to  the  inhalation  of 
coal  dust,  the  smoke  of  gunpowder  and  oil  lamps,  or  carbonic  acid  gas, 
entering  the  lung.  Is  the  powder  deposited  directly  and  primarily  in  the 
minute  tissue  of  the  organ,  or  is  the  carbon  deposited  secondarily,  and 
by  a process  of  secretion  from  the  blood  ? 

Before  we  can  answer  these  questions,  there  are  two  other  series  of 
cases,  which  it  is  necessary  to  take  into  consideration.  Persons 

have  been  known  to  have  the  black  spit,  and  black  infiltrated  appearance 
of  the  lungs,  with  caverns,  without  ever  having  been  in  a coal-mine,  or 
exposed  in  any  way  to  gunpowder  smoke.  Several  such  cases  are 
given  in  the  paper  of  I)r.  W.  Thomson.  One  of  these  is  by  Dr. 

Browne,  now  Commissioner  of  Lunacy  for  Scotland;  another  by  the 
late  Dr.  Moir  of  Musselburgh.  The  subject  of  this  last  case  was  never 
exposed  to  noxious  vapors,  unless  it  might  be  carbonic  acid^  as  he  was 
the  proprietor  of  an  extensive  brewery,  and  in  the  daily  habit  of  in- 
specting the  tun-rooms,  the  large  vats  in  which  overflow  with  that  dele- 
terious gas.  Another  case  was  observed  by  the  same  gentleman,  in  the 
person  of  a coachman,  where,  after  death,  the  lungs  were  found  to  con- 
tain collections  of  an  inky  or  tarry  fluid,  which  stained  the  fingers,  as 
if  with  soot  or  charcoal.  A fourth  and  similar  case,  in  a woman,  is  re- 
lated by  Dr.  Yeitch.  In  none  of  these  cases  were  the  individuals 
exposed  to  the  fumes  of  smoke,  or  coal  dust.  I have  myself  seen 
several  of  such  cases;  in  one  especially,  a cyst  in  the  bronchial  gland 
existed,  about  the  size  of  the  human  eye-ball,  filled  with  a black  inky 
fluid. 

2r/,  M.  Gruillot,  of  Paris,  has  brought  forward  another  series  of  cases 
in  old  persons.*  He  is  physician  to  the  hospital  for  aged  people,  and 
says  there  is  scarcely  an  individual  of  advanced  life  who  does  not  pre- 
sent the  carbonaceous  deposit  in  the  lung,  generally  most  marked  at  the 


* Archives  Generales  de  Medeciiie,  vol.  67. 


CAKBONACEOUS  LUNGS. 


761 


apex.  The  carbon  often  exists  in  crude  masses,  obliterating  the  vessels 
and  bronchial  tubes.  I have  also  seen  many  cases  of  this  kind,  and 
there  can  be  no  doubt  that  the  longer  we  live,  the  more  carbon  is  depos- 
ited in  the  lungs.  In  infants,  as  is  well  known,  these  organs  are  of  a 
light  pink  color,  and  they  become  more  gray  and  of  a deep  blue  or  black 
tint  as  life  advances. 

What  are  we  to  conclude  from  these  cases  ? The  black  matter  in  all 
of  them,  when  chemically  examined,  is  undoubtedly  free  carbon,  and  is 
distinguished  by  the  action  of  chemical  agents;  hence  it  is  not  likely  to 
be  an  alteration  of  haeinatin,  resulting  from  bloody  extravasations  into 
the  pulmonary  tissue,  as  Virchow  supposes.  It  never  presents  the 
brownish  color  or  structural  character  we  have  shown  to  be  present  in 
coal,*  a circumstance  opposed  to  its  being  derived  from  without,  in  the 
form  of  dust.  Dr.  Pearsonf  thought  that  we  are  always  insensibly 
breathing  an  air  more  or  less  loaded  with  smoke,  the  results  of  combus- 
tion, and  other  impurities ; and  that  this  of  course  accumulates  the 
older  we  get.  If  this  opinion  were  true,  it  should  be  more  common  in 
persons  who  inhabit  densely  populated  and  manufacturing  towns,  as 
London,  Liverpool,  Manchester,  or  Glasgow.  Yet  we  do  not  find  this 
to  be  the  case.  The  air  in  Paris  is  remarkably  pure,  the  fires  of  man- 
ufactories are  few,  and  yet  there,  according  to  Guillot,  it  is  common. 

On  the  other  hand,  should  we  conclude  that  it  is  formed  internally 
by  a chemical  process,  in  all  cases  ? If  so,  must  we  ascribe  it  to  the 
inhalation  of  carbonic  acid  gas,  rather  than  to  carbon  in  a minutely 
divided  state,  inspired  from  without?  In  the  present  state  of  our 
knowledge,  we  cannot  answer  these  questions  with  any  exactitude. 

Another  point  of  great  interest  is  the  apparent  antagonism  of  carbo- 
naceous deposits  with  tubercle. 

We  frequently  find  the  black  lungs  of  colliers  to  contain  small  or 
large  ulcerated  cavities,  with  bands  crossing  them;  but  we  rarely  find 
tubercle.  In  one  or  two  cases  chronic  tubercle  has  been  found ; but  it 
does  not  appear  that  the  caverns  filled  with  black  matter  in  the  miner 
are  owing  to  tubercle.  Such  is  the  analogy,  however,  existing  between 
these  cavities,  and  the  syms  ptomthey  occasion,  that  the  disease  has  been 
named  “ black  phthisis  ” by  several  persons.  Some  have  supposed  that 
tubercular  phthisis  is  first  set  up,  and  that  the  carbonaceous  deposit  is 
then  insinuated  among  the  textures  and  ulcerations.  By  others,  and 
especially  by  the  late  Dr.  Mackellar,  it  is  maintained  that  there  is  never 
tubercle  in  these  cases,  and  that  ulceration  is  entirely  owing  to  the  accu- 
mulation of  masses  of  carbon  which  are  expectorated.  I have  carefully 
examined  several  lungs  in  various  stages  of  the  disease,  but  have  never 
been  able  to  satisfy  myself  of  the  existence  of  tubercle.  The  difficulty 
of  the  investigation,  however,  is  very  great,  for  it  is  probable  that,  did  a 
tubercular  exudation  exist,  it  would  be  so  impregnated  with  the  carbo- 
naceous matter,  as  not  to  be  recognisable  even  under  high  powers.  On 
the  other  hand,  the  bronchial  tubes  are  frequently  loaded  with  purulent 
matter  of  the  usual  appearance,  but  which,  instead  of  presenting  pus- 

* See  the  Author’s  paper  on  the  structure  of  various  kinds  of  coal.  Transactions 
of  the  Royal  Society  of  Edinburgh,  vol.  xxi.  part  I. 

f Philosophical  Transactions,  1853. 


762 


DISEASES  OF  THE  RESPIRATORY  SYSTE]H. 


corpuscles,  is  loaded  with  particles  closely  resembling  those  found  in 
softened  tubercle. 

Guiliot  has  alluded  to  the  well-known  fact,  that  in  old  persons  who 
present  traces  of  tubercle,  the  cretaceous  concretions  are  always  sur- 
rounded by  black  matter.  He  thinks  that  the  carbonaceous  deposit 
compresses  the  capillaries  which  immediately  surround  the  tubercle,  pre- 
vents its  further  exudation,  and  so  induces  cure.  But  this  is  by  no 
means  invariable.  Still  it  is  an  undoubted  fact,  that  the  black  matter, 
like  tubercle,  always  exists  in  greatest  proportion  at  the  apex  of  the 
lung,  and  the  rarity  of  recent  tubercle  in  combination  with  it,  leads  us 
to  suppose  that  it  exerts  a peculiar  influence  on  tubercular  deposits.  I 
have  also  seen  black  matter  surrounding  tubercle  of  the  peritoneum,  but 
in  this  situation  it  has  not  been  free  carbon,  for  long  immersion  in  spirit 
has  caused  the  disappearance  of  all  color.  (See  Fig.  353.) 

So  far  as  my  observations  have  yet  carried  me,  no  difference  is  to  be 
determined  structurally  between  the  pigment  of  melanosis  and  that  of 
the  disease  under  consideration.  Some  cells  spit  up  by  the  miner,  con- 
taining black  granules,  exactly  resemble  those  in  melanic  cancer.  (Com- 
pare Figs.  359  and  3G0.)  On  the  other  hand,  there  is  a marked  differ- 
ence in  the  chemical  constitution ; as  in  the  one,  the  black  pigment, 
whatever  be  its  nature,  is  fugitive,  and  removable  by  mineral  acids ; in 
the  other,  fixed,  and  unchanged  even  under  the  blow-pipe.  Hence 
all  black  deposits  may  be  divided  into  two  classes ; to  distinguish 
which  we  may  call  one  class  by  the  name  it  has  so  long  borne,  viz., 
“ melanotic^''  and  the  other,  from  its  chemical  composition,  “ carhona- 
ceous^ 

With  regard  to  the  treatment  of  individual  cases  of  black  phthisis, 
there  is  little  to  bo  said.  The  disease,  once  established,  does  not  admit 
of  cure  by  art;  and  it  is  a curious  fact,  that  a man  may  work  in  a coal 
mine  for  many  years  without  the  black  spit ; but  when  it  comes  on,  even 
should  he  leave  the  mine  immediately,  he  will  continue  to  expectorate 
carbonaceous  matter  for  a long  time  afterwards.  Of  this  both  the  cases 
before  us  are  corroborative,  and  the  circumstance  is  one  which  consti- 
tutes a strong  argument  in  favor  of  those  who  contend  for  the  disease 
being  dependent  upon  a secretion  rather  than  a mechanical  deposition  of 
carbon.  A palliative  treatment,  guided  by  the  nature  of  the  symptoms 
and  strength  of  the  constitution,  is  all  that  is  admissible.  The  only 
means  of  preventing  the  disease  seems  to  consist  in  ventilating  the  mines 
where  colliers  work,  or  adopting  the  means  of  carrying  off  the  fumes  to 
which  the  moulders  of  iron  and  copper  are  exposed.  Such  prophylactic 
measures  are  equally  called  for,  whatever  theory  of  the  nature  of  the 
disorder  shall  ultimately  be  proved  to  be  correct. 


SECTION  VIII. 


DISEASES  OE  THE  GEHITO-URINART  SYSTEM. 

In  no  department  of  medicine  has  our  knowledge  of  the  diagnosis  and 
treatment  of  disease  made  more  rapid  progress  in  recent  times  than  in 
that  relating  to  disorders  of  the  genito-uriiiary  system.  Notwithstand- 
ing what  has  been  very  justly  said  as  to  the  impropriety  and  frequent 
danger  of  unnecessary  mechanical  exploration  of  the  uterine  passages 
with  instruments,  it  cannot  be  denied  that,  used  with  judgment  and  dis- 
cretion, they  have  materially  contributed  to  a recognition  and  successful 
treatment  of  lesions  that  would  otherwise  have  been  unknown  or  mis- 
understood. The  use  of  the  microscope  in  the  examination  of  the  urine, 
conjoined  with  an  histological  investigation  of  morbid  alterations  in  the 
kidney,  hitherto  grouped  together  under  the  name  of  “ Bright’s  Disease,” 
has  also  thrown  a flood  of  light  upon  a class  of  disorders  formerly  in- 
volved in  the  greatest  obscurity,  besides  opening  up  a fleld  to  the  chemi- 
cal pathologist  in  his  endeavor  to  work  out  the  transformations  necessary 
for  the  excretory  processes,  which  cannot  be  too  highly  valued.  From 
these  various  investigations  medicine  has  already  derived  great  advan- 
tage, and  will  doubtless  obtain  much  more.  The  diseases  of  the  genera- 
tive organs  of  women,  however,  constitute  at  present  so  peculiarly  a 
speciality  of  the  obstetrician,  that  the  only  one  of  them  that  I shall 
allude  to  is 


OYABIAN  DROPSY. 

Case  CLXVI.'^ — Ovarian  Dropsij — Frequent  Paracentesis — Excision 
of  both  Ovaries — Strangulation  of  the  Intestine — Phlebitis — Death 
from  Ileus  the  seventieth  day  after  the  operation. 

History. — Jessie  Fleming,  unmarried,  aet.  20— admitted  July  6th,  1845.  She 
states,  that  eighteen  months  ago  she  first  perceived  a tumor  in  the  lower  part  of  the 
abdomen,  deep  seated  in  the  middle  of  the  hypogastrium.  She  can  assign  no  cause  for 
its  appearance.  The  tumor  rapidly  increased  in  bulk,  until  at  the  end  of  ten  months 
the  abdomen  was  greatly  distended—  so  much  so,  that  respiration  and  progression  were 
rendered  difficult.  Paracentesis  was  now  performed,  and  forty  imperial  pints  of  a viscid 
yellowish-colored  fluid  were  removed.  The  abdomen,  however,  again  rapidly  increased 
in  size,  and  paracentesis  was  again  had  recourse  to.  The  operation  has  now  been  per- 
formed six  times,  the  intervals  between  each  becoming  less  and  less  lengthened,  and 
the  amount  of  fluid,  though  always  considerable,  varying  in  amount.  Her  general 
health  has  been  little  affected  by  the  disease. 


* Reported  by  Mr.  D.  P.  Morris,  Clinical  Clerk. 


764 


DISEASES  OF  THE  GENITO-URINARY  SYSTEM. 


Symptoms  on  Admission. — At  present,  July  6th,  she  has  pain  in  the  loins  which 
comes  on  when  the  dropsy  is  large.  Special  senses  and  common  sensibility  normal.  Her 
sleep  is  much  disturbed  by  breathlessness,  and  by  the  semi-erect  posture  the  dropsy 
requires.  Motion  is  impeded  by  the  size  of  the  abdomen,  and  from  its  great  weight. 
There  is  much  muscular  weakness.  The  abdomen  measures  48^  inches  at  its  largest 
girth,  which  is  just  above  the  navel.  It  fluctuates  distinctly.  Dulness  of  the  liver 
cannot  be  defined  by  percussion.  The  skin  of  the  abdomen  is  marked  by  transverse 
fissures  or  marks  of  a purplish  color ; it  often  feels  very  hot  and  as  if  it'were  burst- 
ing ; tongue  clean ; appetite  a little  impaired ; no  thirst  or  sickness  ; bowels  regular  ; 
stools  somewhat  fluid,  but  of  healthy  aspect ; urine  scanty,  thick,  high-colored,  of  acid 
reaction,  containing  a yellowish  brown  sediment,  but  unaffected  by  heat ; skin  dry,  not 
warmer  than  usual.  She  states  that  she  never  perspires.  Has  no  cough  or  pectoral 
complaints  except  dyspnoea,  which  is  very  severe  at  night.  On  auscultation  the  chest 
appears  to  be  healthy.  Pulse  88,  sharp  and  small ; heart’s  sounds  apparently  abrupt, 
but  natural.  The  catamenia  have  appeared  at  irregular  intervals,  sometimes  of  three 
weeks,  at  other  five  weeks,  and  when  present  are  profuse. 

Proghess  of  the  Case. — Prom  this  time  she  remained  generally  in  about  the  same 
condition.  The  urine  passed  in  the  twenty-four  hours  never  exceeded  twelve  ounces, 
and  on  one  occasion  was  as  low  as  six  ounces.  The  abdomen  gradually  became  more 
tense  and  the  dyspnoea  more  urgent.  July  \2th. — Mr.  Syme  performed  the  operation 
of  paracentesis  of  the  abdomen.  The  trocar  was  introduced  to  the  left  of  the  linea 
alba^  about  two  inches  above  the  pubic  bone.  Five  imperial  gallons  of  a yellow-col- 
ored transparent  fluid  were  removed.  The  last  four  ounces  which  came  off  were  viscid 
like  white  of  egg,  and  contained  a few  yellowish  opaque  flocculi.  The  fluid  was  densely 
coagulable  on  application  of  heat  or  nitric  acid.  The  flocculi,  when  examined  with  the 
microscope,  were  found  to  be  composed  not  of  lymph,  as  was  at  first  supposed,  but  of 
numerous  cells,  varying  in  size  from  the  2000th  to  the  900th  of  an  inch  in  diameter. 
The  great  majority  were  about  the  1000th  of  an  inch.  They  were  slightly  gianular,  of 
round  and  oval  shape,  unaffected  by  water,  but  becoming  more  transparent  on  the  ad- 
dition of  acetic  acid,  and  exhibiting  a distinct  nucleus  about  the  3000th  of  an  inch  in 
their  long  diameter.  (See  Fig.  470.)  The  nucleated  cells  were  embedded  in  a granu- 
lar matter  which  could  easily  be  broken  down.  Shortly  after  the  operation,  she  com- 
plained of  considerable  pain  in  the  abdomen  towards  the  left  side,  which  was  not 
increased  on  pressure.  Fifty  minims  of  tincture  of  opium  to  be  takeir  immediately. 
July  — Has  continued  to  feel  more  or  less  pain  in  the  abdomen,  which  is  not 
superficial  or  peritoneal.  The  bowels  have  been  freely  opened  by  compound  jalap 
powder,  and  she  has  passed  from  48  to  60  oz.  of  urine  daily.  The  puncture  is  now 
healed ; the  abdomen  is  still  voluminous,  but  soft.  On  palpation,  a tumor  with  dis- 
tinct margins,  about  the  size  of  the  adult  human  head,  may  be  distinctly  felt,  firmly 
attached  inferiorly  within  the  pelvis,  but  its  upper  portion  movable  to  a considerable 
extent  from  side  to  side.  She  describes  the  pain  as  being  of  a dull,  gnawing,  and  con- 
tinued character ; not  lancinating  nor  increased  on  movement.  Pulse  98,  of  natural 
strength;  tongue  slightly  furred;  has  tolerable  appetite;  no  thirst,  but  says  she  vom- 
its every  thing  she  takes.  The  matters  vomited  are  thrown  up  about  ten  minutes  after 
each  meal,  in  successive  mouthfuls,  accompanied  by  gnawing  pains  at  the  stomach. 
These  latter  pains  are  felt  under  the  false  ribs  on  the  right  side.  The  stomach  is  often 
felt  to  be  distended,  followed  by  considerable  eructations  of  gas ; bowels  have  been 
open  four  or  five  times;  urine  much  incx’eased  in  amount  since  the  operation;  to-day 
she  passed  thirty-eight  ounces.  The  compound  jalap  powder  was  directed  to  be  given 
again.  July  l^th. — To-day  she  was  carefully  examined  by  Professor  Simpson,  who 
employed  his  uterine  bougie.  By  this  means  the  fundus  of  the  uterus  was  raised  above 
the  brim  of  the  pelvis,  where  it  was  distinctly  felt  presenting  its  obtuse,  rounded,  natu- 
ral form.  The  Professor  stated  his  opinion  that  the  tumor  was  connected  to  the  left 
ovary  by  a narrow  pedicle.  Urine  ten  ounces.  July  l^th. — The  examination  of  yes- 
terday was  followed  by  great  pain.  She  described  this  as  being  “ tremendous,”  and 
seated  in  the  back.  The  nurse  said  she  cried  out  as  a woman  in  labor.  About  two 
and  a half  hours  afterwards  a draught  containing  one  drachm  of  solution  of  morphia 
was  given.  It  relieved  the  pain,  but  it  continued  until  11  p.m.  An  anodyne  and  ether 
draught  was  then  given,  which  was  immediately  rejected  by  vomiting.  August  lih. — 
Since  last  report  the  vomiting  has  gradually  abated  under  the  influence  of  opium  and 
creasote  pills.  The  urine,  however,  has  again  diminished  in  amount,  and  for  the  last 
ten  days  has  only  been  from  ten  to  twelve  ounces,  while  the  size  of  the  abdomen  has 


OVARIAN  DROPSY. 


765 


slowly  increased  to  its  former  volume.  To-day,  paracentesis  was  performed  by  Dr. 
James  Duncan,  and  five  and  a half  gallons  of  fluid  removed,  presenting  the  same  char- 
acters as  that  described  July  12th.  Soon  after  the  operation  she  experienced  consid- 
erable pain  in  the  back  and  upper  parts  of  the  abdomen,  which  ceased  at  midnight 
after  taking  a draught  with  half  a drachm  of  the  solution  of  morphia.  A7i^.  16th. — 
Since  last  report  has  been  in  the  Surgical  Hospital.  Dr.  Bennett  proposed  to  the 
acting-surgeons  severally  the  operation  of  ovariotomy,  which  they  declined  to  perform. 
To-day,  accordingly,  she  returned  to  the  medical  ward.  During  the  interval  her  gen- 
eral health  has  been  good.  The  fluid  in  the  abdomen  is  again  accumulating.  By  a 
careful  examination  the  tumor  can  be  ascertained  to  be  quite  free  from  adhesions  to 
the  anterior  walls  of  the  abdomen.  These  latter  can  be  pulled  forwards  and  held 
steady,  while  the  tumor  is  made  to  roll  freely  beneath.  Passed  during  the  last  24  hours 
eighteen  ounces  of  urine.  The  liver  was  carefully  percussed.  Its  extreme  dulness  in 
the  right  hypoehondrium  is  three  inches  ; it  is  pushed  considerably  upwards,  the  upper 
line  of  dulness  being  on  a level  with  the  nipple.  Her  general  health  is  not  so  robust 
as  when  she  first  entered  the  house.  Dismissed  from  the  Infirmary  August  2Uh. 

September  3i. — After  leaving  the  Infirmary,  she  went  into  lodgings,  having  been 
placed  by  Dr.  Bennett  under  the  care  of  Dr.  Handyside.  On  the  2d  that  gentleman 
performed  paracentesis,  and  removed  four  gallons  of  fluid,  and  to-day,  having  satisfied 
himself  that  this  was  a case  urgently  calling  for  the  performance  of  ovariotomy,  he 
consented  to  perform  it  according  to  the  request  previously  made  to  him  by  Dr.  Ben- 
nett. Sept.  Mh. — Bowels  have  been  opened  four  times  during  the  night,  the  last  time 
at  8 this  morning,  from  a purgative  of  Ext.  Colocynth  gr.  x.,  administered  yesterday 
evening,  and  a domestic  enema  given  this  morning.  She  is  in  good  health  and  spirits. 
Tongue  clean. 

Operation  of  Ovariotomy. — The  operation  was  performed,  September  5i/t,  at  half- 
past 12,  by  Dr.  Handyside,  in  the  presence  of  Drs.  Beilby,  Simpson,  W.  Campbell, 
A.  D.  Campbell,  Baillie,  Bennett,  and  Struthers,  and  Professor  Goodsir.  The  tempe- 
rature of  the  room  was  raised  to  72°.  The  patient  was  placed  on  a table  before  a good 
light,  her  feet  resting  on  a stool,  and  her  shoulders  raised  and  supported  by  pillows. 
Dr.  Handyside,  now  standing  to  the  right  of  the  patient,  made,  with  a strong  scalpel, 
an  incision  of  about  three  inches  in  length  through  the  skin  and  subcutaneous  cellular 
tissue,  midway  between  the  umbilicus  and  pubis,  and  over  the  linea  alba.  This  inci- 
sion was  deepened  carefully,  the  linea  alba  divided,  and  the  peritoneum  reached.  A 
fold  of  this  membrane  was  pinched  up  with  the  forceps,  and  a small  opening  made  into 
it.  Through  this  opening  some  glairy  fluid  escaped,  indicating  that  the  cavity  of  the 
abdomen  had  been  opened.  With  a probe-pointed  bistoury  the  peritoneum  was  now 
slit  open  to  the  extent  of  an  inch  less  than  the  external  wound.  A large  quantity  of 
the  glairy  fluid  then  escaped,  which  occasioned  some  delay.  Through  this  opening 
Dr.  Handyside  now  introduced  two  of  his  fingers,  in  order  to  ascertain  that  no  adhe- 
sions existed  on  the  exterior  surface  of  the  tumor.  None  being  felt,  the  wound  was 
dilated  upwards  for  other  three  inches,  with  a probe-pointed  bistoury,  which  was 
guided  by  two  fingers  introduced  into  the  abdomen.  Through  this  opening  Dr.  Handy 
side  introduced  his  whole  hand,  and  finding  the  tumor  nowhere  adherent,  the  wound 
was  extended  upwards  to  rather  more  than  midway  between  the  umbilicus  and  the 
ensiform  cartilage,  and  downwards  to  within  two  inches  of  the  symphysis  pubis.  In 
cutting  upwards,  the  umbilicus  was  avoided,  the  incision  passing  to  the  left  side  of  it. 
Through  the  large  opening  the  fundus  of  the  tumor  now  presented,  and  the  charge  of 
it  was  committed  to  Professor  Simpson,  who  drew  it  gently  outwards.  At  this  time, 
as  well  as  before  and  after,  care  was  taken  to  prevent  protrusion  of  the  intestines. 
This  was  done  by  Mr.  Goodsir,  who,  with  both  hands,  pressed  the  edges  of  the  wound 
downwards  and  backwards  against  the  intestines  and  from  the  tumor.  On  the  ante- 
rior aspect  and  fundus  of  the  tumor  were  now  observed  several  round  smooth-edged 
apertures,  through  which  some  of  the  glairy  fluid  was  seen  to  escape,  being  of  the  same 
character  as  that  which  had  flowed  from  the  peritoneal  cavity,  but  rather  more  viscid 
in  consistence.  One  of  these  openings  was  dilated  with  a bistoury,  which  allowed  of 
the  escape  of  a large  quantity  of  the  glairy  fluid.  This  had  the  desired  effect  of  dimin- 
ishing considerably  the  size  of  the  tumor.  The  pedicle  of  the  tumor  was  next  exam- 
ined, and  it  was  found  to  consist  of  the  left  broad  ligament  of  the  uterus,  somewhat 
elongated  and  enlarged,  but  not  altered  in  texture.  The  uterus  was  seen  to  be  of 
normal  size,  though  of  a rose-red  color,  and  to  be  unconnected  with  the  tumor,  except 
through  the  medium  of  the  ligament.  The  pedicle  of  the  tumor  being  now  put  on  the 


DISEASES  OF  THE  GENITO-URINAET  SYSTEil. 


vee 

stretch  by  exerting  slight  traction  on  the  latter,  a strong  curved  needle,  in  a fixed  han- 
dle, and  carrying  a strong  double  ligature,  was  passed  through  its  middle.  The  double 
end  of  the  ligature  being  divided,  each  half  was  tied  separately,  so  that  each  included 
one  half  of  the  pedicle.  Some  delay  was  occasioned  by  the  difficulty  experienced  in 
tying  the  ligatures,  as  the  elasticity  of  the  part  included  caused  the  first  half  of  the 
knot  to  slacken  before  the  other  half  could  be  thrown.  The  tumor  now  required  to 
be  removed.  This  was  done  by  cutting  carefully  with  a scalpel  at  about  an  inch  be- 
yond the  part  surrounded  by  the  ligatures.  In  doing  so,  a cyst,  which  had  extended 
down  to  the  pedicle,  was  necessarily  opened,  and  some  more  of  the  glairy  fluid  escaped. 
During  the  division  of  the  pedicle,  venous  blood  escaped  freely  from  the  tumor,  but 
after  tine  removal  of  that  latter,  no  bleeding  occurred  from  the  divided  surface  of  the 
pedicle,  although  the  mouth  of  at  least  one  large  artery  was  visible.  The  right  ovary 
was  now  examined,  and  it  was  found  to  be  enlarged  to  the  size  of  a walnut,  and  to  con- 
tain several  small  cysts.  Accordingly,  Dr.  Handyside  proceeded  to  remove  it  also.  A 
needle  carrying  a double  ligature  was  passed  through  the  middle  of  the  ligament  of  the 
ovary,  and  the  ends  tied  separately  in  the  same  manner  as  on  the  other  sid^e.  No  bleed- 
ing followed  the  division  of  the  ligament  beyond  the  ligatures.  The  portions  of  the 
broad  ligaments  which  were  left  were  unaltered  in  structure.  The  four  ends  of  ligature 
attached  to  each  broad  ligament  were  now  tied  together  around  the  latter,  and  then 
three  of  the  ends  cut  off,  so  as  to  leave  one  only  from  each  side  hanging  at  the  lower 
angle  of  the  wound.  The  blood  mixed  with  the  remainder  of  the  glairy  fluid  was  now 
sponged  carefully  out  of  the  lower  part  of  the  abdomen  and  the  pelvis,  which  were  ex- 
posed. The  peritoneum  lining  the  abdominal  wall,  as  well  as  that  covering  part  of  the 
intestines,  was  now  examined,  and  seen  to  be  of  a red  color ; but  on  no  part  was  there 
any  mark  of  the  effusion  of  lymph.  Such  of  the  intestines  as  were  seen  were  quite 
natural  in  their  appearance.  All  oozing  of  blood  from  the  incisions  in  the  abdominal 
wall  having  ceased,  no  vessel  having  required  ligature,  the  edges  of  the  wound,  with 
the  careful  exclusion  of  the  peritoneum  only,  were  approximated  and  retained  in  accu- 
rate apposition  by  means  of  ten  twisted  sutures.  Corresponding  parts  of  the  edges 
of  the  incision  were  indicated  by  the  dark  points  and  cross  lines  which  were  previously 
marked  with  the  nitrate  of  silver,  and  wdiich,  on  the  now  flaccid  skin,  were  found  to 
be  of  great  use.  A long  pad  of  lint  was  next  laid,  as  a compress,  along  each  side  of 
the  wound,  and  a lighter  one  over  it,  and  these  were  retained  by  broad  strips  of  adhe- 
sive plaster.  Lastly,  over  these  pressure  was  made,  and  support  given,  by  the  ends 
of  a double  many-tailed  bandage,  which  had  been  placed  under  the  patient  before  the 
operation  began,  and  which  were  crossed  and  pinned  alternately  at  opposite  sides  of  the 
abdomen.  The  patient  was  then  placed  in  bed,  a dry  blanket  having  been  previously 
wrapped  round  the  thighs  and  pelvis.  The  patient  bore  the  operation  well.  At  one 
time  she  felt  faint,  but  syncope  never  occurred,  so  that  no  stimuli  were  given.  The 
pulse  never  sunk  below  80,  but  remained  most  of  the  time  between  90  and  100.  The 
operation  occupied  in  all  about  forty  minutes.  Fifteen  of  these  were  taken  up  in  the 
preliminary  incision,  examination,  and  removal  of  the  large  tumor, — five  in  the  re- 
moval of  the  small  one,  and  twenty  in  sponging  out  the  pelvis,  introducing  the  sutures, 
and  applying  the  compresses,  straps,  and  the  many-tailed  roller. 

Subsequent  Progress  oe  the  Case. — Immediately  after  the  operation  one  drachm 
of  the  solution  of  Morphia  was  administered.  At  4 p.m.  she  complained  of  acute  pain 
in  the  abdomen,  and  two  grams  of  solid  Opium  w^ere  given  in  the  form  of  pill.  At  8 p.m. 
another  grain  of  Opium  was  taken.  At  9 p.m.  the  pain  ceased  on  her  being  turned  in 
bed.  The  pulse  was  100,  soft,  and  eight  oz.  of  urine  w'ere  drawn  off  by  the  catheter. 
September  <oth. — Has  taken  during  the  night  a drachm  and  a half  of  the  solution  of 
Morphia.,  w'hich  occasioned  drowsiness  but  no  sleep.  At  2 p.m.  there  was  slight  diffi- 
culty of  breathing.  At  9 p.m.  the  pulse  was  148,  full  and  strong,  and  difficulty  of 
breathing  was  increased ; 20  oz.  of  blood  were  taken  from  the  arm. — Sept.  *ith. — At  2 
P.M.  Avas  allowed  to  have  a little  w'arm  gruel,  followed  fifteen  minims  of  the  “ black 
dropfi  as  she  was  very  irritable  and  restless.  Sept.  8/A. — Last  night  had  some  beef-tea 
and  toast,  and  slept  several  hours.  The  wound  was  dressed  at  2 p.m.  for  the  first  time. 
Union  by  first  intention  had  taken  place  everywhere,  except  where  the  ligatures  inter- 
pose. Sept.  10th. — Wound  discharging  freely  around  the  ligatures.  Complains  of 
tormina  and  restlessness.  Bowels  open.  At  9 p.m.  there  was  considerable  tenderness 
of  the  abdomen,  and  twenty-four  leeches  were  applied.  Sept.  llth. — Passed  a tolera- 
ble night.  Abdominal  tenderness  diminished,  but  still  pain  in  left  iliac  region.  Pulse 
130,  soft.  Respirations  35,  but  easy.  Twenty  leeches  to  be  applied  over  seat  of  pain., 


OVARIAN  DROPSY. 


767 


and  three  grains  of  James'  powder^  with  half  a grain  of  Opium.,  every  three  hours. 
Soda  water  with  Raspberry  vinegar  for  drink.  Sept.  22c?. — Since  last  report  has  gone 
on  well— occasional  symptoms  having  been  carefully  treated.  For  the  last  few  days 
has  complained  of  cough,  but  on  auscultation  and  percussion  the  lungs  appear  to 
be  healthy.  The  nourishment  has  been  gradually  increased,  and  she  has  taken  eggs 
and  beef-tea,  and  to-day  allowed  two  oz.  of  steak  for  dinner.  Between  three  and 
four  oz.  of  laudable  pus  escape  daily  from  the  wound  round  the  ligatures.  Sept. 
28/!7i  — Is  so  well  that  she  sat  up  in  a chair  for  some  time.  Appetite  much  im- 
proved, and  has  been  eating  meat  daily.  October  Sd. — Has  had  slight  diarrhoea. 
The  discharge  from  the  wound  is  copious  and  foetid.  In  the  evening,  on  pulling  one 
of  the  ligatures,  it  came  away,  with  a slough  about  three  inches  long,  and  the 
diameter  °of  a crow  quill.  To  have  a grain  of  opium.  Oct.  lOth. — Looseness  of 
bowels  returns  occasionally  notwithstanding  the  use  of  Lead  and  Opium  pills. 
Cough  has  been  troublesome,  with  to-day  tenacious  sputa,  slightly  tinged  here  and 
there  of  a rusty  color.  On  examining  the  chest,  a crepitating  rale  is  heard  for  the 
first  time  about  the  middle  third  of  left  back,  and  interiorly  there  is  sonorous  rale, 
both  with  inspiration  and  expiration.  Over  the  right  back  the  respiratory  murmurs 
are  generally  harsh,  with  increased  vocal  resonance,  but  no  rale.  On  tightening  the 
ligature,  which  is  still  firmly  attached,  about  three  ounces  of  thick  greenish  oflensive 
pus  flowed  from  the  opening.  To  lie  on  the  face  as  much  as  possible.  IJ  Mucilag. 
§j  ; Sxjr.  Simp.\  Vin.  Ipecac,  aa  ^ ss ; Sol.  Mur.  Morph.  3 ij  ; Aq.  Font.  §iv; 
M.  Sumat  ^ ss  quartd  qudque  hord.  At  9 p.m.  the  ligatures,  on  being  firmly  pulled, 
suddenly  came  away,  producing  a sensation  as  if  she  had  received  a blow  in  the 
abdomen.  There  was  no  slough  attached,  and  the  separation  was  not  followed  by 
blood,  although  flakes  of  dead  tissue  were  observed  in  the  pus.  Pressure  was  made 
by  pads  over  the  iliac  fossa  and  umbilical  region,  so  as  to  direct  the  pus  externally. 
Oct.  207/?. — Since  last  report  there  has  been  much  cough,  with  all  the  signs  and 
symptoms  of  linitted  pneumonia  of  both  lungs,  posteriorly  and  inferiorly.  The  pulse 
has  varied  from  120  to  140,  and  been  soft,  and  the  treatment  has  consisted  of  rest 
in  bed,  anodynes  at  night,  with  wine  and  nutrients.  Yesterday  a blister  was 
applied  to  the  left  thorax,  inferiorly,  and  to-day  she  is  much  better.  All  crepitation 
has  disappeared ; the  cough  has  ceased.  Over  left  back  inferiorly,  near  spinal 
column,  there  is  a space  the  size  of  a hand,  dull  on  percussion.  In  the  last  few  days 
she  has  been  eating  food  with  appetite,  and  sitting  up  an  hour  daily.  November  ls7. 
— Since  last  report,  although  the  physical  signs  of  chest  have  undergone  little  change, 
her  general  health  has  been  so  good  that  she  has  been  up  daily,  and  walks  freely 
about  her  room.  About  half  an  ounce  of  healthy  pus  is  discharged  daily  from  the 
wound.  At  half-past  4 p.m.,  during  the  temporary  absence  of  the  nurse,  feeling 
very  hungry,  she  went  to  the  press,  where  the  provisions  were  kept,  and  ate  half  a 
teacupful  of  arrowroot,  half  a pint  of  strong  soup,  a small  piece  of  ro:ist  beef,  and  a 
piece  of  bread,  being  all  the  food  she  could  get  at.  Immediately  afterwards,  she 
experienced  severe  griping  pains  over  the  whole  abdomen,  followed  by  vomiting  of 
the  matters  taken.  The  abdomen  became  distended  and  tympanitic  above  the 
umbilicus,  and  a curve  of  intestine  was  very  prominent  in  this  situation,  and  clear 
on  percussion.  A few  drops  of  01.  Menth.  Pip.  afforded  slight  relief,  and  warm 
fomentations  were  applied  to  the  abdomen.  Frequent  vomiting  of  a greenish  fluid, 
however,  continued,  and  in  the  evening  five  grains  of  Opium  were  given  in  the  form 
of  cuvpository.  Nov.  2d. — An  enema  was  given  at  10  a.m.,  and  another  four  hours 
afterwards,  without  causing  any  evacuation  from  the  bowels,  which  have  not  been 
opened  since  6 p.m.  on  the  31s7  of  October.  8 p.m. — There  has  been  frequent  retch- 
ing during  the  day  with  discharge  of  mouthfuls  of  mucus.  Marked  difference 
between  tympanitic  fulness  and  distention  above  the  umbilicus,  and  the  flatness  and 
collapse  of  the  abdomen  below  it.  Had  nothing  to  eat,  and  drank  only  a little 
coffee.  ^ Calomel  gr.  viij  ; Gum.  Opii  gr.  ij  ; Conserv.  Rosar:  q.  s.  Ft.  pit.  ij. 
One  to  be  taken  immediately.  Four  pounds  of  warm  water  to  be  injected  slowly,  if 
no  motion  by  \2  o'clock,  to  have  an  enema,  composed  of  an  infusion  of  six  ounces  of 
boiling  water  added  7o  15  grains  of  tobacco.  Nov.  Sd. — The  warm  water  injection 
returned  immediately  with  much  flatus  and  some  small  pieces  of  feculent  matter. 
The  tobacco  injection  was  not  given.  This  morning  the  countenance  is  anxious ; 
pulse  120,  small ; tongue  furred ; great  thirst ; no  appetite ; considerable  distention 
of  the  upper  part  of  the  abdomen,  and  a distended  knuckle  of  inte.stine  prominent 
and  strongly  marked  out  below  the  integument,  pressure  on  which  causes  tenderness. 


DISEASES  OF  THE  GENITO-IJEINARY  SYSTEM. 


16S 

Twelve  leeches  to  he  applied  to  the  abdomen.  To  have  the  tobacco  injection.  8 p.m. — 
This  morning  the  tobacco  injection  (not  quite  the  whole  of  it)  was  given.  It  wag 
retained  ten  minutes,  and  caused  considerable  collapse,  with  tremors  and  vomiting. 
Two  large  warm-water  injections  have  been  subsequently  given,  which  have  returned 
without  faeces.  No  tenderness  of  abdomen,  to  which  a turpentine  embrocation  is 
ordered  to  be  applied.  Nov.  Uh. — Complained  last  night  of  a throbbing  pain  in  the 
calf  of  left  leg,  and  swelling  of  foot  and  ankle.  To-day  the  whole  limb  is  swollen  as 
high  as  the  groin,  and  an  induration  is  felt  in  the  course  of  the  femoral  vein.  The 
vomited  matters  were  clearly  faeculent.  From  this  time  she  gradually  sank.  She 
vomited  from  time  to  time  matter  sometimes  faeculent,  at  others  bilious,  and  occa- 
sionally felt  colic  pains.  She  became  greatly  emaciated,  which  permitted  the  swollen 
and  tympanitic  intestines  to  be  strongly  marked  out  above  the  umbilicus.  The  pulse 
varied  from  130  to  150,  and  was  not  absolutely  weak  until  the  day  she  died.  Calomel 
and  opium  pills  were  continued,  with  occasional  injections  per  anum,  and  small 
quantities  of  nourishment.  The  mind  remained  unclouded  to  the  last,  and  latterly 
the  tympanitic  distention  of  abdomen  and  swelling  of  right  inferior  extremity  some- 
what diminished.  On  Nov.  12<A,  at  midnight,  she  requested  the  nurse  to  raise  her  up. 
This  was  done,  when  she  fell  back  and  expired — the  70th  day  after  the  operation. 

Sectio  Gadaveris. — Forty  hours  after  death. 

The  body  was  greatly  emaciated.  The  head  was  not  opened. 

Thorax. — The  cavity  of  the  pleura  on  the  left  side  contained  about  one  ounce, 
and  on  the  right  about  two  ounces  of  serum.  On  the  left  side  the  pleurae  were 
adherent  so  strongly,  that  the  lung  was  lacei  ated  in  removing  it : this  more  espe- 
cially between  the  inferior  surface  of  the  lung  and  upper  suiface  of  the  diaphragm. 
On  the  right  side  the  pleurae  were  adherent  at  the  apex,  and  over  inferior  lobe,  but 
the  adhesions  were  easily  torn  through.  The  anterior  margin  of  the  upper  lobe  of 
the  left  lung  was  emphysematous  ; its  posterior  portion  slightly  engorged.  On 
section  it  crepitated  readily,  and  was  healthy  in  structure.  The  inferior  lobe  felt 
dense  externally,  and  on  section  the  parenchyma  was  of  a brownish  red  color ; 
splenified ; easily  breaking  down  under  the  finger,  and  portions  of  it  placed  in  water 
sunk  nearly  to  the  bottom  of  the  vessel.  The  two  upper  lobes  of  the  right  lung 
very  emphysematous  anteriorly,  engorged  posteriorly  and  inferiorly,  but  otherwise 
healthy.  The  anterior  half  of  the  inferior  lobe  also  emphysematous,  with  here  and 
there  indurated  patches  of  chronic  lobular  pneumonia.  The  posterior  half  of  this 
lobe  was  splenified  throughout,  as  in  the  opposite  lung.  The  lining  membrane  of 
the  bronchi  was  healthy,  here  and  there  covered  with  mucus.  Both  lungs  were 
small  in  volume.  The  heart  was  small  and  pale.  Its  right  cavities  contained  a firm 
dark  coagulum.  The  valves  and  structure  of  the  organ  healthy.  In  the  aorta  there 
was  a small  but  firm  coagulum,  partly  decolorized. 

Abdomen. — On  reflecting  the  walls  of  the  abdomen,  a few  chronic  bands  of  lymph 
were  torn  through,  uniting  the  opposite  portions  of  peritoneum.  The  line  of  incision 
was  firmly  united  except  at  its  lower  end,  where  a round  opening  existed  about  the 
size  of  a pea.  On  the  peritoneal  surface  the  union  was  marked  by  a dark  blackish 
line,  which  was  perfectly  smooth  and  free  from  lymph.  The  omentum  was  thin  and 
transparent,  destitute  of  fat,  and  stretched  tightly  over  the  intestines.  Its  inferior 
margin  adhered  strongly  to  the  visceral  and  parietal  peritoneiim,  about  an  inch  above 
the  pubic  bones.  The  omentum  was  cut  through  transversely  about  its  middle,  and 
the  intestines  below  exposed,  which  were  greatly  distended  with  gas.  These  were 
found  to  be  portions  of  the  ileum,  the  coils  of  which  were  more  or  less  adherent  to 
each  other,  to  the  mesentery,  omentum,  and  to  the  neighboring  organs,  by  bands  of 
chronic  lymph.  The  adhesions  were  now  carefully  torn  through,  the  gut  liberated 
and  traced  downwards.  Exactly  five  feet  and  a half  from  the  caecum,  above  and  to 
the  left  of  the  umbilicus,  the  intestine  was  constricted  by  a band  of  lymph,  as  if  a 
ligature  had  been  tied  round  it.  Above  the  constriction  the  gut  was  distended  to 
about  the  size  of  the  wrist ; below,  it  was  collapsed  to  the  size  of  the  little  finger. 
Air  could  be  pressed  from  the  superior  portion  into  the  inferior,  but  the  passage  of 
water  poured  from  above  was  completely  checked  at  the  seat  of  stricture.  All  the 
intestines  .above  the  stricture  were  greatly  distended  with  gas  ; those  below  it,  includ- 
ing the  caecum,  colon,  and  rectum,  were  small  and  collapsed.  The  cavity  of  the 
pelvis  was  blocked  up,  and  separated  from  the  general  c.avity  of  the  abdomen  by  firm 
adhesions  between  the  surfaces  of  the  abdominal  walls,  the  omentum  and  knuckles  of 
intestine.  The  peritoneum  in  this  place,  and  especially  in  the  left  iliac  hollow,  was 


OVARIAN  DROPSY. 


769 


covered  with  a dense  layer  of  chronic  lymph.  This  lymph  was  about  one-eighth  of 
an  inch  in  thickness,  of  a dirty  greenish  color,  mixed  with  black  pigmentary  matter, 
of  great  hardness  to  the  feel,  and  cut  under  the  knife  like  cartilage.  With  some 
trouble,  the  united  knuckles  of  intestine  and  portions  of  omentum  involved  were 
separated  and  drawn  out.  A cavity  was  thus  exposed,  about  the  size  of  an  orange, 
situated  between  the  uterus  and  rectum,  lined  throughout  by  the  same  dense,  chronic 
lymph  spoken  of  above.  The  anterior  surface  of  the  uterus  was  firmly  united  to  the 
bladder  by  chronic  adhesions.  On  the  right  side  about  one  inch  of  the  Fallopian  tube 
and  broad  ligament  remained,  the  extremities  of  which  were  closely  united  to  the 
anterior  wall  of  the  cavity.  On  the  left  side  the  margins  of  the  uterus  and  short 
pedicle  of  the  broad  ligament  were  so  united  to  the  walls  of  the  cavity  that  they 
could  not  be  separated.  This  cavity  or  pouch  between  the  uterus  and  rectum  com- 
municated with  the  external  opening,  and  was  evidently  the  place  where  the  pus 
during  life  had  accumulated.  A sinus  opened  into  it  superiorly,  which  on  being 
traced  upwards  was  seen  to  extend,  above  the  descending  colon,  between  the  peri- 
toneum and  intestines  as  high  as  the  diaphragm  on  the  left  side,  where  it  terminated 
in  a cul-de-sac,  the  size  of  a hen’s  egg.  The  sinus  was  about  the  size  of  the  little 
finger,  and  lined  throughout  by  the  same  dense,  greenish  lymph  formerly  noticed. 
The  cul-de-sac  was  full  of  dirty-yellow  offensive  pus,  and  bounded  by  a portion  of  the 
stomach  and  left  lobe  of  the  liver  internally  ; the  diaphragm  above  and  posteriorly  ; 
and  the  colon  and  spleen  externally  and  inferiorly.  It  also  was  lined  with  dense 
chronic  lymph.  The  mucous  membrane  of  the  stomach  and  small  intestines  was 
healthy.  The  latter  contained  a clayey  colored  soft  fgeculent  matter.  The  large 
intestines  were  empty.  No  appearance  of  inflammation  existed  at  the  constricted 
part.  The  internal  surface  of  the  rectum,  extending  seven  inches  from  the  anus,  w'as 
intensely  vascular,  thickened,  and  inflamed.  Six  ulcers,  varying  in  size  from  a six- 
pence to  that  of  a shilling,  were  scattered  over  the  diseased  part  of  the  gut,  one  of  the 
largest  being  only  an  inch  from  its  extremity.  They  were  round  in  shape,  and  covered 
with  a raised  dirty  greenish  slough.  The  liver^  kidneys^  and  spleen  were  anaemic, 
but  healthy  in  structure.  The  femoral  and  sephena  veins  could  be  felt  hard  and  dis- 
tended below  the  integuments.  On  dissection,  these,  as  well  as  the  external  iliac 
vein^  up  to  the  point  where  it  passed  under  the  layer  of  lymph,  in  the  left  iliac  hollow 
formerly  described,  were  found  to  be  obstructed  by  a coagulum  of  blood.  This 
coagulum  was  adherent  to  the  internal  wall  of  the  vessel,  was  partially  decolorized, 
and  of  the  consistence  of  soft  cheese.  This  obstruction  of  the  vessels  ceased  about 
three  inches  below  Poupart’s  ligament. 

Description  op  the  Tumor  removed. — The  tumor  which  involved  the  left 
ovary,  on  being  removed,  weighed  nine  pounds  and  a half.  It  was  of  an  oval  form, 
and  measured  thirteen  inches  in  its  longest,  and  nine  inches  and  a half  in  its  shortest 
diameter.  Its  envelope  was  composed  of  white,  dense,  and  glistening  fibrous  tissue, 
having  upon  its  external  surface  patches  of  various  sizes,  resembling  chronic  lymph. 
On  its  anterior  surface  might  be  seen  openings,  or  ulcerations,  varying  in  size.  The 
edges  of  these  ulcerations  were  smooth  and  rounded,  and  of  the  same  thickness  as  the 
fibrous  envelope.  The  cut  surface,  which  had  been  near  the  ligature,  now  presented 
a large  opening  into  the  tumor,  through  which  numerous  cysts,  varying  in  size  from 
a pea  to  that  of  a billiard  ball,  protruded.  The  incision  into  it,  made  during  the 
operation,  had  opened  up  one  of  these  cysts  about  the  size  of  a cocoa-nut.  The  tumor 
was  sent  to  the  University  Museum,  minutely  injected  by  Mr.  Goodsic,  and  afterwards 
cut  up,  in  order  to  show  its  internal  structure.  In  dividing  it,  some  of  the  internal 
cysts  were  found  to  be  full  of  pus,  whilst  others  contained  the  usual  glairy  fluid  com- 
mon to  these  tumors.  Three  preparations  were  made  from  this  tumor,  which  may  be 
seen  in  the  museum,  and  which  demonstrate  the  following  facts  ; — 

Is^,  A portion  of  the  fibrous  sac,  showing  the  attachment  of  numerous  cysts  varying 
in  size  and  shape.  A minute  injection  has  been  thrown  into  the  arteries  (?)  and 
exhibits  how  richly  the  walls  of  the  internal  cysts  are  supplied  with  blood-vessels. 

. One  of  these  cysts,  about  the  size  of  a small  hen’s  egg,  has  its  upper  half  fully  injected, 
whilst  the  lower  half  is  pale.  The  margin  between  the  two  is  uneven  but  abrupt, 
and  from  the  creamy  and  distended  appearance  of  the  cyst,  there  can  be  no  doubt 
that  it  is  full  of  pus. 

2(/,  A portion  of  the  fibrous  sac,  showing  the  incision  which  separated  the  tumor 
from  its  attaehments.  The  opening  is  of  an  irregular  form,  about  three  inches  in  its 
longest  diameter. 

3(/,  A portion  of  the  fibrous  sac,  showing  the  ulcerated  openings  formerly  described. 

49 


^70 


DISEASES  OF  THE  GENITO-UKINART  -SYSTEM. 


The  right  ovary  was  about  the  size  of  a walnut.  It  was  formed  externally  of  a 
dense  fibrous  capsule,  and  internally  of  several  small  cysts.  The  natural  stroma  of 
the  organ  had  entirely  disappeared. 

Commentary. — The  life  of  this  young  woman  was  rendered  miser- 
able by  the  enormous  size  of  her  abdomen,  and  the  difiSculty  it  caused 
to  the  functions  of  respiration,  micturition,  locomotion,  etc.  She 
earnestly  desired  that  any  operation  should  be  performed  which  held 
out  a prospect  of  relief,  and  bore  the  excision  of  both  ovaries,  which 
was  most  skilfully  performed,  with  the  greatest  courage.  From  this 
she  may  be  said  to  have  recovered,  for,  notwithstanding  the  chest  com- 
plication which  arose,  she  was  from  the  forty-eighth  to  the  fifty-eighth 
day  after  the  operation  so  well,  that  she  sat  up  and  walked  about  with- 
out inconvenience.  On  this  last  day,  feeling  the  intense  hunger  of  a 
convalescent,  she  took  advantage  of  the  nurse’s  absence,  and  ate 
largely.  The  stomach  thereby  was  distended,  the  intestines  displaced, 
so  that  a filament  of  chronic  lymph,  attached  to  the  abdominal  walls, 
became  twisted  round  a portion  of  bowel,  causing  complete  mechanical 
strangulation  of  it,  and  death  twelve  days  later,  with  all  the  symptoms 
of  ileus.  To  this  accidental  circumstance,  and  not  to  any  direct  influence 
of  the  operation,  must  the  fatal  result  be  attributed. 

A difference  of  opinion  existed  among  the  practitioners  who  witnessed 
the  case  and  dissection  as  to  how  the  cavity  or  pouch  containing  pus, 
between  the  uterus  and  rectum,  and  the  sinus  leading  from  it  up  to  the 
diaphragm,  were  connected  with  the  pressure  made  on  the  abdomen  by 
the  many-tailed  bandages  and  compresses,  in  order  to  direct  the  matter 
towards  the  external  opening.  Some  thought  that  the  pressure  eni* 
ployed,  instead  of  directing  matter  downwards,  may  have  forced  a portion 
of  it  upwards  ; while  others  believed,  that  if  the  pressure,  which  latterly 
was  much  relaxed,  had  been  more  steadily  continued,  the  formation  of 
that  cavity  and  sinus  might  have  been  prevented.  The  question  is 
important,  however,  in  reference  rather  to  the  proper  treatment  of  future 
cases,  than  to  the  fatal  event  of  this  case  ; for  the  symptoms  of  ileus  and 
the  death  of  the  patient  were  obviously  dependent  on  the  constriction  of 
the  portion  x»f  ileum  above  noticed  by  a baud  of  lymph  which  was  at  the 
distance  of  some  inches  from  any  part  of  the  wound,  and  had  no  connec- 
tion either  with  the  cavity  or  the  sinus. 

Although  various  lesions  were  found  after  death,  their  origin  and 
connection  with  each  other  will  easily  be  understood  from  a perusal  of 
the  case,  and  of  the  post  mortem  examination. 

There  is  n«  longer  any  necessity  to  enter  into  the  question  as  to  how 
far  such  operations  are  justifiable.  My  conviction  of  its  necessity  twenty 
years  ago,  derived  from  the  operations  of  Lizars,  Clay,  and  Atlee,  is  now 
generally  admitted  to  be  correct,  while  even  those  surgeons  who  main- 
tained it  was  opposed  to  the  true  principles  of  their  art,  at  present  sanc- 
tion its  performance,  tiad  ovariotomy  been  performed  in  the  case  of 
Fleming  in  the  wards  of  the  Infirmary,  it  must  be  obvious  that  the 
accident  which  caused  her  death  would  not  have  occurred. 

Case  CLXYII.'^ — Ovarian  Dropsy — Spontaneous  Ulcerative  Opening 
of  the  Cyst  into  the  Bladder,  and  Evacuation  of  its  Contents — Recovery. 

History. — Anne  Typer,  a servant,  asst.  25,  was  admitted  Xov.  8,  1848.  She  had 
Reported  by  Hr.  James  Struthcrs,  Clinical  Clerk. 


OVARIAN  DROPSY. 


in 


been  delivered  fourteen  days  previously  of  a male  child  in  the  Maternity  Hospital,  the 
labor  bein'*’  a natural  one,  and  presenting  nothing  unusual.  On  the  birth  of  the  cliild, 
however,  the  abdomen  still  continued  enlarged,  and  at  lirst  led  to  the  suspicion  that 
another  foetus  remained  in  the  uterus.  After  a time,  the  true  nature  of  the  ease  was 
rendered  manifest,  and  a large  swelling  was  deteeted,  which  was  movable  to  a certain 
extent,  and  presented  all  the  characters  of  an  encysted  tumor  of  the  left  ovary. 

Symptoms  on  Admission. — The  abdomen  was  swollen  to  about  the  size  usual 
during  the  sixth  or  seventh  month  of  pregnancy.  The  tumor  extended  from  the 
epigastrium  to  the  pubes,  but  bulged  considerably  towards  the  left  side.  Its  surface 
was  irregular ; and  two  large  nodules,  each  the  size  of  a cocoa-nut,  existed  about  its 
centre.  It  ivas  tense  and  firm  to  the  feel,  somewhat  elastic,  but  no  fluctuation  could 
be  detected.  The  tumor  was  firmly  fixed,  and  the  seat  of  constant  pain,  especially  in 
the  left  lumbar  region,  which  was  increased  by  pressure,  or  lying  on  the  right  side,  or 
on  assuming  the  erect  posture.  The  urine  was  of  a slightly  yellow  color,  and  pre- 
sented its  normal  characters.  The  digestive,  respiratory,  circulatory,  nervous,  and 
integumentary  organs  appeared  to  be  healthy.  She  had  observed  the  tumor  seven 
months  before  her  delivery ; and  it  ha-;  gone  on  gradually  increasing,  and  been  some- 
what painful  from  the  first.  Eight  leeches  were  ordered  to  the  most  painful  part  of 
the  abdomen. 

Progress  of  the  Case. — For  four  days  the  patient  remained  in  the  same  condi- 
tion, the  local  pain,  however,  having  been  relieved  by  the  leeches.  On  Nov.  12,  my 
attention  was  directed  to  the  urine,  which  now  presented  a copious  white  deposit, 
occupying  two-fifths  of  the  jar,  while  the  supernatant  portion  was  of  a light  amber 
color,  and  unusually  viscid.  The  deposit  was  determined  by  the  microscope  to  con- 
sist of  pus,  mingled  with  a few  granule  corpuscles.  The  clear  portion  was  strongly 
coagulable  by  heat  and  nitric  acid.’  At  first  it  was  imagined  th'it  the  cyst  had  burst 
into  the  vagina,  but  the  patient  and  nurse  concurred  in  saying  that  there  was  no  dis- 
charge between  the  intervals  of  micturition,  and  that  all  the  fluid  came  from  the 
bladder.  The  urine  presented  the  same  characters  for  the  next  three  days ; the 
amount  discharged  during  the  twenty-four  hours  being  about  three  pints.  On  the 
15^/i,  the  tumor  had  somewhat  diminished  in  size,  its  hardness  and  tensity  had  disap- 
peared, and  distinct  fluctuation  was  perceptible  in  it.  A broad  flannel  roller  was 
ordered  to  be  applied  flrmly  round  the  abdomen.^  and  compression  made  by  means  of 
pasteboard.,  previously  soaked  and  modelled  to  the  abdominal  surface.  From  this  time 
the  abdomen  rapidly  diminished  in  volume,  while  the  amount  of  purulent  viscous  fluid 
discharged  from  the  bladder  varied  from  three  to  five  pints  in  the  twenty-four  hours. 
The  appetite  and  general  health  continued  good  ; and  she  was  ordered  nutritious  diet, 
with  fo’ar  ounces  of  wine  daily.  On  the  23(Z,  the  amount  of  pus  contained  ki  tl.e 
urine  was  greatly  lessened,  and  the  clear  portion  presented  only  a slight  haziness  on 
the  addition  of  nitric  acid.  On  the  the  abdomen  had  regained  its  natui’al  size, 
although  a dense  mass,  evidently  the  collapsed  ovarian  sac,  could  readily  be  dis- 
tinguished, occupying  the  left  iliac  and  hypochondriac  regions.  The  urine  now  also 
was  natural  in  quantity,  and  presented  only  a slight  sediment,  consisting,  as  shown  by 
the  microscope,  of  some  crystals  of  oxalate  of  lime,  and  a few  pus  globules.  From 
this  period  she  may  be  said  to  have  recovered.  She  suffered  occasionally  from  uneasy 
feelings  on  the  left  side,  sometimes  amounting  to  pain,  which  were  relieved  by  the  ap- 
plication of  four  leeches,  followed  by  a small  blister.  One  of  the  leeeh  bites  ulcerated 
superficially,  but  soon  healed  up.  She  was  dismissed  on  the  18th  of  December,  ex- 
pressing herself  as  being  well  in  every  respect,  having  been  sitting  up  and  running 
about  the  ward  for  the  fortnight  previous.  The  indurated  mass  in  the  left  iliac  region 
was  greatly  diminished  in  size,  but  still  very  perceptible  to  the  feel,  though  not  to  the 
eye. 

Commentary. — The  history  of  this  case  can,  I think,  only  lead  to  one 
conclusion,  namely,  that  an  ovarian  encysted  tumor  was  present  on  the 
left  side;  that  the  individual  cysts  had,  if  not  altogether,  at  all  events 
for  the  most  part,  broken  down  to  form  one  large  cavity ; that  the  con- 
tents of  this  cavity  had  suppurated,  and  a fistulous  opening  formed 
either  into  the  ureter  or  bladder  (most  probably  the  latter),  through 
which  the  contained  fluid  was  evacuated,  permitting  collapse  of  the  sac 
and  cure  of  the  disease.  The  permanency  of  this  cure  would  depend 
upon  whether  all  the  secondary  cysts  had  been  ruptured  and  were  broken 
flown  before  the  fistulous  opening  took  place.  This  is  a point  which 


772 


DISEASES  OF  THE  GEXITO-UEINAEY  SYSTEM. 


it  was  impossible  to  ascertain  with  certainty  ; but  a careful  examina- 
tion of  the  woman  before  she  left  the  Infirmary,  convinced  me  that  no 
rounded  nodules  or  cysts  could  anywhere  be  felt. 

The  only  instance  I am  aware  of,  in  which  an  opportunity  presented 
itself  of  dissecting  an  ovarian  encysted  tumor  some  time  after  its  spon- 
taneous rupture,  was  in  an  individual  I saw  examined  by  the  late  Dr. 
Makellar. — [Monthly  Journal^  Jan.  1847,  p.  558.)  In  that  case  the 
cavity  of  the  cyst  was  almost  obliterated,  and  its  walls  were  thickened 
and  of  cartilaginous  hardness.  A fistulous  opening,  however,  was  kept 
up  between  the  tumor  and  the  abdominal  walls,  below  the  umbilicus, 
where  it  had  burst,  and  the  patient  sank  from  the  continued  discharge. 
How  far  a communication  with  the  external  atmosphere  in  this  instance, 
and  the  presence  of  chronic  peritonitis,  may  have  operated  unfavorably, 
I do  not  know ; but  the  total  cessation  of  all  discharge,  and  absence  of 
these  circumstances  in  the  case  related,  augurs  well  for  her  permanent 
recovery. 

Whether  a fistulous  communication  between  the  ovarian  sac  and 
urinary  passages  be  favorable  or  not,  is  uncertain  ; for  I have  been  unable 
to  discover  any  recorded  case  in  which  this  has  ever  happened.  Many 
instances  are  to  be  met  with  where  similar  cysts  have  burst  into  the 
peritoneum,  the  fluid  being  absorbed,  and  excreted  in  large  quantities 
by  the  kidney  as  urine.  Other  cases  are  to  be  met  with,  where  the  con- 
tents of  the  tumor  have  burst  externally  by  ulceration  through  the  ab- 
dominal walls,  or  into  the  vagina,  or  into  the  intestines ; but  in  none,  so 
far  as  I am  aware,  previous  to  the  one  now  related,  have  the  contents 
of  the  tumor  been  evacuated  directly  as  a purulent  viscous  fluid  from 
the  bladder,  proving  a direct  communication  with  that  organ. 

Case  C LX VIII. ^ — Ovarian  Dropsy  which  gradually  emptied  itself  spon- 
taneously hj  openings  through  the  Fallopian  Tube — Singular  attempt  at 

Imposition  of  Figs''  Bladders^  for  Cystic  Formations  in  the  Uterus. 

History. — Elizabeth  Allan,  aet.  43,  servant,  a tolerably  stout  healthy-looking 
woman — admitted  September  80th,  1852.  States  that  she  enjoyed  good  health  up  to 
the  year  1029,  when  she  experienced  a lingering  post  partum  recovery.  In  1830  her 
abdomen  commenced  to  swell ; she  was  tapped,  and  190  oz.  of  fluid  removed.  For 
six  years  she  was  under  medical  treatment ; but  then  (1836)  she  had  so  far  recovered 
that  she  was  once  more  able  to  follow  her  usual  occupation.  In  1841  the  abdominal 
swelling  returned,  and  continued  till  1848.  At  the  beginning  of  that  year,  the  abdo- 
men being  greatly  swollen,  she  felt  something  give  way,  followed  by  intense  burning 
abdominal  pain,  and  a copious  discharge  of  an  opaque  fluid  from  the  vulva.  The  pain 
subsided  in  a few  days,  and  some  weeks  afterwards  she  was  much  better,  and  was 
enabled  to  get  out  of  bed.  She  says  the  same  thing  has  happened  upwards  of  tw’enty 
times  since,  at  various  intervals;  the  last  occurred  on  the  27th  of  August  1862.  She 
also  states  that  about  seventeen  cysts  or  polypi  have  at  different  times  been  removed 
from  the  uterine  passages — their  removal  being  preceded  by  bearing  down  pains. 
During  all  this  time  the  catamenia  have  appeared  regularly,  and  lasted,  on  an  average, 
from  eight  to  ten  days.  She  further  says,  that  for  the  last  twelve  years  she  has  had 
repeated  attacks  of  hasmatemesis.  In  1852,  her  attention  was  drawn  by  her  medical 
attendant  to  a bulging  beneath  the  left  clavicle,  where  she  has  frequently  experienced 
a deep-seated  pain  of  a burning  character,  with  a sense  of  trembling  or  vibratory 
movement. 

Symptoms  on  Admission. — On  admission,  the  patient  complains  of  uneasiness  and 
pain  in  the  lower  part  of  the  abdomen,  and  of  frequent  tympanitic  distention.  On 
examination,  the  abdomen  presents  the  appearance  of  a woman  in  the  sixth  or  seventh 


Reported  by  Mr.  W.  M.  Calder,  Clinical  Clerk. 


OVARIAN  DROPSY. 


773  . 


month  of  pregnancy — is  everywhere  tympanitic  on  percussion,  but  on  palpation 
there  is  an  undefined  fulness  and  induration  in  the  left  iliac  and  hypochondriac  regions 
— :io-pain  on  pressure  when  the  patient’s  attention  is  directed  from  the  part.  The 
left  side  of  the  chest  appears  fuller  than  the  right  side,  but  expands  well  on  inspira- 
tion. No  dulness  on  percussion ; respiratory  sounds  normal ; no  cough  or  pulmonary 
symptoms.  Below  the  acromial  extremity  of  the  left  clavicle,  a loud  blowing  murmur 
can  be  heard  over  the  subclavian  artery,  which  is  inaudible  on  the  right  side.  Cir- 
culatory, digestive,  urinary,  and  integumentary  systems  otherwise  normal. 

Progress  of  teie  Case. — The  patient  complained  of  tympanitis  and  pain,  for 
which  she  was  treated  by  occasional  purgatives,  enemata,  carminatives,  and  anti- 
spasinndics.  On  the  6th  of  October,  I requested  Dr.  Simpson  to  examine  her  per 
vaginim.  He  found  the  cervix  uteri  about  three  quarters  of  an  inch  in  length,  in- 
creased in  thickness  and  density.  The  os  uteri  was  patulous,  and  admitted  easily  the 
first  phalanx  of  the  index  finger.  The  edges  were  rough.  The  body  of  the  uterus  was 
m:)bil8,  but  its  volume  was  increased.  The  left  ovary  was  enlarged,  and  the  rectum 
distended  posteriorly.  At  this  time  the  patient  expressed  her  opinion  that  a discharge 
of  fluid  was  about  to  take  place.  Nothing  occurred,  however,  until  the  5th  of 
November,  when,  a little  before  five  o’clock  p.m.,  rising  to  micturate,  she  felt  some- 
thing give  way  in  the  lower  part  of  abdomen,  and  about  50  oz.  of  fluid  escaped  on  the 
floor.  A small  quantity  was  carefully  collected,  and  was  found  to  consist  of  slightly 
opalescent  serum,  of  sp.  gr.  1005,  slightly  coagulable  by  means  of  heat  and  nitric  acid. 
On  introducing  the  uterine  probe,  the  cavity  of  the  uterus  measured  three  inches  and 
a half  in  length,  and  contained  nothing  abnormal.  Nothing  unusual  followed  the  dis- 
charge of  fluid.  On  the  '2%th  of  December^  there  was  also  a considerable  watery  dis- 
charge. 

During  all  this  time  she  continued  to  complain  of  vague  abdominal  pains,  which 
were  evidently  feigned.  She  Avas  carefully  watched,  and.  no  cysts  had  come  away. 
On  the  Mh  of  Jartuar>f  she  expressed  herself  so  well  that  she  was  desirous  of  going 
out.  Peeling  satisfied  that  this  request  on  her  part  was  to  procure  the  means  of  im- 
position, permission  to  go  out  was  granted,  and  Mr.  William  Ciilder,  one  of  the 
cliuiciil  clerks,  agreed  to  follow  her.  She  went  straight  to  the  market,  and  was  seen, 
after  making  inquiries  of  one  or  two  butchers,  to  purchase  a pig’s  bladder.  Three  days 
afterwards,  January  I was  shown  at  the  visit,  a macerated  piece  of  this  bladder, 
which  she  affirmed  had  been  passed  during  the  night,  and  was  a portion  of  a ruptured 
cyst.  According  to  her  own  account,  there  had  been  violent  bearing-down  pains  for 
three  nights  previously.  I proceeded  to  inspect  the  substance,  and  on  informing  her 
that  it  was  a piece  of  pig’s  bladder,  her  astonishment  and  alarm  may  easily  bo  con- 
ceived. She  subsequently  confessed  this  imposture,  but  nothing  could  induce  her  to 
communicate  anything  with  regard  to  her  former  ones. 

Commentary. — In  June  1852,  I received  from  a highly  respectable 
practitioner  in  the  north  of  Scotland,  a bottle  containing  several  cysts, 
with  a letter  informing  me  that  they  had  been  passed  per  vayinam  by 
this  woman  then  laboring  under  ovario-uterine  disease.  He  wrote  that 
“ The  patient,  about  eighteen  years  ago,  had  a mature  child.  Her  labor 
was  followed  by  an  attack  of  peritonitis,  and  she  dates  her  present  ail- 
ments from  this  period.  Before  the  case  came  under  my  care,  she  had 
been  long  in  hospital  for  ovarian  dropsy,  and  was  there  repeatedly  tapped. 
During  the  last  few  years  she  has  passed  per  vagmaniy  from  time  to  time, 
one  of  the  membranous  productions  of  which  I herewith  send  you  speci- 
mens. You  will  perceive  that  in  some  instances  they  were  perfect  casts 
of  the  interior  of  the  uterus ; in  others  they  have  been  broken  in  tlie  re- 
moval. When  she  first  applied  to  me,  the  paracentesis  had  been  delayed 
beyond  the  usual  time.  The  dropsical  accumulation  was  great,  and  her 
general  health  in  a very  unsatisfiictory  state  for  surgical  interference ; 
and  before  I could  make  up  my  mind  to  operate,  nature  kindly  came  to 
the  relief  of  doctor  and  patient,  and  managed  the  thing  so  well  that  I 
have  allowed  the  good  dame  to  have  everything  her  own  way  since.  She 
did  it  thus  : a membranous  cyst  was  thrown  off,  and  this  was  immediately 


V74 


DISEASES  OF  THE  GEXITO-UEINAKY  SYSTEM. 


followed  by  the  discharge,  fer  vaginam,  of  the  dropsical  fluid,  to  the 
amount  of  several  pints.  That  this  also  came  from  the  uterus,  I'satisfied 
myself  by  tactile  examination  whilst  the  fluid  was  passing.  Since  then 
this  process,  the  discharge  first  of  the  membrane  (distended  with  serum), 
and  immediately  after  of  the  effusion,  has  been  repeated  every  few  months, 
the  patient  in  the  interval  enjoying  an  astonishing  measure  of  health.” 

Without  entering  into  a minute  description  of  these  cysts,  it  will 
suflice  to  say,  that  after  carefully  examining  them,  I came  to  the  conclu- 
sion that  they  were  the  urinary  bladders  of  some  animal — and  from  the 
size  (between  two  and  three  inches  in  their  long  diameter),  perhaps  of 
lambs  or  small  pigs.  They  had  evidently  been  macerated,  and  the  ex- 
ternal and  half  of  the  muscular  coat  removed,  and  the  smooth  mucous 
surface  turned  inside  out.  In  some  of  them,  however,  there  could  be 
sec-n  the  two  openings  of  the  ureters,  whilst  in  others  fragments  of  one 
or  both  tubes  were  still  attached.  On  communicating  my  opinion  as  to 
the  nature  of  these  cysts  to  her  medical  attendant,  and  hinting  that  so 
far  the  woman  was  an  impostor,  he  replied  as  follows : — 

“ I removed  two  or  three  of  the  membranes,  on  as  many  difierent 
occasions,  from  the  vagina,  and  the  state  of  the  os  uteri,  as  ascertained 
on  their  removal,  was  always  such  as  to  leave  no  doubt  in  my  mind  as  to 
their  having  been  ejected  from  the  uterine  cavity.  On  each  occasion  the 
woman  sufiered  severely,  having  had  regular  and  painful  uterine  contrac- 
tions, till  the  diseased  product  was  expelled,  and  profuse  haemorrhage 
afterwards  generally  inducing  syncope.  I mentioned  in  my  former  note 
that  I have  more  than  once  felt  the  dropsical  fluid  (which,  as  I also  stated, 
is  generally  discharged  shortly  after  the  sac)  passing  from  the  os  uteri. 
Add  to  this  that  the  woman’s  circumstances  are  such  that  it  would  be 
next  to  impossible  for  her  to  procure  the  means  of  perpetrating  the  trick 
you  suspect  her  of.  The  membranes  w^ere  kept  by  me  for  years  immersed 
in  spirits.  May  not  this  circumstance  have  rendered  your  examination 
of  them  less  satisfactory.” 

In  this  letter  my  correspondent  announced  his  intention  of  sending 
the  woman  to  Edinburgh,  if  I would  take  her  into  the  Clinical  Ward  of 
the  Infirmary.  This  I promised  to  do,  and  having  passed  another  ‘‘  cyst” 
in  the  interval,  she  came  to  Edinburgh. 

On  reviewing  the  facts  of  this  case,  it  appears  probable  that  C3’Sts 
formed  in  the  left  ovary  had  burst  at  successive  times  into  some  portion 
of  the  left  Fallopian  tube,  and  so  been  gradually  emptied;  and  that  with 
a view  of  exciting  further  sympathy,  she  had  introduced  the  macerated 
urinary  bladders  of  lambs,  sheep,  or  pigs  into  the  vagina,  and  pretended 
that  they  had  been  formed  in  the  uterus. 

Case  CLXIX."^ — Ovarian  Dropsy — Perforation  of  the  Descending  Colon 

from  without  inwards — Death  from  Ichorhcemia  and  persistent  Diarrhoea. 

History. — Janet  M‘Leod,  single,  aet.  38,  a shirt-maker — admitted  May  16th,  1863. 
Observed,  four  years  ago,  that  her  waist  was  somewhat  enlarged,  and  that  there  was 
swelling  and  pain  in  the  right  iliac  region.  The  abdomen  gradually  enlarged,  but  she 
sutfercd  no  inconvenience  until  September  1862,  when  she  ceased  to  menstruate,  and 
suffered  from  occasional  Icucorrhoea,  breathlessness,  and  difficulty  of  micturition.  On 
the  morning  of  Api  il  7th  she  woke  with  severe  pain  diffused  over  the  abdomen.  Pur- 
gatives caused  no  relief;  and  on  the  12th  she  could  pass  no  urine,  and  vomited  all 

* Reported  by  Mr.  Alfred  Lewis,  Clinical  Clerk. 


OVAEIAN  DROPSY. 


775 


ingesta.  These  symptoms,  though  somewhat  ameliorated  since,  have  continued  more 
or  less  up  to  the  present  time. 

Symptoms  on  Admission. — The  abdomen  is  greatly  enlarged  and  tense,  measuring 
38^  inches  in  circumference,  is  symmetrical,  dull  on  percussion,  and  on  palpation 
communicates  a distinct  feeling  of  fluctuation.  There  is  considerable  pain  on  pres- 
sure, especially  in  the  epigastric  and  right  hypochondriac  regions.  The  skin  is  hot, 
and  she  perspires  at  times  profusely.  Though  not  emaciated  she  has  a haggard  look. 
Respiration  thoracic.  Pulse  120,  weak  and  small.  Tongue  furred  ; no  appetite  ; 
great  thirst ; constipated.  Passes  urine  with  great  difficulty.  On  being  removed  with 
a catheter  it  was  found  to  be  1035  sp.  gr.,  not  albuminous,  but  loaded  with  urates. 
Catamenia  ceased;  no  leucorrhoea  ; other  functions  normal.  Haheat  01.  Ricini  § ss; 
R Sp.  ./Eilier.  Nit.  3 ij  ; Chlorodynce  3 ss  ; Mint.  CampJiorce  § j — Signa  To  be 
taken  at  hed-thne.  A large  warm  poidtice  to  he  applied  to  the  abdomen.  May  29//i. — 
Has  continued  to  feel  constant  pain  on  right  side  of  abdomen,  increased  on  pressure, 
with  fever,  sleeplessness,  and  constipation.  Anodynes,  gentle  laxatives,  with  occa- 
sional starch  enemata,  and  moist  warmth  locally,  have  failed  to  give  relief.  To-day 
there  is  looseness  of  the  bowels,  much  of  the  pain  is  diminished,  and  she  feels  better. 
May  ^Oth. — Bowels  have  been  opened  four  times.  An  injection  with  3 ss  of  Acetate 
of  Lead  and  TTxij  of  Tr.  Opii.  From  this  time,  however,  the  diarrhoea  became  per- 
sistent, and  caused  great  weakness,  for  which,  in  addition  to  astringents  by  mouth  and 
rectum,  nutrients  and  wine  were  liberally  administered.  The  fever  became  more  in- 
tense ; the  tongue  brown  and  dry  ; face  sallow  ; pulse  130,  weak  ; the  local  pain  was 
diminished  ; and  she  sunk,  exhausted,  June  14th. 

Sectio  Cadaveris. — Thirty  hours  after  death. 

Body  emaciated.  Abdomen  prominent,  especially  superiorly,  where  it  was  tym- 
panitic on  percussion.  It  measured  38  inches  in  circumference. 

xVbdomen. — On  cutting  through  the  abdominal  parietes  a cavity  the  size  of  an 
adult  head  was  opened  into,  containing  foetid  air  and  ichorous  purulent  matter.  Its 
walls  were  formed  by  a large  ovarian  cyst,  which  was  united  to  the  parietal  perito- 
neum anteriorly,  to  the  intestines  laterally,  superiorly,  and  inferiorly,  while  posteriorly 
the  right  ovary  was  seen  to  be  greatly  enlarged  and  transformed  into  cysts,  varying  in 
size  from  a millet  seed  to  a cocoa-nut.  In  the  descending  colon  was  a ragged,  gan- 
grenous opening,  about  the  size  of  a shilling,  freely  communicating  with  the  ovarian 
cavity,  wider  on  its  peritoneal  than  on  its  mucous  surface.  On  removing  the  large 
ovarian  tumor,  the  cysts  were  found  to  contain  various  fluids.  In  a few  was  a fluid 
like  coffee  grounds,  in  others  pus,  but  in  most  colloid  matter.  All  the  other  organs 
were  healthy. 

Commentary. — This  case  exhibits  an  example  of  a large  ovarian 
tumor  causing  peritonitis  and  adhesions  to  the  neighboring  viscera,  and 
at  length,  by  pressure  upon  the  descending  colon,  perforating  a passage 
through  that  gut.  The  symptoms,  which  previous  to  the  perforation 
had  been  those  of  great  local  pain  and  constipation,  were  immediately 
changed  on  the  communication  taking  place.  The  pain  diminished,  and 
diarrhoea  became  the  leading  symptom.  Air  entering  the  ovarian  sac 
from  the  gut,  produced  ichorous  suppuration,  ichorhaemia,  and  death  by 
exhaustion.  These  symptoms  well  contrast  with  the  effects  of  perforation 
of  the  gut  taking  place  from  within  outwards. 

Pathology  of  Ovarian  Dropsy. 

The  subject  of  encysted  tumors  of  the  ovary  has  been  considerably 
elucidated  by  Hodgkin,  Seymour,  Bright,  Cruveilhier,  Midler,  and  nu- 
merous recent  observers.  From  these  it  would  appear  that  the  ovary  may 
be  the  seat,  1st,  of  a simple  cyst ; 2d,  of  a compound  cyst,  formed  of  a 
capsule  containing  a number  of  secondary  cysts  ; and  3d,  of  similar  cysts 
more  or  less  combined  with  a sarcomatous  structure,  generally  considered 
of  a cancerous  nature.  The  first  of  these  seldom  becomes  larger  than  an 
orange,  and  is  for  the  most  part  only  detected  after  death.  The  two  latter 


776 


DISEASES  OF  THE  GENITO-URINARY  SYSTEM. 


frequently  reach  a large  size,  and  contain  several  gallons  of  fluid,  con- 
stituting what  has  been  called  ovarian  dropsy.  In  these  cases,  the  accu- 
mulation of  fluid  sooner  or  later  interferes  with  the  process  of  respiration, 
so  as  to  render  paracentesis  necessary.  This  operation  is  repeated  again 
and  again  at  shorter  intervals,  until  the  patient  sinks.  On  dissection, 
death  is  found  to  have  been  occasioned  by  peritonitis,  by  suppurative  in- 
flammation within  the  sac,  or  by  exhaustion. 

The  source  of  the  fluids  removed  by  tapping  in  ovarian  dropsy,  was 
pointed  out  by  me  in  1846.^  On  some  occasions  the  serum  exists  within 
the  cavity  of  the  abdomen,  and  the  tumor  can  be  felt  to  move  or  float  in 
it.  At  other  times  it  is  confined  within  the  cystic  tumor.  Thus  some 
have  supposed  the  fluid  to  be  ascitic,  caused  by  pressure  on  the  large 
abdominal  veins,  whilst  others  have  supposed  that  the  growth  irritates 
the  peritoneum,  and  occasions  an  increased  effusion  of  serum.  In  the 
case  of  Fleming  (Case  CLXVI.),  it  was  also  argued  by  some  of  the  ob- 
jectors to  ovariotomy,  that  excision  of  the  tumor  would  not  remove  the 
ascites,  as  that  was  probably  dependent  on  causes  unconnected  with  it. 
Now,  in  that  and  in  similar  cases,  where  four  or  five  gallons  have  fre- 
quently been  removed  from  the  abdominal  cavity,  it  must  be  evident 
that  the  amount  of  fluid  could  not  be  contained  in  the  cysts  of  a tumor 
only  the  size  of  the  human  head.  Neither  could  it  have  been  the  result 
of  peritonitis,  as  the  fluid  was  clear  and  of  a brownish  amber  color. 
Again,  the  liver  and  other  abdominal  viscera  were  healthy,  and  they 
could  not  have  caused  venous  obstruction  ; nor  was  it  likely  that  such  an 
ovarian  tumor,  floating  as  it  did  mostly  in  fluid,  could  by  its  pressure,  have 
occasioned  efi'usion  of  that  fluid  from  the  veins.  It  must  be  concluded, 
therefore,  that  in  such  cases  the  fluid  is  secreted  within  the  tumor,  and 
passes  through  one  or  more  openings  in  its  walls  into  the  peritoneal  cavity. 

The  mode  of  growth  and  the  structure  of  encysted  tumors  of  the  ovary. 
— In  all  the  specimens  of  the  disease  I have  examined,  whether  the 
growth  is  only  the  size  of  a walnut,  or  is  so  large  that  it  has  entirely  filled 
the  abdomen,  the  original  form  and  structure  of  the  ovary  has  dis- 
appeared. Some  suppose  a new  growth  is  formed  in  the  organ.  Others 
consider  the  cysts  are  produced  by  accumulating  fluid  distending  the  spaces 
in  the  areolar  tissues  of  the  organ.  I have  always  maintained  that  they 
originate  from  the  Grraafian  vesicles,  and  that  the  external  capsule  is 
formed  by  the  thickening  and  extension  of  the  fibrous  membrane  which 
covers  the  organ.  The  recent  observations  of  Dr.  Wilson  Fox  not  only  sup- 
port this  view,  but  indicate  very  ingeniously  how  the  papillary  growths 
so  frequently  observed  on  the  internal  walls  of  the  cysts  are  concerned  in 
the  production  of  secondary  cysts.  According  to  him  the  papillae,  covered 
with  epithelium,  on  being  pushed  outwards  leave  spaces  between  them, 
which  subsequently  enlarging  and  being  occluded  at  their  orifice  produce 
the  cysts.  These,  he  thinks,  by  the  growth  of  partitions  or  formation  of 
re-duplications,  may  occasion  other  internal  cysts,  and  so  the  process  be 
repeated.  This  idea  will  be  better  understood  by  Figs.  465,  466. 

Sooner  or  later  the  enlarged  ovary  is  found  to  consist  of  a dense 
fibrous  envelope  or  sac,  containing  internally  numerous  secondary  cysts 
attached  to  its  walls.  As  the  tumor  developes  itself  these  cysts  become 

* Pathological  and  Clinical  Observations  on  encysted  Tumors  of  the  Ovary. 
Edinburgh  Medical  and  Surgical  Journal,  vol.  Ixv. 


OVAEIAN  DROPSY. 


larf^er  more  numerous,  and  crowded  together.  Each  individual  second- 
ary" cyst  contains  a clear  glairy  or  gelatinous  fluid,  and  is  composed  ot  a 


firm  fibrous  capsule,  lined  by  a smooth  membrane.  On  making  a thin 
section  completely  through  the  walls  of  these  cysts,  their  greatest  thick- 
ness will  be  found,  on  .a  microscopic  examination,  to  be  composed  of 
fibrous  tissue,  lined  internally  by  a layer  of  epithelial  cells.  The  whole 
are  richly  supplied  with  blood-vessels. 


Fig.  467.  Fig.  468.  Fig.  469.  Fig.  470. 


As  the  tumor  enlarges,  it  ascends  from  the  pelvis,  where  it  is  origin- 
ally confined,  and  occupies  more  and  more  of  the  abdominal  c-avity.  The 
Fallopian  tube  aud  broad  ligament  become  elongated.  The  fimbriated 
extremity  of  the  former  is  sometimes  obliterated,  at  others  it  stands  out 
from  the  morbid  mass.  Sometimes  the  tumor  forms  adhesions  externally, 
more  or  less  extensive,  to  the  peritoneum,  omentum,  colon,  or  neighbor- 
ing viscera.  At  others  it  floats  loose  in  a fluid  within  the  abdominal 
cavity. 

Meanwhile  the  internal  cysts  press  upon  each  other,  they  become  dis- 

Fig.  46.5.  Vertical  section  through  the  wall  of  an  ovarian  cyst,  showing  the  papil- 
lary growths  (6)  and  the  spaces  between  them  (a)  which,  on  being  closed  in,  become 
cysts  lined  with  epithelium.  A cyst  so  formed  is  seen  below  (e). — Wihon  Fox. 

Fig.  466.  Subsequent  formations  proceeding  in  the  walls  of  simple  cysts  so  pro- 
duced causing  compound  cysts  (a,  b). — Wiho7i  Fox.  100  diain. 

Fig.  467.  Section  of  the  wall  of  an  ovarian  cyst,  with  epithelial  cells  in  situ. 

Fig.  468.  Polygonal  epithelial  cells  from  the  same  lining  membrane. 

Fig.  469.  Oval  epithelial  cells  from  the  lining  membrane  of  an  ovarian  cyst. 

Fig.  470.  Cells  in  fluid  removed  from  an  ovarian  dropsy.  250  diam. 


778 


DISEASES  OF  THE  GENITO-URINARY  SYSTEM. 


tended  with  fluid,  the  blood-vessels  are  compressed,  and  in  such  places 
further  growth  is  checked.  In  consequence  of  this,  absorption  of  their 
structure  occurs,  and  one  or  more  open  into  each  other,  as  was  pointed 
out  by  Hodgkin,  constituting  a multilocular  cyst.  Occasionally  the 
pressure  acting  upon  the  external  sac  causes  it  to  become  thinner  and 
thinner,  until  at  length  perforations  are  produced  in  it  also,  through 
which  the  fluid  contents  of  the  cyst  escape  into  the  abdominal  cavity. 
Thus  relieved  from  pressure,  the  margins  of  these  perforations  become 
once  more  vascular,  and  of  considerable  thickness,  often  resembling  the 
round  perforating  ulcer  of  the  stomach  so  well  described  by  Cruveilhier. 
Under  such  circumstances,  the  internal  membrane  of  the  cyst  continues 
to  secrete  and  pour  its  fluid  into  the  peritoneum,  rendering  paracentesis 
necessary.  At  other  times  the  external  sac  adheres  to  the  abdominal 
walls,  and  the  secondary  cysts  only  burst  or  open  into  each  other  inter- 
nally, so  that  after  a certain  period,  three,  two,  or  only  one  cavity  may 
remain,  with  bands  stretching  across  and  forming  imperfect  septa,  or  with 
a few  small  cysts  attached  to  the  internal  wall,  and  clearly  indicating  its 
original  structure.  In  either  case,  sooner  or  later,  suppuration  is  in  most 
instances  established  within  one  or  more  of  the  cysts,  or  within  the  ex- 
ternal sac  itself.  This  suppuration  seems  to  occur  in  some  cases  by  the 
formation  of  pus  corpuscles  in  the  gelatinous  matter  ; in  others  by  an  in- 
flammatory exudation  filling  the  cyst,  which  is  afterwards  converted  into 
pus.  The  patient  does  not  long  survive  this  occurrence.  If  perforation 
have  taken  place  in  the  external  wall  of  the  tumor,  peritonitis  is  general- 
ly induced;  if  not,  the  patient  sinks  exhausted,  whether  the  pus  be 
evacuated  or  not.  Occasionally  more  or  less  blood  is  extravasated  into 
the  inflamed  cysts,  which,  with  the  various  stages  of  suppuration,  cause  the 
sanguinolent,  coiFee-like,  greenish,  or  purulent  fluids  so  often  observed. 

The  gelatinous  contents  of  the  cysts  vary  greatly  in  difi’erent  cases: 
in  some  being  diffluent,  in  others  glairy  like  white  of  egg,  whilst  in  many 
it  is  semi-solid,  resembling  coagulated  calf ’s-foot  jelly,  or  strong  size. 
When  fluid,  it  frequently  contains  flocculi,  which  are  patches  of  epithelial 
membrane,  more  or  less  united  together  by  granular  matter.  When 
gelatiniform,  it  often  contains  faint  oval  corpuscles,  or  a few  primitive 
corpuscles.  (See  Figs.  202,  203.)  Occasionally  an  opalescent  or  opaque 
creamy  appearance  is  communicated  to  the  jelly  by  the  formation  of  pus 
corpuscles  or  minute  granules  (Fig.  322),  and  sometimes  it  is  wholly 
filamentous,  mixed  with  granule  cells  and  other  products  of  inflammation. 

This  jelly-like  matter  presents  various  characters,  chemical  and  struc- 
tural. Acetic  acid  frequently  causes  to  be  precipitated  a white  mem- 
brane, having  all  the  characters  of  fibrous  tissue.  Grranules,  cells,  and 
filaments  may  also  be  observed  in  it  in  various  stages,  as  is  the  case  with 
recent  exudation  from  the  serous  membranes,  or  in  other  simple  forms 
of  hyaline  blastema. 

•Not  unfrequently  the  ovary  contains  hairy  and  other  growths,  teeth 
(p.  203),  and  calcareous  deposits,  and  may  be  the  seat  of  cancer.  In 
this  last  case  I also  pointed  out  and  figured  in  the  memoir  referred  to, 
that  the  so-called  cancer  often  consists  of  an  epithelioma  of  a remarkable 
kind,  columnar  epithelial  cells  forming  and  separating  in  great  abund- 
ance.* I have  now  examined  several  such  diseased  ovaries;  one  espe- 
^ Ibid.  Case  II.  Fig.  1. 


OVAKIAN  DEOPSY. 


779. 


cially,  forwarded  to  me  by  the  late  Mr.  Russell,  of  Birmingham,  exhibited 
to  tlie  naked  eye  all  the  characters  of  cystic  eucephaloma,  and  yielded  an 
abundant  milky  juice.  On  examining  this  with  a microscope,  it  was 
seen  to  contain,  1st,  numerous  columnar  epithelial  cells,  with  fatty 
granules  accumulated  within  their  broad  extremities  ; 2d,  a multitude  ot 
diaphanous  celloid  bodies,"  and,  3d,  numerous  free  nuclei,  as  in  Figs. 
471,  472,  473.  See  also  Fig.  207. 


The  diagnosis  of  ovarian  tumors  was  formerly  very  defective ; so 
much  so,  indeed,  as  in  some  cases  to  have  led  to  the  opening  of  the 
abdomen  to  excise  a tumor  which  bad  no  existence,  and  in  many  others 
to  the  performance  of  an  operation  when,  from  adhesions  or  other  causes, 
the  growth  could  not  be  removed.  In  all  cases  of  abdominal  tumor, 
there  are  two  questions  which  every  practitioner  desires  to  answer  with 
certainty,  namely,  1st,  What  is  the  seat  ? and,  2d,  What  is  the  nature  of 
the  tumor  ? With  regard  to  the  first  point,  I must  refer  to  obstetrical 
works,  in  which  all  the  circumstances,  local  and  general,  are  pointed  out, 
which  distinguish  such  ovarian  growths  from  pregnancy,  with  which  they 
have  often  been  confounded.  Therein  also  will  be  found  the  means  of 
exploring  the  cavity  of  the  uterus  with  the  uterine  sound,  an  instrument 
which,  by  enabling  the  practitioner  to  elevate,  depress,  or  bring  forward, 
the  fundus  of  the  organ,  so  as  to  permit  of  its  being  felt  through  the 
integuments,  in  various  positions  above  the  pubis,  affords  most  valuable 
information. 

In  cases  of  ovarian  dropsy,  the  information  thus  arrived  at  is  negative, 
but  this  becomes  of  immense  importance  when  the  question  arises  (as  it 
always  does,)  Is  the  tumor  uterine  or  ovarian  ? In  the  case  of  Fleming 
this  point  was  anxiously  debated,  but  when  on  the  introduction  of  the 
sound  the  fundus  of  the  uterus  could  be  distinctly  felt  above  the  pubis 
presenting  its  usual  rounded  character,  there  could  no  longer  be  any  sus- 
picion that  the  tumor  originated  in  that  organ.  Again,  by  pushing  the 
uterus  from  side  to  side,  we  are  enabled  to  act  upon  the  ovaries  and  to 
determine,  by  the  impulses  communicated  to  the  hand,  whether  the 

Fig.  4*71.  Groups  of  columnar  epithelium  in  the  juice  of  an  encephalomatous  cystic 
growth  of  the  ovary,  with  fatty  granules  accumulated  at  their  extremities. 

Fig.  472,  Diaphanous  celloid  bodies,  naked  nuclei,  and  granule  cells. 

Fig.  473.  a,  The  nuclei  after  the  addition  of  acetic  acid ; 6,  the  columnar  epitheli- 
um acted  on  by  the  same  re  agent.  250  diam. 


V80 


DISEASES  OP  THE  GENITO-URINARY  SYSTEM. 


tumor  be  on  the  right  or  left  side,  and  to  form  a tolerable  idea,  in  certain 
cases,  whether  it  be  free  or  attached.  By  means  of  this  instrument,  then, 
we  are  materially  assisted  in  resolving  the  first  important  question  re- 
garding the  seat  of  the  tumor. 

A microscopic  examination  of  the  fluid  removed  by  paracentesis  may 
also  sometimes  give  important  indications  as  to  the  nature  of  the  tumor. 
If,  for  instance,  the  fluid  be  clear,  with  polygonal  or  rounded  and  swollen 
epithelial  cells  (see  Figs.  468  and  470),  they  are  highly  characteristic  of 
cystic  ovarian  growths.  If  columnar  epithelial  cells  are  found  in  quan- 
tity there  is  probably  an  epitheliomatous  cancroid  of  the  ovary  (see  I^gs. 
207,  471  and  472).  If,  on  the  other  hand,  there  be  pus  or  blood  cor- 
puscles, areolar  texture,  or  calcareous  salts  and  deposits,  the  amount  of 
purulent  formation,  hemorrhage,  disintegration,  or  mineral  degenera- 
tion, may  be  judged  of  thereby. 

Treatment  of  Ovarian  Dropsy. 

The  anatomical  examination  of  encysted  tumors  of  the  ovary  must 
convince  every  one  that  they  are  not  curable  by  internal  medicines. 
The  idea  that  a dense  fibrous  envelope,  containing  numerous  secondary 
cyLts,  all  richly  furnished  with  blood-vessels,  can  be  absorbed  through 
the  agency  of  mercury,  iodine,  or  any  other  drug,  is  purely  imaginary. 
There  is  not  one  positive  fact  to  support  such  an  opinion.  Neither  can 
it  be  supposed,  from  what  has  been  described  of  the  mode  in  which  these 
tumors  are  developed,  that  so  long  as  any  of  the  secondary  cysts  remain 
intact,  a cure  can  be  hoped  for.  But  we  have  seen  that  the  natural 
course  of  these  secondary  cysts  is  to  open  into  each  other,  until  at  length 
only  one  large  cyst  remains.  Under  such  circumstances  it  may  be  con- 
ceived that  a rupture  might,  by  exciting  inflammation,  and  thus  destroy- 
ing the  secreting  surfaces,  or  inducing  adhesions  between  them,  cause  a 
radical  cure  of  the  disease.  Such  is  probably  the  explanation  of  those 
rare  cases  of  cysts,  well  established  in  science,  which  have  apparently 
burst,  and  rapidly  disappeared.  A case  of  this  kind  has  been  recorded 
by  Lebert,*  in  which  the  tumor  burst  into  the  peritoneum  and  subse- 
quently disappeared.  In  other  cases  the  tumor  may  unite  with  neigh- 
boring hollow  viscera,  and  by  ulceration  empty  its  contents  into  them,  so 
that  they  are  discharged  (Cases  CLXVII.,  CLXVIII.,  and  CLXIX.),  or 
it  may  open  on  the  external  surface.  When  a perfect  cure  has  been 
brought  about  in  this  way,  it  wdll  generally  be  observed  that  the  progress 
of  the  morbid  growth  has  been  chronic,  that  consequently  time  has  been 
allowed  for  all  the  secondary  cysts  to  open  into  each  other,  and  that  the 
itiflammation  which  follows  the  rupture  may  then  be  supposed  to  act  by 
obliterating  or  causing  adhesions  between  the  walls  of  the  cyst,  as  in  the 
case  of  hydrocele.  When,  on  the  other  hand,  sudden  rupture  of  the  ex- 
ternal sac  takes  place,  whilst  some  of  the  cysts  remain  entire,  the  termi- 
nation in  cure  is  impossible,  and  the  peritonitis  and  other  effects  occa- 
sioned more  frequently  cause  death. 

The  occasional  occurrence  of  such  spontaneous  recoveries  has  led  to 
the  proposition  of  producing  permanent  artificial  openings,  with  a view  of 

*Physiologie  Pathologique,  tome  ii.  p.  VI. 


OVAEIAN  DROPSY. 


781 


imitating  a natural  cure.  Mr.  Bainbridge  of  Liverpool  suggested  making 
an  incision  into  the  sac,  and  uniting  its  edges  with  the  external  'vvound ; 
and  Dr.  Tilt  of  London  has  proposed  making  a minute  aperture  by  means 
of  Vienna  paste,  so  as  to  cause  a permanent  opening.  Such  practice  can 
only  be  useful  at  a particular  period  in  the  growth  of  ovarian  tumors — 
that  is,  when  all  the  internal  cysts  have  broken  down  into  one.  But 
such  cases  are  exceedingly  rare,  and  such  practice  can  be  of  no  real 
advantage  until  we  learn  to  distinguish  in  the  living  subject  unilocular 
from  multilocular  cysts.  Numerous  cases  and  dissections  of  ovarian 
tumors  have  convinced  me,  that,  in  the  present  state  of  the  art,  this 
knowledge  is  not  to  be  arrived  at  with  any  degree  of  certainty ; and 
that  consequently  any  proposal,  however  valuable  in  itself,  which  is 
founded  upon  the  assumption  of  our  possessing  that  knowledge,  is  not 
likely  to  be  practically  beneficial.  The  same  remark  applies  to  injections 
of  the  tincture  of  iodine  or  any  other  fluid,  which  can  only  operate  on 
individual  cysts,  and  not  on  the  entire  growth. 

It  is  astonishing  how  some  individuals  accommodate  themselves  to 
very  large  abdominal  swellings.  I have  known  several  cases  where  the 
patient  has  labored  under  an  enormous  encysted  tumor  of  the  ovary 
for  ten  and  even  fifteen  years.  On  the  other  hand,  many  facts  demon- 
strate that  when  once  paracentesis  is  had  recourse  to  as  a palliative  mea- 
sure, suppuration  within  the  cysts,  and  a cachectic  state  of  the  constitution 
is  more  likely  to  supervene.  One  important  practical  rule,  therefore,  to 
be  followed  in  the  treatment  of  these  cases  is,  not  hastily  to  have  recourse 
to  tapping,  but,  rather,  by  all  possible  means  of  delay,  to  further  the 
natural  disposition,  which  the  internal  cysts  exhibit  under  pressure  of 
forming  one  large  sac.  This  once  accomplished  there  is  nothing  incon- 
sistent in  supposing  that  inflammation  produced  artiflcially  is  as  capable 
of  producing  a permanent  cure  as  is  a spontaneous  rupture.  There  is 
every  reason  to  believe  that  artificial  pressure  is  capable  of  facilitating 
the  absorption  of  the  walls  of  the  secondary  cysts,  and  their  opening  into 
each  other;  but  we  possess  no  means  of  ascertaining  when  only  one  sac 
is  produced.  That  it  has  succeeded  in  obliterating  and  ultimately  curing 
the  disease,  however,  has  been  proved  by  Mr.  Isaac  Brown,"*  who  by 
binding  a book  on  the  tumor  firmly,  has  caused  inflammation  and  disin- 
tegration of  the  internal  cysts,  and  then  letting  out  the  pus,  has  actually 
cured  some  cases.  The  practice,  however,  is  by  no  means  safe. 

Case  CLXVII.  seems  to  me  illustrative  of  the  efiects  of  pressure.  It 
must  be  acknowledged  that  the  seven  months  which  had  elapsed  between 
the  time  the  tumor  was  first  perceptible,  and  the  period  when  it  spon- 
taneously burst  into  the  bladder  and  collapsed,  was  a remarkably  short 
one.  In  the  most  favorable  cases  this  result  takes  about  two  years  to 
accomplish  by  itself ; but  in  the  instance  of  Pyper,  the  tumor  was  sub- 
jected to  the  gradually  increasing  and  equable  pressure  of  the  pregnant 
uterus,  and  to  its  influence  must,  I think,  be  attributed  the  fortunate 
result  and  rapid  breaking  down  of  the  secondary  cysts.  The  ulceration 
into  the  bladder  was  probably  determined  by  the  direction  the  pressure 
had  assumed  in  this  case,  and,  of  course  could  not  be  imitated  artificially. 

There  still  only  remain  two  methods  of  curing  an  ovarian  dropsy  by 
art — viz.,  1st  by  excison ; and  2d,  by  pressure  followed  by  puncture. 

* See  cases  recorded  in  the  Lancet. 


V82 


DISEASES  OP  THE  GENITO-UEINARY  SYSTEM. 


Cases  CLXVII.  and  CLXVIII.  confirm  the  views  suggested  by  pathology 
with  regard  to  the  modus  operandi  of  the  latter  treatment;  and  if  in  cases 
which  do  not  admit  of  extirpation,  pressure  be  so  gradually  and  equably 
applied  as  to  obliterate  the  internal  or  secondary  cysts,  an  artificial  open- 
ing then  made  would  cure  the  disease.  The  difficulty  is  to  ascertain 
when  the  moment  for  making  the  puncture  has  arrived — in  other  words, 
when  a multilocular  is  converted  into  a unilocular  cyst.  In  the  present 
state  of  the  art,  this,  as  I have  said,  is  impossible  ; but  as  an  exact  in- 
dication of  the  difficulty  is  often  the  best  preliminary  to  its  removal, -I 
do  not  despair  of  one  day  seeing  it  completely  conquered  by  the  cultiva- 
tors of  medicine. 

As  regards  excision,  the  practice  of  late  years  has  tended  to  confirm 
its  propriety  in  such  cases  as  that  of  Fleming,  (Case  CLXVI.),  in  which 
the  tumor  has  no  adhesions  of  any  extent  to  the  abdominal  walls,  where 
its  presence  is  the  cause  of  great  deformity  and  much  suffering,  and  where 
the  youth  and  general  health  of  the  patient  and  freedom  from  other 
diseases,  hold  out  hopes  of  a favorable  termination.  The  general  result 
of  the  now  numerous  operations  by  Clay,  Atlee,  Baker  Brown,  Spencer 
Wells,  Thomas  Keith,  and  others,  is  about  one  death  in  three,  although 
there  is  a belief  that  if  greater  care  were  observed  in  choosing  only  ap- 
propriate cases,  the  ratio  of  mortality  would  be  much  diminished. 


NEPHRITIS  AND  PYELITIS. 


Case  CLXX.* — Acute  Nepliro^Pyelittis — Recovenj. 

History. — Helen  Kessick,  set.  65,  a nurse — admitted  November  25,  1852.  States 
that  for  the  last  twenty  years  she  has  been  subject  at  intervals  to  occasional  pains  in 
the  lumbar  region.  She  had  never  experienced  any  difficulty  or  uneasiness  in  mictu- 
rition, till  about  five  years  ago,  when  she  noticed  that  the  urine  was  tinged  with  blood ; 
this  was  accompanied  with  pain  in  the  right  lumbar  region,  preceded  by  shivering, 
and  followed  by  febrile  symptoms.  She  was  admitted  into  the  Royal  Infirmary,  where 
she  remained  for  seven  weeks,  and  was  dismissed  cured.  She  had  no  return  of  the 
symptoms  till  about  twelve  months  ago,  when  she  was  again  seized  with  shivering,  and 
a return  of  the  lumbar  pain.  During  the  summer  the  urine  was  tinged  with  blood  for 
two  days,  but  afterwards  again  became  normal,  and  she  continued  better  till  about 
four  weeks  ago,  when  she  once  more  experienced  pain  on  passing  water,  which,  with 
increased  uneasiness  in  the  lumbar  region,  has  continued  up  to  the  present  date. 

Symptoms  on  Admission. — On  admission,  tongue  much  furred  ; appetite  bad ; great 
thirst ; no  nausea ; complains  of  pain  in  the  epigastric  region,  but  no  tumor  or  hard- 
ness can  be  detected ; bowels  have  not  been  opened  for  two  days.  She  has  considerable 
pain  in  right  lumbar  and  both  hypochondriac  regions,  also  in  the  hypogastrium  after 
making  water,  which  is  passed  in  less  quantity  than  usual.  Urine  sp.  gr.  1016,  coag- 
ulable  by  heat  and  nitric  acid,  and  deposits,  on  standing,  a copious  ropy  mucus-like 
sediment,  showing,  under  the  microscope,  large  quantities  of  pus  globules,  and  a few 
crystals  of  triple  phosphate ; pulse,  76,  soft ; no  palpitation  of  heart ; complains  of 
occasional  headache  with  frequent  giddiness,  and  muscae  volitantes  ; sleeps  ill  at  night, 
and  complains  much  of  cold  feet ; other  functions  normal.  Liquor.  Potass.  ; Bp. 
Addi.  Nit.  afi  3 ij  ; Bol.  Mur.  Morph.  3 iii ; Mist.  Camph.  ? v.  M.  Snniat  3 ss  quarid 
qudqnehord.  R 01.  Ricini  ^j.  Sumat  siatim.  To  nse  barley  roater  as  a drink. 

Progress  of  the  Case. — December  Uh. — Feels  very  weak  ; continues  otherwise  in 
much  the  same  state ; urine  still  albuminous,  with  copious  deposits,  containing  pus  and 

* Reported  by  Mr.  F.  B.  de  Chaumont,  Clinical  Clerk. 


NEPHRITIS  AND  PYELITIS. 


783 


triple  phosphates.  To  have  3 oz.  of  loine.  Dec.  11. — Continued  to  improve  till  last 
nignt,  when  she  was  seized  with  shivering  and  pain  in  lumbar  and  epigastric  regions; 
great  nausea  and  vomiting ; tongue  moist,  but  much  furred  ; great  headache  ; urine  as 
before.  Omitt.  mist,  et  vinum.  R Sol.  Antimon  3 iij  ; Sp.  AEth.  Nit.  3 j ; Aquae  Acet, 
Ammon,  et  Aquae  § iiss.  M.  Sumat  ter  indie.  Warm  fomentations  to  be  ap- 
plied to  the  loins.  Dec.  13. — Was  rather  better  yesterday,  but  has  still  pain  in  right 
lumbar  region.  To-day  she  is  still  sick,  the  pain  in  right  lumbar  region  somewhat 
increased ; there  is  great  dysuria ; the  urine  is  of  high  color  ; still  albuminous,  sp.  gr. 
1018,  with  copious  sediment,  showing,  under  the  microscope,  numerous  blood  globules, 
and  a quantity  of  debris  of  cells  mixed  with  the  pus  and  triple  phosphates,  which  are 
still  as  abundant  as  formerly.  Dec.  l^th. — Was  no  better  yesterday,  and  began  to 
complain  of  severe  pain  in  the  hypogastrium.  Omitt.  mist.  Tinct.  Hposcijam.  § ss  ; 
Sol.  Mur.  Morph.  3 iss  ; Mucilaginis  ^ij  ; Aquae  §iii.  M.  Sumat  3 j ter  in  die.  To-day 
she  still  complains  of  the  pain  in  hypogastric  and  lumbar  regions.  The  urine  is 
diminished  in  quantity,  and  deposits,  on  standing,  a viscid  tenacious  sediment,  which, 
in  addition  to  the  blood  corpuscles,  pus,  and  triple  phosphates,  now  shows  casts  of  the 
urinary  tubes,  crowded  with  granules.  7b  he  cupped  on  the  lumbar  region  to  8 oz. 
Dec.  16^/i. — Only  6 oz.  were  obtained  by  the  cupping.  The  pain  in  back  is  much 
relieved,  and  she  is  able  to  sit  up  in  bed  without  uneasiness,  but  there  is  still  pain  in 
the  hypogastrium  ; pulse  72,  soft;  tongue  still  furred;  no  nausea  or  vomiting,  but  some 
pain  in  the  bowels  ; headache  nearly  gone  ; urine  of  a dirty  red  color,  still  coagulable, 
showing  blood,  pus,  and  phosphates  under  the  microscope,  as  before.  Habeat  enema 
domesticum  et  sumat  Sol.  Mur.  Morph.  3 ss.  et  Mucilaginis  3 j ex  aquf  hord  somni. 
Dec.  ISth. — Symptoms  much  the  same  as  at  last  report.  Urine  sp.  gr.  1015,  and  again 
shows  casts  of  the  urinary  tubes.  The  bladder  was  sounded  to-day,  but  nothing  ab- 
normal could  be  detected.  Dec.  20th. — Urine  contains  a large  quantity  of  gelatinous 
mucus,  in  which  a few  broken-down  granular  casts  can  bo  detected.  Sol.  Mur. 
Morph.  3 ss  ; Tinct.  Hyoscyam.  3 i ; Mucilaginis  3 j ; Fiat,  haust.  omni  nocte  sumcndus. 
U-  Decoct,  llvce  Ursi  | x ; Tinct.  Hyoscyam.  3 j ; Sp.  jEih.  Nit.  | j ; Mucilaginis  § ij. 
M.  swnat  3 i ter  indie.  Dec.  20th. — Continues  in  much  the  same  state,  but  the  pain 
in  the  hypogastrium  has  considerable  increased.  She  had  some  sweating  last  night, 
and  the  pulse  is  now  86  and  soft ; the  tongue  is  still  furred  ; no  appetite  ; great  thirst; 
bowels  not  open  for  some  days ; great  dysuria  ; urine  presents  the  same  characters  as 
before.  Applic.  hirudines  quatuor  hypogastrio  et  postea  bene  fovcatur.  Pulv. 
Jalapce  et  Pulv.  Scammon.  aa  gr.  vi.  M.  Sumat  hord  somni\  Sol.  Adur.  Morph. 
3ss;  Mucilaginis  §j.  M.  Sumat  eras  mane.  Dec.  20th. — The  pain  in  the  hypogas- 
trium having  greatly  abated,  the  leeches  were  omitted  at  the  patient’s  request ; the  bowels 
were  weli  opened  by  the  medicine.  To-day  she  feels  much  better,  and  slept  well  with- 
out the  draught.  Tongue  more  clean  and  moist,  but  the  urine  contains  rather  more 
blood.  Jayiuary  li7,  1853. — She  still  continues  improving,  but  pain  in  the  hypogas- 
trium is  not  quite  gone.  The  urine  is  more  natural  in  color,  the  deposit  greatly  de- 
creased, and  the  blood  has  now  disappeared.  Alarch  0th. — Since  last  report  has  expe- 
rienced occasional  lumbar  pain,  but  on  the  whole  has  been  slowly  getting  well.  The 
urine,  which  has  gradually  been  geiting  clearer,  is  reported  to-day  as  quite  normal, 
and  free  from  albumen.  A slight  hernial  protrusion  has  been  discovered  in  the  right 
iliac  region,  to  which  a truss  was  applied.  March  2%th. — Dismissed  relieved  of  all 
her  symptoms. 

Commentary.—  This  was  a case  of  acute  nepl)ritis,  with  tendency  to 
recurrence,  exhibiting  local  pain,  inflammation  of  the  mucous  membrane 
(pyelitis),  as  shown  by  the  excessive  discharge  of  mucus  and  pus,  and 
inflammation  of  the  secreting  substance  of  the  organs,  as  proved  by  the 
frequent  appearance  of  blood,  casts  of  the  tubes,  and  the  persistent 
albumen.  During  a period  of  four  months,  however,  during  which  a 
variety  of  treatment  was  had  recourse  to,  as  recounted  in  the  report,  all 
the  urinary  symptoms  disappeared,  although  there  was  still  a tendency 
to  the  return  of  pain  in  the  lumbar  region.  This  case  indicates  the  mode 
in  which  acute  cases  of  the  kidney  frequently  pass  into  chronic  ones ; 
but  from  the  circumstance  that  the  right  kidney  only  was  attacked,  and 
that  the  left  one  could  still  secrete  a sufficient  quantity  of  urine,  no 
oedema  or  dropsy  occurred. 


784 


DISEASES  OF  THE  GENITO-URINAKY  SYSTEM. 


Case  CLXXI.^ — Suhamite  Nephritis^  with  great  Anasarca — Recovery. 
Acute  Nephritis  of  Left  Kidney — Recovery. 

History. — Anne  Hewison,  set.  18,  a servant — admitted  Dec.  14th,  1856.  She  has 
been  in  the  Surgical  Hospital  on  three  occasions  during  the  last  four  months,  on  account 
of  abscesses  in  and  about  the  axillae,  from  which  she  is  now  free.  For  six  weeks  she 
has  experienced  pain  in  the  lumbar  regions,  most  severe  when  the  weather  was  cold, 
and  increased  by  coughing  and  hard  breatliing.  A fortnight  ago  she  observed  that 
the  feet  and  abdomen  were  swollen.  Since  then  she  has  become  slightly  anasarcous. 

Symptoms  on  Admission. — The  integument  all  over  the  body  is  oedematous,  and 
the  face  especially  is  considerably  swollen.  All  the  depending  parts  of  the  trunk, 
together  with  the  extremities,  are  pale,  pitting  readily  on  pressure.  The  catamenia 
have  appeared  on  three  occasions  at  the  interval  of  a fortnight,  and  been  very  copious. 
The  urine  is  highly  albuminous,  sp.  gr.  1010,  diminished  greatly  in  quantity,  but  the 
exact  amount  cannot  be  ascertained.  Numerous  waxy  casts  are  visible  in  it  under  the 
microscope.  The  chest  is  resonant  everywhere  on  percussion.  Sibilant  sounds  are 
audible  at  the  apex  of  right  lung,  both  with  inspiration  and  expiration,  the  remains, 
she  says,  of  a cold  that  has  troubled  her  for  five  weeks.  She  suffers  occasionally  from 
palpitation ; but  the  circulatory  system  on  examination  is  normal.  Pulse  80,  of  good 
strength.  The  abdomen  very  tumid,  with  distinct  fluctuation,  and  painful  on  pressure 
over  the  whole  anterior  surface,  but  most  so  on  the  right  side  opposite  the  lumbar 
region.  The  digestive  system,  otherwise,  and  the  nervous  functions,  are  normal. 
Habeat  Potass.  Bitart.  Dj  ter  in  die. 

Progress  of  the  Case. — December  \%th. — The  amount  of  urine  passed  is  greatly 
increased  and  has  amounted  to  51  oz.  during  the  last  24  hours.  Dec.  'lOth. — The  whole 
body  is  now  much  less  oedematous.  Pulse  75.  Passed  150  oz.  of  urine  during  the 
last  24  hours.  Dec.  ^loth. — Has  passed  about  100  oz.  of  urine  daily,  which  is  pale, 
sp.  gi’.  1010,  and  now  only  faintly  albuminous.  (Edema  of  extremities  has  now  disap- 
peared, but  still  some  swelling  of  face  and  abdomen.  There  are  slight  febrile  symp- 
toms. Pulse  100,  weak.  Complains  to-day  of  sore  throat.  The  tonsils  are  enlarged, 
and  the  mucous  membrane  of  fauces  congested.  An  astringent  gargle  was  ordered., 
and  warm  poultices  to  be  applied  to  the  throat.  Dec.  26(/o — Yesterday  afternoon  and 
to-day  she  passed  urine  of  a dark-brown  color.  It  is  highly  albuminous,  with  a sedi- 
ment composed  of  urates  and  blood  discs,  as  seen  under  the  microscope.  There  is 
pain  in  the  left  loin.  Throat  not  so  painful.  Face  anxious.  Pulse  90,  of  good  strength. 
To  omit  the  bitartrate  of  potass.  IJ  Sp.  jEther.  Nit.  3 ij  ; Mucilaginis  § ij  ; Aq.  Font. 
§\'j.  M.  Two  table-spoonfuls  to  be  taken  every  four  hours  ; warm  fomentations  to  the 
left  lumbar  region.  Dec.  28^/i. — Has  continued  to  feel  pain  in  the  left  loin,  which  is  in- 
creased on  pressure.  Has  passed  24  oz.  of  urine  during  the  last  24  hours,  highly  albu- 
minous, less  dark,  and  now  of  a light  chocolate  color,  turbid,  with  no  layer  of  fat 
perceptible  on  repose,  but  numerous  tube-casts  and  some  urates  and  blood  corpuscles 
seen  in  it  with  the  microscope.  All  sore  throat,  fever,  and  oedema  of  the  integuments 
have  now  di>=appeared.  Pulse  84,  firm,  Dec.  ^\st. — Has  passed  from  50  to  60  oz.  of 
urine  daily.  Has  still  dull  pain  in  the  loins,  but  otherwise  better.  From  this  time  she 
began  to  sit  up  and  walk  about  the  ward.  The  lumbar  pains  returned  at  intervals,  but 
finally  left  her  Ja7i.  2Uh.  The  urine  also  retained  a trace  of  albumen  for  sometime  ; 
occasionally,  however,  disappearing  fora  day.  On  the  l^thof  Jan.  she  took  Potass. 
Bitart.  gr.  x.  ter  in  die.  The  urine  was  examined  daily,  and  on  Jan.  Tlth  up  to  the 
30^/q  not  a trace  of  albumen  could  be  discovered.  She  was  then  dismissed  quite  well. 

Commentary . — In  this  case,  a somewhat  chronic  form  of  nephritis 
or  Bright’s  disease  appeared  before  her  admission,  which  occasioned 
intense  general  anasarca  of  the  body,  and  was  characterised  by  albumi- 
nous urine  containing  numerous  waxy  casts.  The  oedematous  face  and 
general  appearance  were  in  this  girl  highly  distinctive  of  renal  dropsy. 
The  strong  diuretic  effects  of  the  bitartrate  of  potash  in  scruple  doses, 
caused  this  to' disappear.  She  was  then  seized  with  acute  nephritis  of 
the  left  kidney,  as  indicated  by  the  febrile  symptoms,  pain  in  the  left 
loin,  increased  on  pressure,  bloody  and  turbid  urine,  etc.  From  this 


* Reported  by  Mr.  M‘Leod  Pemberton,  Clinical  Clerk. 


NEPHRITIS  AND  PYELITIS. 


'785 


also  she  gradually  recovered  under  the  employment  of  gentle  diuretics, 
demulcents,  and  warm  fomentations  locally.  All  trace  of  tendency  to 
permanent  albuminuria — so  common  a sequela  of  nephritis — was  also  got 
rid  of  by  the  action  of  small  doses  of  cream  of  tartar.  The  occurrence 
of  sore  throat  and  febrile  symptoms  with  this  last  attack,  induced  me 
to  inquire  carefully  as  to  whether  there  was  any  proof  of  scarlatina,  but 
I could  not  discover  any. 

Case  CLXXII.* — Acute  Desquamative  Nephritis^  proving  rapidly 
fatal  from,  Diminished  flow  of  Urine,,  General  Anasarca,  and 
(Edema  of  the  Lungs. 

History. — William  Lawson,  set.  34,  married,  was  admitted  to  the  Skin  Ward 
November  28,  1856,  for  an  attack  of  scabies,  which  had  lasted  four  months.  He 
has  been  drinking  freely  lately — is  anaemic  and  emaciated.  On  examination, 
innumerable  minute  isolated  vesicles  are  to  be  seen  scattered  over  the  whole  body, 
with  the  exception  of  the  head  and  neck ; most  abundant  on  the  flexor  surfaces. 
On  the  legs  there  are  a few  patches  of  eczema.  Dec.  2d. — He  was  ordered  to  rub 
himself  all  over  twice  a day  with  simple  lard,  which,  on  the  6th,  was  exchanged  for 
sulphur  ointment. 

Commencement  of  the  Disease. — December  \lth. — Especial  attention  was  directed 
to  him  to-day  in  consequence  of  cough  and  evident  dyspnoea.  He  thinks  he  must 
have  caught  cold  from  being  so  long  naked  when  employed  rubbing  himself.  Since 
the  '7th  he  has  observed  slight  oedema  of  his  feet,  which  was  followed  by  coufih. 
He  has  paid  little  attention  to  these  symptoms.  The  urine  is  found  to  be  highly 
albuminous  and  of  brownish  color.  On  microscopic  examination  of  the  sediment, 
it  was  seen  to  contain  numerous  desquamative  tube  casts.  His  cough  troubles  him 
chiefly  at  night,  when  he  finds  there  is  difficulty  in  breathing  or  lying  in  the  hori- 
zontal posture.  On  percussion  there  is  slight  impairment  of  resonance  over  right 
chest  anteriorly,  below  level  of  third  rib.  There  is  no  increase  of  vocal  resonance. 
The  respiratory  murmurs  are  more  feeble  than  on  the  left  side,  and  inspiration  is 
occasionally  sibilant.  Posteriorly,  percussion  over  lower  half  of  both  sides  gives 
resonance  of  a somewhat  flat  tone.  Fine  moist  sounds  attend  the  close  of  inspira- 
tion, and  expiration,  feeble  below,  is  exaggerated  superiorly.  8p.  uEther.  Nit. 

I ss ; Tr.  Digitalis;  Tr.  Scillce,  aa  3 iss  ; Aquam  ad  ^ vi.  M.  A table-spoonful  to  be 
taken  every  four  hours. 

Progress  of  the  Case. — December  \2th. — Over  dull  region  anteriorly  moist 
sounds,  clicking  in  character  and  few  in  number,  attend  the  extreme  close  of  inspira- 
tion. Vocal  resonance  also  slightly  increased  in  area  of  dulness,  and  posteriorly 
there  is  slight  comparative  dulness  over  middle  third  of  right  side.  Urine  of 
brown  smoky  color,  with  blood  corpuscles  visible  under  the  microscope.  Sputum 
scanty,  purulent,  not  streaked  with  blood.  Extract  ^ iv  of  blood  from  the  loins  by 
cupping.  Omit  the  mixture.  To  have  3 ss  of  Bitartrate  of  Potash  three  times  a day, 
and  § ij  of  Grin  daily.  December  IMh. — Since  last  report  the  dyspnoea  has  been  gradual- 
ly increasing,  and  the  pulse  becoming  weaker.  It  is  now  100,  and  soft.  The  sputum 
is  scanty,  purulent,  not  tinged  with  blood.  Percussion  over  both  lungs  inferiorly 
and  posteriorly  is  impaired,  especially  on  the  right  side.  On  auscultation,  a fine 
moist  rattle  accompanies  the  inspiration,  and  there  is  an  increase  of  the  vocal  reson- 
ance. Urine  presents  the  same  characters  as  formerly,  and  contains  chlorides  in 
abundance,  but  does  not  amount  to  § xx  daily.  The  gin  is  increased  to  § iij 
daily.  To  have  § iv  of  port  wine  in  addition.  U Ammon.  Carb.  Dij  ; Tr.  Card.  Comp. 
3 j ; Aquam  ad  f vj  ; Ft.  mist.  A table-spoonfal  to  be  taken  every  second  hour.  December 
nth. — Has  been  steadily  getting  worse.  The  respirations  are  now  40  in  the  minute, 
and  he  is  obliged  to  retain  the  sitting  posture.  Takes  no  nourishment.  Pulse  126, 
very  feeble.  Crepitation  and  increased  vocal  resonance  now  heard  posteriorly  as  high 
as  spine  of  scapula.  No  pain.  Pulse  80,  of  good  strength.  To  be  dry  cupped  over 
chest  and  back ; warm  bottles  to  feet.  Towards  evening  the  face  more  pallid,  hands 
and  forearms  cold  and  slightly  oedematous.  At  9 p.m.  the  breathing  was  48  per 
minute,  and  so  labored  that  he  was  bled  to  about  | xiij.  Towards  close  of  venesec- 
tion the  pulse  at  the  left  wrist,  previously  imperceptible,  could  be  detected  small  and 


60 


* Reported  by  Mr  Wm  Guy  Clinical  Clerk. 


786 


DISEASES  OF  THE  GENITO-URINARY  ST  STEM. 


exceedingly  weak ; and  patient  (on  inquiry)  admitted  himself  to  be  slightly  relieved 
although  to  others  this  was  not  perceptible.  Fifteen  minims  of  Sol.  Mur.  Morph, 
ordered.  December  \d>ih. — His  wife  states  that  he  slept  from  three  to  six  o’clock  this 
morning.  The  dyspnoea  is  as  great  as  before  the  venesection  ; respiration  catching  in 
character.  Has  passed  very  little  urine,  and  that  at  stool ; on  examination  it  was  found 
to  contain  pus  corpuscles  in  considerable  quantity,  besides  the  casts  before  mentioned. 
He  is  obliged  to  sit  up  and  lean  forward  in  bed ; his  intellect  is  somewhat  impaired. 
During  the  night  delirious.  December  20^A. — Evidently  sinking,  but  conscious.  Z>e- 
cember  21st.- — Died  this  morning  at  half-past  three  o’clock. 

Sectio  Cadaver  is. — Thirty -three  hours  after  death. 

The  body  is  generally  anasarcous,  with  great  oedema  of  the  scrotum  ; surhtce  pale ; 
no  trace  of  scabies,  with  the  exception  of  a few  small  circular  cicatrices  about  the 
hands  and  fingers. 

Thorax. — All  the  cavities  of  the  heart  and  large  vessels  were  distended  with 
blood,  for  the  most  part  coagulated  and  decolorized.  The  cavities  of  the  heart 
itself  in  consequence  were  dilated.  This  was  especially  observed  of  the  left  ventricle, 
the  walls  of  which  were  rather  thinner  than  natural.  The  pericardium  and  all  the 
valves  were  healthy.  The  heart  weighed  16  oz.  The  right  pleura  was  everywhere 
strongly  adherent.  The  right  lung  was  moderately  voluminous,  and  felt  heavy. 
On  section,  it  was  seen  to  be  highly  cedematous,  yielding  on  pressure  a copious  frothy 
fluid.  No  solid  exudation  anywhere.  The  left  lung  was  unadherent,  and  rather 
less  voluminous  than  the  right  one,  and  though  cedematous  was  not  so  in  the  same 
degree. 

Abdomen. — On  stripping  off  the  capsule  from  the  surface  of  the  kidneys,  they 
both  appeared  of  their  normal  size,  and  of  a pale  fawn  color.  When  cut  into,  the 
cones  were  found  somewhat  congested,  the  cortical  tissue  pale.  Tlie  latter  con- 
tained numerous  white  lines  or  streaks,  generally  directed  at  right  angles  to  the 
circumference  of  the  organ.  There  was  no  trace  of  granulation,  and  the  density  of 
the  kidneys  was  much  diminished,  the  organs  being  more  soft  than  usual.  The  liver 
was  congested,  but  otherwise  normal ; it  weighed  4 lbs.  The  other  abdominal  viscera 
were  healthy. 

Microscopic  Examination. — On  scraping  a fresh  cut  surface  of  the  kidney,  a 
pulpy  matter  was  readily  obtained,  which,  on  examination  under  a power  of  250  dia- 
meters, was  seen  to  be  composed  of  large  fragments  of  the  tubes,  crowded  with  epi- 
thelial cells,  which  were  agglutinated  together  by  a fine  molecular  matter.  Groups  of 
these  cells  surrounded  by,  or  imbedded  in,  this  molecular  substance,  could  also  be  seen 
isolated.  On  the  addition  of  acetic  acid,  the  molecular  matter  and  the  walls  of  the 
cells  were  rendered  more  transparent,  whilst  the  nuclei  were  unaffected.  The  urine 
in  the  bladder  contained  a few  desquamative  casts  of  the  tubes,  spermatozoa,  and  a 
number  of  isolated  epithelial  cells  from  the  kidney. 

Commentary. — The  acute  disease  of  which  this  man  died  came  on 
in  the  ward  during  the  inunctions  he  practised  over  the  body  in  order 
to  remove  a chronic  scabies,  which  extended  itself  to  a great-  extent  over 
the  integument.  The  first  approach  was  so  slow  as  not  to  excite  at- 
tention— he  himself  considering  it  as  an  ordinary  cold.  On  the  10th 
of  December,  when  cough  and  some  dyspnoea  attracted  my  notice,  the 
feet  and  legs  were  already  cedematous,  and  the  urine  diminished  in 
quantity,  as  well  as  highly  albuminous.  It  was  observable,  however, 
that  there  were  no  symptoms  of  fever,  no  local  pain,  and  the  question 
arose  whether,  in  conjunction  with  diminished  urinary  excretion  there 
was  or  was'  not  pneumonia.  My  diagnosis  in  the  negative  was  assisted 
not  only  by  the  absence  of  febrile  symptoms,  and  by  the  loud  and 
superficial  character  of  the  crepitating  rale  in  both  lungs  spreading 
upwards,  but  by  the  constant  presence  of  chlorides  in  the  urine  (see  p. 
686).  On  the  other  hand,  the  chemical  and  microscopical  examination 
of  the  urine  soon  left  us  in  no  doubt  that  we  had  to  do  with  an  acute 
attack  of  desquamative  nephritis,  producing  general  anasarca,  and  more 
especially  rapid  oeJema  of  the  lungs.  This  diagnosis  was  fully  confirmed 


NEPHRITIS  AND  PYELITIS. 


'787 


by  tlie  dissection  after  death,  the  cortical  portion  of  the  kidneys  being 
pale  and  comparatively  free  from  blood,  whilst  the  tubes  were  gorged 
with  exudative  granular  matter,  mingled  with  a mass  of  epithelial  cells. 
Both  lungs,  especially  the  right  one,  were  infiltrated  with  serum.  The 
rapid  progress  of  this  case,  evidently  dependent  on  obstruction  of  the 
renal  tubes,  seemed  to  demand  active  remedies.  But  the  state  of  the 
pulse  and  tendency  to  prostration  from  the  commencement  forbade 
antiphlogistic  remedies,  even  had  other  considerations  not  pointed  out 
their  inutility  (see  p.  318.)  For  the  same  reasons,  diaphoretics  were 
too  slow  and  uncertain  in  their  action  to  be  depended  on,  although 
morphia  and  local  warmth  were  tried.  Diuretics,  therefore,  were  given, 
and  subsequently  stimulants  to  counteract  exhaustion,  a practice  which, 
though  condemned  b}^  some  on  the  principle  that  we  stimulate  an  organ 
already  in  a state  of  irritation,  we  have  too  frequently  seen  succeed 
when  all  other  remedies  have  failed,  to  have  any  doubt  as  to  its  value. 
The  real  danger,  however,  in  this  case  was  early  to  be  traced  to  the 
consecutive  efiPect  on  the  lungs,  and  the  difficulty  the  heart  experienced 
in  propelling  the  blood  through  those  organs,  so  that  at  length  as  a 
palliative  I determined  on  venesection.  The  man’s  arm  was  so  oedema- 
tous,  and  the  vein  so  small,  that  I was  obliged  to  perform  the  operation 
myself,  and  it  is  remarkable,  as  illustrative  of  the  infrequency  of 
phlebotomy  now-a-days,  that  of  three  advanced  students  present  only 
one  had  ever  seen  an  individual  bled,  and  that  the  nurse  who  held  the 
basin  fainted  away.  At  this  time  the  man’s  pulse  was  imperceptible  at 
the  wrist,  although  the  heart’s  action  was  strong.  He  stated  that  he  felt 
somewhat  better,  but  I regretted  to  observe  that  little  or  no  relief  was 
afforded  to  him. 

Case  CLXXIII.^ — Acute  Desquamative  and  Hemorrhagic  Nephritis 
— Hydrothorax — Collapse  of  the  right  Lung — Pulmonary  (Edema 
and  Bronchitis^  with  symptoms  of  Pneumonia. 

History. — Andrew  Cr.aig,  set.  45,  a waiter,  stout  and  fat — admitted  July  1st, 
1851.  He  has  had  delirium  tremens  several  times,  and  been  of  very  dissipated 
habits.  Six  days  ago,  after  unusual  exertion,  during  which  he  was  exposed  to  wet, 
he  was  seized  with  rigors,  fever,  and  vomiting.  Next  day  he  observed  his  feet  to 
be  oedematous,  and  his  urine  to  be  highly  colored ; cough  and  expectoration  subse- 
quently made  their  appearance,  and  yesterday  the  breathing  became  very  difficult ; 
symptoms  which  continued  to  increase. 

Sy.mptoms  on  Admission. — On  admission  the  body  generally  is  anasarcous,  and  the 
face  puffy  and  bloated.  He  labors  under  great  dyspnoea,  has  a troublesome  cough, 
accompanied  with  a viscid  sputum,  in  some  places  of  a rusty  color,  and  in  others 
mingled  with  clots  of  blood  the  size  of  a pea.  On  percussion  there  is  marked  com- 
parative dulness  at  the  base  of  right  lung  anteriorly,  extending  two  inches  above  the 
hepatic  dulness.  Inspiratory  murmur  over  this  dull  portion  is  accompanied  by 
harsh  and  tubular  breathing,  with  increase  of  the  vocal  resonance.  Posteriorly,  also, 
marked  dulness  on  right  side,  over  lower  half  of  lung,  with  loud  crepitation  on  inspi- 
ration, and  bronchophony.  The  heart  sounds  are  quick,  healthy  in  character,  impulse 
strong.  Pulse  100,  feeble.  The  urine  is  of  a dark  brown  color,  turbid,  and  much 
diminished  in  quantity;  sp.  gr.  1014;  highly  coagulable  on  the  addition  of  heat  and 
nitric  acid,  and  exhibiting  under  the  microscope  numerous  desquamative  casts,  mingled 
with  blood  corpuscles.  Other  functions  normal.  H Vin.  Antim.  3 ij  ; Sp.  jEther. 
Pit.  3 ij  ; AqucB  § vss.  M.  A tahle-spoonful  to  he  taken  every  four  hours.  To  have 
3 iij  of  wine  daily. 


* Reported  by  Mr.  W.  M.  Calder,  Clinical  Clerk. 


18B 


DISEASES  OF  THE  GENITO-URINAEY  SYSTEM. 


Progress  of  the  Case. — 2d. — The  dulness  and  crepitation  posteriorly  is  now 
as  high  as  the  middle  of  scapula  on  right  side,  and  there  is  commencing  dulness,  with 
crepitation  audible  low  down,  posteriorly  over  left  lung.  Dyspnoea  increased.  Other 
symptoms  the  same.  To  be  cupped  over  chest,  and  2 v of  blood  extracted.  Hab. 
Pidv.  Jalap,  comp.  3 j-  J^dy  Zd. — Dulness  now  extends  over  two  thirds  of  both  lungs 
posteriorly  and  inferiorly,  with  loud  bubbling  rattles  on  inspiration,  and  bronchophony. 
Anasarca  has  greatly  increased,  the  lower  extremities  and  the  scrotum  being  enlarged 
and  distended.  Only  8 oz.  of  urine  passed  since  yesterday,  and  of  dirty  brown  color, 
and  turbid ; otherwise  the  same.  Bowels  well  open.  Dyspnoea  now  urgent.  Cough 
frequent  and  troublesome.  Sputum  pneumonic.  Pulse  120,  weak.  To  have  Pot. 
Bitart.  3 three  times  a day.,  and  3 iij  of  gin  instead  of  the  wine ; nutrients.  July 
Ath. — Has  passed  16  oz.  of  urine,  and  is  somewhat  better.  Prostration  continues 
great.  Otherwise  the  same.  July  hth. — Comatose,  and  evidently  sinking.  He  ex- 
pired on  the  morning  of  the  Uh. 

Sectio  Cadaveris. — Fifty  hours  after  death. 

Anasarca  of  the  whole  body. 

Head. — The  subarachnoid  cavity  contained  a considerable  quantity  of  fluid,  ele- 
vating the  surface  above  the  convolutions.  The  lateral  ventricles  contained  little 
serum.  Otherwise  normal. 

Thorax. — Each  pleural  cavity  contained  about  a pint  of  sero-sanguinolent  fluid. 
Both  lungs  condensed  from  collapse  posteriorly,  but  crepitant  anteriorly.  On  section 
they  presented  a smooth  surface  of  purple  color,  and  yielded  on  pressure  a copious 
frothy  fluid.  The  large  bronchi  were  filled  with  muco-purulent  matter,  and  their 
lining  membrane  was  stained  of  a dark  mahogany  color,  and  highly  congested. 
Heart  weighed  19  oz.  Hypertrophy,  with  dilatation  of  right  ventricle.  Valves  healthy. 

Abdomen. — Kidneys  of  large  size,  the  two  weighing  18  oz.  They  were  externally 
of  a brownish  purple  color,  the  vessels  everywhere  congested,  with  hsemorrhagic  spots, 
the  size  of  pins’  heads,  scattered  numerously  over  their  surface.  On  section,  the  cor- 
tical substance  was  mottled  ; the  dark  congested  patches  being  mingled  with  white, 
opaque,  and  fawn-colored  substance.  The  malpighian  bodies  here  and  there  were 
tinged  with  blood.  The  tubular  cones  were  of  a deep  purple  color,  especially  towards 
their  base.  The  mucous  membrane  of  the  pelvis  moderately  congested.  Liver  con- 
gested and  somewhat  enlarged.  Other  organs  normal. 

Microscopic  Examination. — The  fawn-colored  portion  of  the  cortical  substance 
of  the  kidneys  was  soft,  and  the  tubes  crowded  with  desquamated  epithelial  cells 
mingled  with  molecular  exudation.  The  vessels  in  the  congested  parts  were  tinged 
with  blood.  The  haemorrhagic  spots  depended  on  the  extravasation  of  blood  into  one 
or  more  convolutions  of  the  tubes. 

Commentary. — This  case  was  in  many  respects  like  the  last,  but  its 
progress  was  even  more  rapid.  The  pulmonary  oppression  and  oedema 
came  on  more  quickly,  and  having  been  at  first  confined  to  the  right 
side,  accompanied  with  tenacious  sputum  of  a rusty  color,  and  ushered 
in  by  rigors  and  febrile  symptoms,  presented  all  the  symptoms  and 
physical  signs  of  a pneumonia.  Thus  the  febrile  attack  corresponded 
with  the  commencing  period  of  the  supposed  pneumonia.  Then  the  man 
was  a waiter,  and  an  habitual  tippler,  and  we  were  called  upon  to  decide 
whether  the  acute  symptoms  were  connected  with  the  lung  or  with  the 
kidney.  Now  it  is  rare  to  see  a case  of  acute  nephritis  producing  gener- 
al anasarca,  and  running  its  course  so  rapidly,  and  in  consequence  we 
considered  the  renal  disease  to  have  been  chronic — in  short,  an  ordinary 
case  of  Bright’s  disease,  with  supervening  pneumonia.  It  turned  out, 
however,  to  be  an  acute  attack  of  nephritis,  accompanied  by  rigors,  fever, 
vomiting,  etc.,  followed  by  rapid  anasarca,  and  death  by  coma.  The 
rusty  sputum  was  also  calculated  to  mislead ; for  although  the  air  tubes 
were  filled  with  tenacious  purulent  mucus,  there  was  no  appearance  after 
death  of  bloody  extravasation  into  the  parenchyma  of  the  lung.  It 
must,  therefore,  have  been  altogether  bronchitic.  Such  a case  of  acute 


NEPHRITIS  AND  PYELITIS. 


789 


MPplirltis,  so  complicated,  must  be  considered  of  extreme  rarity.  It  oc 
curred  before  the  value  of  testing  the  urine  for  chlorides  was  known,  as 
a diagnostic  sign  of  pneumonia,  or  I might  have  been  assisted  in  attri- 
buting the  acute  symptoms  to  the  kidneys  rather  than  to  the  lungs.  On 
dissection  there  was  found  the  same  desquamative  nephritis  as  in  the 
last  case,  associated  with  haemorrhage  into  the  tubes  and  malpighian 
bodies,  and  intense  congestion  of  the  capillaries,  especially  on  the  sur- 
face. This,  of  course,  added  to  the  obstructive  character  of  the  lesion, 
and  increased  the  fatality  of  the  case.  I cannot  help  thinking  that  many 
such  cases  as  the  two  just  recorded  must  have  been  mistaken  by  physi- 
cians for  pneumonia,  before  the  advantages  of  auscultation  were  known. 
If  complicated  with  aortic  disease,  there  would  have  been  a hard  vibrat- 
ing pulse,  and  large  bleedings,  and  antiphlogistic  remedies  used,  which 
would  have  hastened  the  fatal  result.  Modern  medicine,  by  pointing  out 
that  such  cases  depend  on  obstruction  of  the  uriniferous  tubes  by  desqua- 
mated epithelium  or  extravasated  blood,  surely  demonstrates  that  blood- 
letting can  have  little  to  do  with  their  relief.  Even  as  a palliative  it 
often  fails  as  Case  CL XXII.  sufficiently  shows. 

The  haemorrhage  into  the  tubes  and  great  vascular  congestion  in  this 
case  occasioned  greater  obstruction  to  the  renal  excretion  than  occurred 
in  the  former  one.  Hence  the  uraemia  and  head  symptoms  which  existed 
for  twenty-four  hours  before  death,  a symptom  from  which  Lawson  was 
comparatively  free. 


Case  CLXXIY.^ — Acute  Nephritis — Chronic  Pneumonia — (Edema 
of  the  Lung  and  Anasarca  proving  fatal — Perforating  Ulcer  of 
the  Duodenum^  without  symptoms. 

History. — James  Abernetliy,  aet.  41,  a cooper — admitted  July  21,  1855.  States 
that  he  always  enjoyed  good  health  until  swelling  and  suppuration  occurred  in  his  left 
hand,  for  which  he  entered  the  surgical  hospital  last  April.  Six  weeks  ago  he  ob- 
served his  urine  become  as  dark  as  porter,  and  his  feet  and  legs  to  be  swollen.  These 
symptoms  were  preceded  by  rigors,  but  no  pain  in  the  loins  or  anywhere  else.  The 
oedema  continued  to  extend,  and  three  weeks  ago  dyspnoea  came  on,  which  has  gradu- 
ally increased  until  now.  He  has  had  no  cough  nor  expectoration. 

Symptoms  ox  Admission. — The  urine  is  of  a muddy  brown  color,  deficient  in  quan- 
tity, no  pain  or  difficulty  in  voiding  it.  It  contains  a considerable  amount  of  albumen, 
with  the  normal  amount  of  chlorides ; sp.  gr.  1020.  With  the  microscope  there  can 
be  seen  numerous  waxy  casts  of  various  sizes,  some  stretching  completely  across  the 
field,  and  branched,  others  convoluted.  Many  are  filled  with  epithelium,  several  only 
half  filled,  and  not  a few  are  composed  of  a pale,  diaphanous  membrane.  There  are 
also  present  a few  pus  and  blood  corpuscles,  and  a good  many  granules  and  granule 
cells,  with  an  abundance  of  phosphates.  On  percussing  the  chest  the  resonance  is 
equal  and  good  on  both  sides  anteriorly.  On  the  mouth  being  opened,  a loud  ci’acked- 
pot  sound  can  be  elicited  over  the  whole  anterior  surface  of  right  lung.  Posteriorly 
there  is  dulness  over  the  inferior  half  of  this  lung,  with  pealing  resonance  of  the  voice, 
and  crepitation  on  inspiration.  There  is  also  slight  crepitation,  with  sibilation  over  the 
lower  half  of  the  left  lung  posteriorly,  but  no  dulness  or  increase  of  vocal  resonance. 
Heart  sounds  are  normal ; pulse  94,  regular  but  weak.  No  appetite,  great  thirst ; abdomen 
somewhat  distended  and  fluctuating.  Skin  generally  anasarcous ; that  over  the  back 
pitting  deeply  on  pressure.  The  left  arm,  from  the  elbow  down,  is  one  mass  of  ulcer- 
ation, with  purulent  infiltration  in  the  cellular  tissue.  He  is  very  weak  and  exhausted. 
^ Sp.  yEth.  Nit.  3 ij ; Sp>.  yEth.  Chloric.  3 iss  ; Sol.  Mur.  Morph.  3 j ; Aquam  ad 

* Reported  by  Mr.  Robert  Byers,  Clinical  Clerk. 


V90 


DISEASES  OF  THE  GENITO-UEINAEY  SYSTEM. 


3 viij  ; Ft.  mist.  One  ounce  to  he  taken  every  nighty  or  when  the  breathing  is  urgent, 
Haheat.  Potass.  Bitart.  ter  in  die. 

Progress  of  the  Case. — July  25^A. — There  has  been  little  change  until  to-day, 
when  he  has  become  somnolent.  Cannot  take  nutrients.  Pulse  continues  very  weak. 
Pry  cupping,  diaphor-etics,  and  diuretics  have  failed  to  increase  the  amount  of  mine. 
Continue  nutrients  and  wine,  at  intervals,  July  26^/i. — Loud  crepitations  now  heard 
over  both  lungs  posteriorly.  Dyspnoea  urgent.  Surface  covered  with  sweat,  but  no 
alleviation  in  the  symptoms.  Died  on  the  2'7th. 

Sectio  Cadaveris. — Twenty  hours  after  death. 

Body  generally  anasarcous ; left  forearm  the  seat  of  erysipelatous  ulceration. 

Thorax, — Both  lungs  oedematous,  with  coherent  pleura.  On  separating  these  on 
the  right  side  posteriorly,  the  pulmonary  texture  broke  up,  being  rendered  soft  by 
chronic  pneumonia,  and  being  everywhere  infiltrated  with  serum.  At  the  apex  of 
right  lung,  a few  cretaceous  masses. 

Abdomen. — On  the  under  surface  of  the  right  lobe  of  the  liver,  below  the  peritoneal 
coat,  were  several  calcareous  concretions,  the  size  of  millet  seeds,  adherent  in  two 
places  to  the  coats  of  veins,  and  projecting  slightly  into  their  canal  (phlebolites). 
The  gall-bladder  was  slightly  thickened ; the  cystic  duct  obstructed  in  its  centre  , but 
the  hepatic  duct  pervious.  Both  kidneys  were  of  a pale  yellow  color  externally, 
slightly  mottled  with  vascular  patches.  On  section  the  cortical  substance  was  slightly 
diminished  in  thickness,  and  the  cones  unusually  congested.  An  inch  beyond  the 
pylorus,  the  duodenum  was  perforated  by  a round  ulcer,  the  size  of  a fourpenny-piece, 
the  edges  of  which  were  adlierent  by  soft  lymph  to  the  pancreas  and  a neighboring 
coil  of  intestine.  Internally  the  edge  of  the  ulcer  was  black,  and  around  it  were 
several  patches  varying  in  size  from  a threepenny  piece  to  that  of  a shilling  quite 
black.  The  peritoneum  contained  about  half  a gallon  of  serum.  Other  organs 
normal. 

Microscopic  Examination. — The  cortical  substance  of  the  kidneys  showed  the 
convoluted  tubes  to  be  filled  with  desquamated  epithelium,  a considerable  proportion 
of  which  had  undergone  the  fatty  degeneration. 

Commentary. — Followiug  on  a prolonged  ulceration  in  the  arm, 
which  had  confined  this  patient  to  the  surgical  hospital,  there  super- 
vened desquamative  nephritis,  general  anasarca,  and  oedema  of  the 
lungs,  similar  to  what  occui-red  in  the  two  preceding  cases.  There 
was  also  present  universal  adhesion  of  both  pleurge,  and  disorganization 
of  the  posterior  and  inferior  half  of  the  right  lung,  as  I conceive  from  a 
limited  exudation  into  its  texture.  What,  however,  constitutes  a 
remarkable  feature  in  this  case,  is  the  presence  of  a chronic  ulcer  in 
the  duodenum,  which  had  not  been  manifested  by  any  symptom  what- 
ever ; which  was  attended  by  limited  hemorrhage  into  the  mucous 
coat  of  the  intestine  internally,  and  externally  by  exudation,  or  so- 
called  effusion  of  lymph  (peritonitis),  without  any  local  pain  or  uneasi- 
ness. 

The  term  Desquamative  Nephritis  was  introduced  by  Dr.  Johnson 
to  denominate  a lesion  in  which  the  tubes  of  the  kidney  are  blocked 
up,  not  only  by  exudation,  but  by  the  separation  and  accumulation  of 
their  epithelial  cells.  Such  desquamation,  I believe,  occurs  occasion- 
ally in.  all  epithelial  and  epidermic  structures.  I have  often  seen  it 
in  the  lung,  forming  what  may  be  called  a desquamative  or  vesicular 
pneumonia.  If  it  occurs  generally  throughout  both  kidneys,  as  in  the 
three  last  cases  narrated,  it  is  usually  fatal ; but  if  partial,  and  a 
sufficient  number  of  tubes  are  left  unobstructed,  so  as  to  admit  of 
increased  action  under  the  stimulus  of  diuretics  a cure  may  be  antici- 
pated. Under  such  circumstances,  also,  a spontaneous  recovery  may 
be  hoped  for  which  may  be  assisted  by  diaphoretics.  So  far  from 


NEPHRITIS  AND  PYELITIS. 


V91 


considering  diuretics  injurious,  I believe  that  in  such  cases  they  hold 
out  the  only  chance  of  successful  treatment.  Cupping  and  diaphoretics 
in  such  violent  and  rapid  cases  are  wholly  insufficient  to  overcome  the 
tubular  obstruction,  however  they  may  occasionally  relieve.  On  the 
other  hand,  the  good  effects  of  diuretics  were  well  observed  in  Cases 
CLX.  and  CLXX. 

Case  CLXXY."^ — Nephritis  followed  hy  the  formation  of  a large  Abscess 
in  the  Right  Kidney^  opening  into  the  lumbar  cellular  tissue—  Ulcera- 
tion of  Ureter  and  Bladder — Thichening  of  Mitral  and  Tricuspid 
Valves — Partial  Atrophy  of  Lungs^  with  and  without  Induration — 
Partial  Oedema. 

History. — Margaret  Martin,  set.  47,  servant — admitted  18th  October  1852.  She 
always  enjoyed  good  health  till  about  twelve  months  ago,  when  she  was  exposed  to 
cold,  and  got  her  feet  wet.  Shortly  after,  she  was  attacked  with  dysuria,  and 
observed  that  the  urine  was  of  a very  dark  red  color,  and  much  diminished  in 
quantity.  A week  afterwards,  she  experienced  sharp  cutting  pains  in  the  hypogas- 
trium,  stretching  down  the  thighs.  She  was  still  able,  however,  to  follow  her 
usual  occupation  till  the  beginning  of  September  last,  when  she  suffered  from  pain 
in  region  of  right  kidney,  in  the  larger  joints,  and  from  oedema  of  the  legs,  especially 
the  right.  The  bowels  have  been  very  costive,  and  the  abdomen  has  become  much 
distended.  Four  weeks  ago  she  passed  some  very  dark,  bloody-looking  matter  in 
the  urine,  which  continued  of  a red  color  for  five  days.  Her  habits  appear  to  have 
been  rather  intemperate. 

Symptoms  on  Admission. — On  admission,  the  tongue  is  loaded  in  the  centre  with 
a dark  fur ; great  thirst,  but  appetite  good ; bowels  open.  There  is  distinct  fulness 
and  dulness  on  percussion  in  the  right  lumbar  region,  extending  as  far  forward  as 
the  umbilicus,  and  filling  up  the  space  between  the  false  ribs  and  crest  of  the  ilium  ; 
and  there  is  great  tenderness  on  pressure  over  the  same  extent.  Has  some  pain  in 
micturition,  shooting  down  the  thighs,  especially  on  right  side,  which  is  also  some- 
what oedematous.  Urine  passed  in  very  small  quantity,  sp.  gr.  1015.  It  is  albu- 
minous, and  deposits  on  standing  a copious  sediment,  showing  under  the  microscope 
numerous  pus  and  blood  corpuscles.  Pulse  90,  of  good  strength,  but  occasionally 
intermitting.  She  has  occasional  palpitation.  The  cardiac  d-ulness  is  somewhat 
increased  transversely;  impulse  very  strong,  and  an  indistinct  hollow  murmur 
accompanies  the  first  sound,  and  is  heard  loudest  at  the  apex.  The  thorax  is  con- 
siderably deformed,  and  the  sternum  highly  arched ; but  the  chest  is  otherwise 
normal.  Habeat  enema  c.  01.  Terebinth.  § i. 

Progress  of  the  Case. — Nov.  20^/i. — The  bowels  not  having  been  fully  acted  on 
by  the  enema,  she  was  ordered  last  night  half  a drachm  of  Compound  powder  of 
Jalap.,  which  caused  copious  stools.  Inf  us.  Papav.  § v ; Tinct.  Hyoscyam. 
3 ij  ; Syrupi  § i.  M.  Sumat  § j ter  in  die.  Nov.  21. — Has  been  complaining  much  of 
pain  in  loins  and  right  leg.  She  was  ordered  an  enema  with  half  a drachm  of  the 
Sol.  of  Morphia  on  the  evening  of  the  20th ; and  last  night,  the  pain  having  again 
returned  and  prevented  her  from  sleeping ; she  had  the  following  draught : U Sol. 
Mur.  Morph.  3 ss  ; Tinct.  Hyoscyam.  3j;  Mucilaginis  et  Aq.  Merdh.  aa  § ss.  M. 
Nov.  22. — Feels  much  better  to-day.  There  is  less  swelling  of  abdomen,  little  or 
no  pain  in  the  hypogastrium,  but  a feeling  of  soreness  in  right  lumbar  region. 
Bowels  confined ; urine  passed  in  small  quantity,  albuminous,  and  contains  a large 
deposit,  consisting  chiefly  of  pus.  Nov.  24. — Continues  in  the  same  state,  but  com- 
plains much  of  pain  in  bowels,  which  are  still  confined.  Urine  passed  in  small 
quantity.  She  was  ordered  yesterday  the  following  : — B Bitart.  Potass.  3 ii ; Gambog. 
gr.  ij.  M.  Ft.  pulv.  hora  somni  sumend.  et  habeat  mane  Pulv.  Doveri  gr.  xv.  The 
bowels  were  freely  opened,  with  considerable  relief  to  painful  distention  of  abdomen, 
but  no  diminution  of  the  swelling  and  hardness.  Apyl.  Tinct.  lodin.  abdomini. 
Nov.  28. — Is  complaining  much  of  pain  in  abdomen  and  right  leg,  for  which  she 
had  10  grains  of  Dover's  powder  last  night.,  with  partial  reliefi  The  cough  is  now 
troubling  her  more,  and  she  seems  much  weaker.  1^  HJh.  Chlor.  3 ij  ; Sol.  Mur. 
Morph.  3 j ; Sp.  Ammon.  Aromat.  3 iij  ; Mist.  Camph.  § vss.  M.  Sumat  § ss.  ter 
\n  die.  Nov.  30. — On  auscultation  of  chest,  occasional  moist  rales  are  to  be  heard, 


* Reported  by  Mr.  Francis  M.  Russell,  Clinical  Clerk. 


192 


DISEASES  OF  THE  GENITO -URINARY  SYSTEM. 


with  prolonged  expiration  ; but  no  increase  of  vocal  resonance.  The  sounds  of  th« 
heart  are  heard  very  distinct  over  the  whole  chest ; the  apex  beats  in  epigastrium , 
its  action  is  irregular,  and  a blowing  murmur  accompanies  the  first  sound.  There 
is  still  tenderness  in  right  lumbar  region,  with  great  pain  in  right  iliac  ; the  swell- 
ing of  abdomen  has  not  diminished,  and  upon  deep  pressure,  a distinct  fulness  and 
hardness  can  be  felt  in  right  iliac  fossa,  to  which  four  leeches  were  ordered  to  he  applied 
followed  by  warm,  fomerdations.  8p.  ^ther.  Nit.  ^ss ; Liquor.  Potass.  3 ij  ; 
Mucilag.  § ij  ; Sol.  Mur.  Morph.  3 hj  ; Aquce  ^ hj-  M.  Sumat  § ss  omni  hora. 
Intermitt.  alia  medicamenta.  Habeat  Sp.  Juniperi  Co.  § iii  per  diem.  December  3. 
— Feels  rather  better,  but  bowels  very  costive,  unaffected  by  a powder  of  calomel 
and  jalap  administered  last  night.  The  urine  is  still  albuminous,  sp,  gr.  1015. 
Quantity  not  ascertained.  There  is  now  slight  but  painful  oedema  of  right  arm. 
Hah.  enema  catharticum.  Dec.  6. — Bowels  well  opened.  She  now  feels  much  relieved 
of  the  pain  in  abdomen ; the  tumor  in  right  lumbar,  umbilical,  and  iliac  regions, 
remains  unaffected.  The  oedema  of  leg  has  now  disappeared  ; but  the  pain  and 
swelling  of  arm  have  gradually  increased,  and  extend  as  far  as  the  shoulder.  The 
whole  arm  is  exquisitely  tender.  No  circumscribed  tumors  can  be  anywhere 
detected  in  the  arm  or  axilla.  For  the  last  three  days,  the  quantity  of  urine  has 
varied  from  12  to  20  oz.  in  the  24  hours.  There  is  still  a very  copious  mucus-like 
sediment ; when  examined  by  the  microscope  no  blood  globules  can  now  be  detected  ; 
but  there  are  still  numerous  disintegrated  pus  corpuscles,  with  crystals  of  triple 
phosphate  and  amorphous  urate  of  ammonia.  The  albumen  has  not  disappeared. 
Lotion  of  Acetate  of  Lead  and  Opium  to  be  applied  to  the  arm.,  with  warm  fomenta- 
tions. Dec.  8. — Complains  of  great  pain  in  arm,  which  is  very  much  swollen,  and 
generally  hard,  but  pits  slightly  on  pressure,  and  is  of  a white  color  at  the  upper 
part ; but  at  the  wrist  it  is  much  darker,  and  on  the  back  of  the  hand  two  large 
phlyctenge  have  formed  during  the  night,  and  other  portions  of  the  surrounding 
surface  vary  in  color,  from  a slight  red  to  a yellow  and  brownish  green.  There  is 
some  oedema  of  leg,  but  of  slight  extent ; and,  for  a few  days  back,  some  dark  purple 
spots,  permanent  on  pressure,  have  appeared  on  the  inside  of  right  thigh  and  knee. 
She  complains  much  of  loss  of  sensibility  in  the  arm,  and  of  cold  feet,  but  their 
temperature  appears  natural  to  the  touch.  She  is  very  weak,  and  takes  no  food. 
The  pulse  120,  feeble  and  fluttering.  Urine  sp.  gr.  1015.  Not  affected  by  heat  or 
nitric  acid.  It  is  now  passed  involuntarily  in  bed.  Sp.  Ammon.  Arom.  ; H^th. 
Chlor.  aa  3 ij  ; Tinct.  Card.  Co.  3 h : Mist.  Carnph.  § vii,  M.  Sumat  3 j singulis 
horis.  To  have  4 oz  of  Brandy.  Dec.  9. — Died  this  morning  about  ten  o’clock. 

Sectio  Cadaveris. — Twenty-six  hours  after  death. 

Anasarca,  especially  of  right  arm  and  leg,  but  nowhere  extreme.  A large  tumor, 
elastic,  not  fluctuating,  moderately  tense,  occupied  the  abdomen  on  the  right  side 
from  the  liver  to  the  ilium,  and  from  the  loins  to  the  umbilicus,  projecting  in  either 
direction.  Percussion  over  it  generally  dull.  It  can  be  limited  from  the  liver,  which 
is  not  large. 

Thorax. — Pericardium  contains  about  an  ounce  of  serum,  and  on  the  surface  of 
the  heart  are  numerous  opaque  fibrous  patches.  Heart  rather  small.  The  free  edges 
of  the  tricuspid  and  mitral  valves  were  thickened  and  rounded,  but  with  no  distinct 
appearance  of  deposit  on  their  surface.  In  the  substance  of  the  septal  segment  )f 
mitral  valve,  near  its  roots,  there  were  a few  calcareous  masses.  Weight  of  heart, 
9|  oz.  Lungs. — Right  pleura,  normal ; lung  throughout  free  from  adhesions  ; some 
serous  engorgement,  with  considerable  collapse  posteriorly ; anterioi’ly,  no  marked 
emphysema.  Left  lung  presents  firm  adhesion  over  upper  lobe,  which  is  much  dimi- 
nished in  volume,  and  has  a dense,  scarcely  crepitating  tissue. 

Abdomen. — On  opening  the  abdomen,  the  tumor  was  found  to  be  situated  behind 
the  ascending  colon.  The  right  lobe  of  the  liver  overlapped  it  in  front  to  the  extent 
of  several  inches,  and  was  adherent  to  it  by  firm  and  close  fibrous  bands.  The  peri- 
toneum was  stretched  over  the  tumor  so  as  to  obliterate  the  mesocolic  folds  in  front, 
and  keep  the  ascending  colon  closely  in  contact  with  it.  It  proved  to  be  an  abscess, 
containing  about  a quart  of  fluid,  which  was  sero-purulent  (with  large  proportion  of 
pus),  of  a yellow  color,  with  a faint  greenish  tinge,  and  a good  deal  of  foetor.  The 
main  sac  of  this  abscess  was  situated  in  the  lumbar  cellular  tissue  of  the  right  side, 
and  had  in  front  of  it  the  right  kidney,  the  interior  of  which  communicated  by  several 
ulcerated  openings  with  the  cavity  of  the  abscess.  The  posterior  wall  of  the  abscess 
rested  on  the  lumbar  muscles  and  on  the  rig! it  side  of  the  vertebrae,  the  periosteum 
of  which  was  entire.  The  superior  wall  was  very  closely  adherent  to  the  liver,  which, 


NEPHRITIS  AND  PYELITIS. 


793 


at  its  anterior  part,  had  a depression  or  excavation  about  half  an  inch  in  depth,  and 
two  or  three  inches  in  diameter.  The  left  lobe  of  the  liver  was  displaced  upwards, 
and  the  right  lobe  was  elongated  downwards,  being  closely  adherent  to  the  right  and 
upper  aspect  of  the  swelling.  The  stomach  and  neighboring  viscera  were  displaced 
by  the  tumor,  but  were  healthy.  Left  kidney  normal.  Right  kidney  much  dis- 
organized ; its  size  not  altered ; on  section,  numerous  abscesses  containing  pus  like 
that  within  the  tumor,  occupying  both  the  cortical  and  tubular  part ; tlie  walls  of 
the  abscess  composed  of  flocculent  and  curdy  greyish-yellow  matter,  presenting,  under 
the  microscope,  the  debris  of  cell  forms,  with  very  numerous  granules.  The  pelvis 
of  the  kidney  could  scarcely  be  identified,  being  converted  into  a receptacle  for  pus. 
The  intervening  tissue  between  the  abscesses  was  condensed  and  indurated,  and  at 
some  points  enclosed  a quantity  of  matter  similar  to  that  constituting  the  walls  of 
the  abscesses.  Several  angular  calculi,  the  size  of  mustard  seeds,  were  impacted  in 
one  of  the  infundibula,  the  mucous  membrane  of  which  was  smooth  and  free  from 
ulceration.  On  examination,  they  proved  to  be  composed  chiefly  of  phosphatic 
earthy  salts  and  animal  matter.  The  ureter  was  thickened  throughout,  not  dilated : 
the  mucous  membrane  totally  disorganized,  rough,  and  resembling  the  walls  of  the 
renal  abscesses.  The  bladder  had  also  fully  one  half  of  the  mucous  membrane  re- 
moved in  irregular  patches  by  ulceration  ; the  remaining  parts  were  much  congested, 
but  smooth.  No  deposit  of  calcareous  matter  in  any  quantity.  The  ulceration  of 
the  vesical  mucous  membrane  extended  to  the  neck  of  the  bladder,  and  ended  abruptly 
at  the  commencement  of  the  urethra,  which,  with  the  exception  of  some  congestion 
of  the  mucous  membrane,  was  normal.  The  uterus  contained  a polypus,  the  size  of 
a beau,  composed  principally  of  the  mucous  membrane,  and  attached  to  the  posterior 
wall.  Os  uteri  slightly  tinged  of  a purplish  color.  Ovaries^  vagina^  and  external 
parts  normal.  Other  organs  normal. 

Commentary. — The  occurrence  of  abscess  in  the  kidney  is  often  a 
very  insidious  disease,  existing  frequently  for  many  months,  and  giving 
rise  to  obscure  pain  in  the  back,  occasional  rigor,  feverishness,  and  high- 
colored  or  muddy  urine,  which,  when  examined  microscopically,  may  be 
seen  to  contain  blood  and  pus  corpuscles.  If  the  disorganizing  process  con- 
tinue, and  an  opening  form  externally,  inflammation,  followed  by  suppura- 
tion of  the  cellular  tissue  behind  the  peritoneum,  occurs,  causing  fever 
of  a low  type,  and  oedema  more  or  less  general.  Such  an  occurrence 
usually  proves  fatal.  In  the  present  case,  death  was  delayed  apparently 
from  the  abscess  having  been,  to  a certain  extent,  circumscribed,  and 
forming  a large  cyst,  so  as  to  present  the  form  of  a tumor,  the  nature 
of  which,  during  life,  was  very  difficult  to  determine,  although  the 
renal  disease  was  clearly  apparent. 

Case  CLXXVI.^ — Scrofulous  Nephritis  and  Abscesses  in  the  Kidneys — Kx- 
tensive  deposition  of  Tubercle  in  the  Lungs  and  Intestines. 

History. — George  Paton,  get.  20,  sailor — admitted  19th  July  1854.  States  that 
he  enjoyed  good  health  until  seven  years  ago,  when  he  noticed  his  urine  tinged  with 
blood,  after  having  undergone  considerable  exercise  in  sliding  on  ice.  The  hoema- 
turia  gave  him  no  uneasiness  until  three  weeks  afterwards,  when  he  began  to  suffer 
pain  in  the  epigastrium,  and  a deep-seated  burning  pain  in  the  pelvis.  He  could 
get  little  rest  in  consequence,  and  his  micturition  became  frequent,  almost  every  hour. 
He  continued  to  suffer  more  or  less  in  this  way  for  two  years,  the  pain  and  hmmaturia 
abating,  and  again  recurring  at  intervals  of  a few  weeks.  He  then  went  to  sea,  and 
remained  tolerably  free  of  the  disease  for  three  years.  His  ailment  then  returned 
again  in  aggravated  form,  after  exposure  to  a storm.  He  obtained  admission  on 
board  the  Dreadnought  hospital  ship  at  this  time,  and  had  his  bladder  repeatedly  ex- 
amined for  stone,  but  no  calculus  could  be  detected.  After  being  a few  weeks  in  the 
Dreadnought,  he  left  it  and  went  to  sea  again,  though  in  very  imperfect  health. 
About  twelve  months  ago,  whilst  lying  in  the  Downs,  he  had  a very  severe  attack  of 
deep-seated  pelvic  pain  and  hiematuria.  He  now,  for  the  first  time,  complained  of 
pain  in  the  back,  which  has  never  left  him  since,  and  the  character  of  the  urine 
underwent  a change.  It  became  white  and  turbid,  aud  on  standing,  emitted  a putrid 

* Reported  by  Mr.  Almeric  W.  Seymour,  Clinical  Clerk. 


794 


DISEASES  OF  THE  GENITO-UUmARY  SYSTEM. 


odor.  He  recovered  partially  from  this  attack,  and  went  shortly  afterwards  on  a 
voyage  up  the  Danube,  where  his  disease  became  aggravated  from  the  exposui’e  he 
was  subjected  to.  Since  that  time  his  general  health  has  been  declining  more  rapidly 
than  formerly. 

Symptoms  on  Admission. — On  admission,  he  is  considerably  emaciated,  counte- 
nance pale,  and  his  expression  anxious  ; skin  dry ; urine  white  and  turbid,  sp.  gr.  1010  ; 
on  staaling,  a large  sediment  falls  down,  which  under  the  microscope  is  found  to 
consist  of  pus,  and  under  heat  and  nitric  acid  a large  coagulum  forms.  He  complains 
of  pain  ill  the  hypogastrium  and  right  lumbar  region,  of  a dragging  character ; he 
has  also  pain  in  the  point  of  the  penis  during  and  after  micturition ; tongue  moist 
and  florid ; he  complains  of  sore  throat,  and  on  examination  the  tonsils  are  seen  to  be 
enlarged  and  covered  with  pus.  He  has  tenderness  of  the  epigastrium,  and  is  troubled 
with  vomiting  immediately  after  taking  food.  Bowels  regular.  On  percussing  the 
chest,  dulness  can  be  detected  at  the  apex  of  the  right  lung,  anteriorly  and  posteriorly ; 
on  auscultation  there  is  slight  sibilation  under  the  right  clavicle,  with  slight  increase 
of  the  vocal  resonance.  He  has  a slight  cough,  but  no  expectoration  ; pulse  88,  and 
of  good  strength.  Cardiac  sounds  feeble;  heard  loudest  over  the  sternum,  and  a 
little  to  its  right  side ; otherwise  they  are  healthy.  Ijt  Inf  us.  Lini  Ibj.  To  he  taken 
ad  libitum.  Throat  to  he  sponged  with  a solution  of  nitrate  of  silver'.  Good  diet. 

ProgPvESS  op  the  Case. — July  ‘lUh. — The  sponge  has  been  three  times  applied  to 
the  throat,  and  it  is  nearly  well.  The  pain  has  left  the  hypogastric  region,  and  he 
has  now  a feeling  of  weakness  in  the  right  lumbar  region.  Urine  of  a milky  color, 
contains  less  albumen,  sp.  gr.  lOOY.  Tinct.  lodinei  3 i.  To  be  painted  over  the 
lumbar  region.  B Ttecoct.  JJvce  JJrsi  Ibj.  One  ounce  to  be  taken  four  times  a-day. 
August  d)th. — During  last  week  he  has  been  suffering  from  nausea,  vomiting,  and 
looseness  of  bowels.  Aug.  Vlth. — These  few  days  past  he  has  had  rigors,  followed 
by  heat  of  skin  and  sweating.  The  attacks  last  only  for  a couple  of  hours,  and  come 
on  regularly  at  two  o’clock.  He  has  been  ordered  the  following  pills; — R jSnlph. 
Quince  3 ss  ; Couf.  Rosar.  quant,  suff.  ft.  massa  in  pilul.  xx.  dividenda.  Two  to  be 
taken  every  sixth  hour  during  the  inter missiojis.  Diarrhoea  has  continued,  and  for  it 
he  has  been  using  the  following  mixture : — B Tinct.  Catechu  3 vi ; Rol.  Mur.  Morph. 

3 ij  ; Conf.Aromat.  3i;  Mist.  Cretce  § v.  M.  One  table-spoonful  to  be  taken  three 
times  a-day.  Aug.  14/A. — Diarrhoea  relieved  ; urine  less  turbid ; sp.  gr.  1009  ; not 
coagulable  by  heat  and  nitric  acid.  Aug.  21s^. — Since  last  report  has  been  gradually 
growing  weaker.  Mucous  rale  has  been  occasionally  audible  under  the  right  clavicle  ; 
expectoration  insignificant.  He  has  been  unable  to  retain  any  food  on  his  stomach 
for  several  days,  scarcely  even  wine  and  water.  Diarrhoea  has  also  returned.  Latterly 
his  strength  has  become  very  much  exhausted,  and  during  the  last  two  days  he  has 
lain  in  a state  of  great  prostration ; his  pulse  often  scarcely  to  be  felt  at  the  wrist ; his 
intellect,  however,  never  became  impaired.  This  morning  he  died  at  four  o’clock. 

Sectio  Cadaveris. — Fiftij-eight  hours  after  death. 

Body  much  emaciated ; rigor  mortis  considerable. 

Thorax. — Pericardium  normal ; contained  about  three  drachms  of  clear  straw- 
colored  serum.  Heart  small  and  soft ; valves  healthy ; muscular  substance  pale ; 
under  the  microscope,  the  muscular  fibres  appear  deficient  in  striae,  and  loaded  with 
small  fatty  granules.  Left  pleura  normal.  Right  pleura  presents  dense  adhesions 
over  the  wliole  of  the  lung,  more  marked,  however,  at  the  apex  and  base.  I'he 
right  lung  itself  was  small,  collapsed,  and  excessively  emphysematous  along  its  an- 
terior free  margin.  The  apex  presented  numerous  hard  cicatrices,  and  on  being  cut 
into,  showed  numerous  tubercular  masses  in  all  stages,  some  of  them  commencing 
to  break  down  and  disintegrate,  others  undergoing  the  process  of  hardening  and 
repair.  In  one  spot,  about  an  inch  below  the  apex,  a small  vomica,  about  the  size 
of  a hazel  nut,  existed.  Left  lung  voluminous  ; highly  emphysematous  ; cicatrized 
around  the  apex,  the  cicatrices,  as  in  the  other  lung,  being  very  firm  and  dense. 
On  being  cut  into,  masses  of  tubercular  matter  were  found,  but  in  a more  latent  state 
than  in  right  lung. 

Abdomen. — Liver  normal  in  size,  undergoing  the  fatty  degeneration  ; pale- 
colored  and  friable ; under  the  microscope,  the  hepatic  cells  appeared  loaded  with 
fat.  Spleen  normal.  Small  intestines  healthy,  slightly  congested  towards  the 
lower  part.  Large  intestines.  The  mucous  membrane,  throughout  the  whole  extent, 
but  particularly  in  the  descending  colon,  sigmoid  flexure,  and  rectum,  appeared 
thickened,  congested,  and  in  many  places  ulcerated;  the  ulcers  were  small,  their 
edges  very  slightly  elevated,  and  their  surface  undergoing  the  process  of  separation. 


NEPHRITIS  AND  PYEIJTIS. 


'795 


Right  kidney  was  much  enlarged  ; quite  smooth  ; the  capsule  densely  adherent.  On 
dividing  the  ureter,  pus  escaped  in  considerable  quantity  from  the  pelvis  of  the 
kidney ; and  on  cutting  into  tlie  substance  of  the  gland  itself,  several  ulcers,  varying 
in  size  from  a horse-bean  to  that  of  a small  walnut,  were  found ; their  contents 
varied  in  consistence ; in  some,  the  pus  was  thin  and  diffluent ; in  others,  it  had  the 
consistence  and  appearance  of  white  paint.  The  ureter  on  this  side  was  greatly 

thickened,  of  the  size  of  an  ordinary  little  finger ; the  thickening  extended  beyond 

the  orifice  of  the  ureter  along  the  trigone  of  the  bladder ; the  ureter  was  quite  per- 
vious, and  contained  a quantity  of  pus.  Left  kidney  was  small  and  lobulated ; the 
substance  of  the  gland  was  found  to  have  disappeared,  leaving  a large  cavity,  which 
was  enclosed  by  a covering  of  the  proper  substance  of  the  kidney,  not  exceeding  four 
lines  in  thickness,  and  filled  with  cheesy  matter  of  the  consistence  of  putty ; the 
ureter  was  closed,  except  for  two  inches  above  the  bladder ; externally,  it  was  of 
normal  size;  muscular  wall  of  bladder  somewhat  thickened,  especially  around  the 

orifice  of  the  right  ureter ; mucous  coat  congested  and  much  softened ; the  bladder 

contained  about  6 oz.  of  thick,  turbid,  semi-purulent  matter. 

Commentary. — In  this  oase,  the  renal  abscesses  formed  in  a young 
man  of  scrofulous  constitution,  and  exhibited  a more  lingering  tendency 
than  in  the  former  one.  Indeed,  notwithstanding  the  great  disorganiza- 
tion found  in  the  kidneys  after  death,  the  fatal  result  was  chiefly  brought 
about  by  the  intestinal  disease,  and  the  exhaustion  caused  by  colliquative 
diarrhoea.  The  left  kidney  evidently  presented  the  incipient  changes 
which  commonly  precede  the  spontaneous  cure  of  scrofulous  abscesses  in 
this,  as  in  other  internal  organs.  The  purulent  matter  presented  the 
consistence  of  putty,  the  animal  portion  having  for  the  most  part  been 
broken  down  and  absorbed,  while  the  mineral  portion  was  comparatively 
increased.  In  this  manner,  not  uofrequently  encysted  cretaceous  masses 
form  in  the  kidney  and  remain  latent,  the  rest  of  the  renal  substance 
performing  its  normal  function.  Sometimes  an  entire  kidney  may,  in 
this  manner,  be  completely  destroyed,  and  the  whole  converted  into  a 
calcareous  mass,  of  which  I possess  a remarkable  example,  from  an  indi- 
vidual who  had  quite  recovered  from  the  disease,  and  whose  remaining 
kidney,  though  enlarged,  was  in  its  texture  healthy.  Indeed,  the  sponta- 
neous cure  of  tubercular  depositions  in  the  kidney,  presents  the  same 
pathological  history  as  that  we  have  described  of  similar  lesions  occurring 
in  the  lungs,  p.  738,  and  the  puckerings,  cicatrices,  cretaceous  and  calca- 
reous concretions  resulting:  from  them,  have  a similar  simiificance.  It 
follows  that  our  general  principles  of  treatment  should  also  be  the  same, 
namely,  supporting  the  constitution  by  analeptics  and  especially  by  cod- 
liver  oil,  so  as  to  enable  nature  to  bring  about  a cure.  This  ought  always 
to  be  the  primary  object  of  treatment;  whilst  remedies  directed  to  the 
renal  symptoms  should,  although  by  no  means  neglected,  be  subordinate 
to  that  great  end.  In  the  present  case  this  indication  could  not  be  ful- 
filled on  account  of  the  great  irritability  of  the  alimentary  canal,  especially 
of  the  stomach.  For  another  example  of  this  disease,  see  Case  CLX. 

Case  CLXXVII.'^ — Calculous  Nephritis  and  Gangrenous  Abscess  of  Right 

Kidney — Waxy  Liver — Recto-Vesical  Fistula. 

History. — James  Allan,  aet.  25,  a tin  and  copper  smith — admitted  August  18, 
1848.  At  three  years  of  age  was  cut  for  stone  by  Mr.  Liston.  Thereafter  he  enjoyed 
good  health  until  three  years  ago,  when,  after  straining  himself  at  a trial  of  strength, 
he  was  suddenly  seized  with  a sharp  pain  in  the  right  flank,  just  below  the  ribs.  At 
the  same  time  the  urine  became  turbid,  and  was  of  a high  color.  The  pain  left  him 
at  the  end  of  three  months,  but  the  turbidity  of  the  urine  continued.  After  six 
months’  interval  he  had  a similar  attack — this  time,  he  says,  induced  by  drinking  a 

* Keported  by  Mr.  Frederick  Hunter,  Clinical  Clerk. 


796 


DISEASES  OF  THE  GENITO-URINARY  SYSTEM. 


glass  of  spirits — whicli  also  lasted  three  months.  After  another  interval  of  about  sis 
months,  the  pain  and  urinary  symptoms  again  returned,  and  have  continued  more  or 
less  sevei'e  ever  since.  He  was  in  the  surgical  hospital  for  three  months,  where  he 
was  frequently  examined  for  stone,  but  none  was  found.  At  this  time  he  was  observed 
on  several  occasions  to  pass  air  by  the  urethra,  the  urine  being  of  a gangrenous  odor. 
He  left  the  surgical  hospital  last  May,  and  has  been  somewhat  better  since,  the  urine 
for  some  time  having  been  clear  and  healthy.  But  having  bathed  in  the  sea  a fort- 
night ago,  he  was  seized  with  rigors,  followed  by  fever,  together  with  the  former  local 
symptoms,  which  have  continued  ever  since. 

Symptoms  on  Admission, — The  countenance  is  pale  and  sallow,  expression  de- 
jected ; body  not  emaciated,  but  with  a general  look  of  chronic  disease.  He  com- 
plains of  great  pain  and  tenderness  in  the  right  lumbar  region,  which  on  examination 
presents  a fulness,  without  great  deformity,  but  well  marked  when  compared  with  the 
opposite  side.  The  hepatic  dulness  on  percussion  measures  five  inches  vertically, 
the  lower  margin  anteriorly  being  on  a line  with  the  umbilicus,  and  stretching  across 
the  abdomen  into  left  hvpochondrium.  He  has  never  suffered  from  pains  shooting 
down  to  the  bladder,  nor  in  the  bladder  itself.  But  there  is  occasional  pain  after 
micturition,  and  always  frequent  desire  to  pass  urine — indeed  every  hour — although 
little  is  voided.  The  urine  is  turbid,  of  dirty  yellow  color;  acid,  of  sp.  gr.  1017, 
very  foetid,  highly  coagulable,  and  contains  a considerable  sediment  of  pus  and  mucus. 
The  pulse  is  108,  soft.  Tongue  covered  with  a whitish  fur.  Appetite  good.  Other 
functions  well  performed.  IJ  Tart.  Antim.  gr.  ij  ; Aqtice  § viij  ; Solve.  Svmat  § ss 
tertid  qunque  Jiord.  Applicent.  hirudines  viii.  laferi  dolenti.,  ei  postea  foveatur. 

Progress  of  the  Case. — September  26?/i. — The  local  pain  has  been  relieved  by 
the  treatment,  but  it  returns  with  severity  at  intervals.  For  some  time  the  urine  has 
been  clear.  He  has  had  a .slight  diarrhoea,  which  has  been  checked  by  a chalk  and 
aromatic  mixture  ; and  has  occasionally  taken  at  night  Pulv.  Doveri  gr.  viij.  October 
Sd. — Two  days  ago  was  again  seized  with  rigors,  fever,  and  acute  pains  in  the  right 
flank.  The  urine  is  again  loaded  with  pus  and  mucus,  and  of  foetid  odor.  The 
appetite  is  gone;  there  is  thirst  and  frequent  vomiting.  Pulse  120,  soft.  A saline 
antimordal  mixture.  Oct.  ^th. — Anxious  countenance  ; pain  continues,  preventing 
sleep.  Can  take  no  nourishment.  Much  exhausted.  Vomiting  diminished.  Pulv. 
Doveri  ^Y.  X.  hora  somni.  Nutrients.  Wine  four  ounces  daily.  Warm  fomentations 
to  the  side  Oct.  \0th. — Local  pain  somewhat  diminished.  Complains  of  diarrhoea. 
Ijl  Acid.  Qallic.  3 ss  ; Opif  gr.  xij  ; Conf.  Rosar.  q.  s.  ; ft.  pil.  xij.  Sumat  unam 
sextd  qudque  hord.  Oct.  Ibth. — Since  last  report  has  gradually  sunk,  and  died  this 
morning. 

Sectio  Cadaveris. — Forty-eight  hours  after  death. 

Thorax. — Pericardium  contained  about  a drachm  of  turbid  serum,  with  a few 
floating  flakes  of  lymph.  Lungs  and  heart  healthy. 

Abdomen. — The  liver  was  considerably  enlarged,  and  had  undergone  the  waxy 
degeneration ; its  substance  being  pale  and  dense,  with  a smooth  surface  on  section. 
On  attempting  to  remove  it,  the  right  lobe  tvas  found  to  be  adherent  to  the  colon  ; 
and  on  separating  this  adhesion  with  the  fingers,  a quantity  of  pus  escaped.  This 
originated  from  a large  abscess  in  the  right  kidney.,  containing  about  half  a pint  of 
pus,  mixed  with  curdy  matter.  The  superior  wail  was  composed  of  the  substance 
of  the  liver,  a portion  of  the  lower  and  posterior  border  of  which  organ  was  absorbed. 
The  posterior  wall  rested  on  the  quadratus  lumborum  muscle,  and  anteriorly  it  was 
in  contact  with  the  transverse  colon  and  the  pyloric  end  of  the  stomach.  When 
opened  from  behind,  the  walls  of  the  abscess  were  found  to  be  covered  with  shreds  of 
gangrenous  tissue,  of  a dark  greenish  color,  of  gangrenous  odor.  Renal  substance 
could  only  be  detected  at  the  lower  part ; the  rest  of  the  kidney  was  converted  into  a 
fibro-cystic  structure,  in  some  places  of  great  density.  Two  of  the  cysts  contained 
uric  acid  calculi ; one  resembling  in  size  and  form  two  walnuts  united  together  by  a 
neck,  the,  other  of  a somewhat  angular  form,  with  rounded  edges,  the  siz-e  of  a hazel 
nut.  These  calculi  were  embedded  in  pus,  and  partly  projected  into  what  might  have 
been  the  pelvis  of  the  kidney,  but  which  was  converted  into  a fibrous  sac  communi- 
cating with  the  ureter.  The  bladder  presented  at  its  neck  the  cicatrix  ot  an  incision 
made  in  the  usual  situation  for  lithotomy.  About  two  inches  above  this  were  three 
mucous  excrescences  the  size  of  ))eas.  in  the  centre  of  these  was  a depressed  spot, 
through  which  a director  readily  passed  backwards  and  upwards  through  the  cellular- 
tissue  into  the  rectum.  The  mucous  surface  of  the  rectum  at  this  point  was  highly 
vascular,  and  covered  with  lymph  in  patches  to  the  extent  of  four  inches  in  depth 


NEPHRITIS  AND  PYELITIS. 


797 


round  the  gut.  Left  kidney  weighed  13^  oz.,  and  appeared  healthy  in  structure. 
Other  organs  normal. 

Microscopic  Examination. — The  structure  of  the  left  kidney  was  quite  natural. 
The  liver  presented  the  usual  atrophied  and  translucent  appearance  in  the  cells, 
characteristic  of  the  waxy  degeneration,  a few  only  containing  a small  number  of  fat 
granules. 

Commentary . — The  local  and  general  symptoms  in  this  case  were  so 
clear,  as  to  leave  me  in  no  doubt  from  the  first  that  this  man  had  a 
calculus  emb:dded  in  his  right  kidney,  causing  an  abscess  in  that  organ. 
The  recurring  rigors  and  fever,  with  pains  shooting  down  the  right  groin 
to  the  bladder,  and  occasional  vomiting ; the  turbid,  blcody,  purulent, 
and  gangrenous  urine ; the  remarkable  fulness  in  the  right  lumbar 
region,  with  tenderness  on  pressure ; and  the  past  history  of  the  case, 
constituted  an  unmistakable  group  of  phenomena  diagnostic  of  calculous 
nephritis.  Indeed,  so  certain  was  the  fact,  that  more  than  once  nephro- 
tomy was  spoken  of  as  a possible  means  of  relieving  him,  every  other 
organ  with  the  exception  of  the  liver  being  at  one  time  apparently 
healthy.  It  was  with  great  interest,  therefore,  that  the  dissection  after 
death  was  watched,  which  fully  confirmed  the  diagnosis.  It  also  pointed 
out  that  the  other  kidney  was  enlarged  and  healthy,  performing  double 
duty  without  difficulty;  that  the  liver  was  enlarged  and  waxy,  and  that 
a recto-vesical  fistula  existed,  causing  disease  of  the  intestinal  mucous 
membrane,  to  which  the  diarrhoea  latterly  might  be  attributed.  In 
reference  to  an  operation,  it  appeared  to  me  at  the  time  that  it  might 
easily  have  been  effected  after  the  method  of  Marchetti/^  as  the  two 
calculi  were  loose  within  cysts,  and  surrounded  by  pus.  The  enlarge- 
ment of  the  liver  prevented  the  performance  of  such  an  operation  being 
seriously  entertained  in  this  case.  But  here,  as  in  ovariotomy,  the  great 
difficulty  is  to  establish  in  the  living  subject  an  exact  diagnosis,  and  this 
I had  no  difficulty  in  doing  six  weeks  before  his  death,  and  when  his 
general  health  was  tolerably  good.  For  such  a disease  nothing  but 
palliatives  are  to  be  thought  of.  As  the  size  of  the  stone  cannot  be 
known,  diluents  are  indicated  with  the  possibility  of  favoring  its  descent 
along  the  ureters  to  the  bladder,  a pract  ce  which,  should  it  fail  in  that 
respect,  is  also  useful  in  carrying  off  the  pus  which  may  accumulate  in 
the  pelvis  of  the  kidney,  should  perchance  any  healthy  secreting  texture 
still  remain  in  it. 

Case  CLXXVIII.f — Chronic  Pyelitis^  and  Cystic  Kidneys — Dilatation 
of  Ureters — Fungoid  Ulceration  of  Urinary  Bladder. 

History. — Jane  Watson,  set.  74,  widow — admitted  November  15th,  1852.  As  far 
as  can  be  ascertained  from  the  patient,  whose  mental  faculties  are  very  much  impaired, 
she  has  been  laboring  under  her  present  complaint  for  the  last  eight  months.  About 
that  time  she  was  exposed  to  cold  from  sleeping  on  damp  straw,  and  was  seized  with 
rigors,  pain  in  the  back,  and  in  the  larger  joints.  The  urine  at  the  same  time  de- 
creased considerably  in  quantity,  with  frequent  micturition,  accompanied  by  pain. 
These  symptoms  lasted  for  about  a month,  after  which  the  amount  of  water  passed  be- 
came greatly  increased  in  quantity,  and  dysuria  disappeared.  For  the  last  three 
months,  the  urine  has  been  occasionally  mixed  with  blood,  continuing  for  a few  days, 

* An  account  of  a gentleman  being  cut  for  the  stone  in  the  kidney,  with  a brief 
inquiry  into  the  antiquity  and  practice  of  nephrotomy,  by  C.  Bernard. — Phil.  Trant.^ 
October  1696. 

\ Reported  by  Mr.  Robert  Francis  M.  Russell,  Clinical  Clerk. 


798 


DISEASES  OF  THE  GENITO-URINART  SYSTEM. 


and  then  becoming  natural.  Since  the  date  of  her  first  attack,  she  has  complained  of 
pain  in  the  region  of  the  right  kidney,  much  increased  at  those  periods  when  blood  was 
observed  in  the  urine. 

Symptoms  on  Admission. — On  admission,  she  has  a peculiar  cachectic  appearance, 
and  is  much  emaciated.  Tongue  moist,  cracked  in  the  centre,  great  thirst,  appetite 
impaired,  bowels  costive.  She  has  considerable  pain  and  tenderness  on  pressure  in  the 
right  lumbar  region,  where  there  is  also  some  fulness.  The  urine  is  passed  in  consid- 
erable quantity,  specific  gravity  1010,  alkaline,  highly  coagulable  on  the  addition  of 
heat  and  nitric  acid.  It  is  quite  turbid  when  passed,  and  deposits  on  standing  a copi- 
ous yellowish  gelatinous-like  sediment,  which,  under  the  microscope,  is  seen  to  contain 
numerous  pus  corpuscles,  granule  cells,  and  casts  of  the  tubes,  crowded  with  gran- 
ules. When  the  bladder  is  about  half  empty,  there  is  frequently  a sudden  stoppage 
of  the  flow  of  urine,  Avhen  she  suffers  from  severe  pain  in  the  hypogastri'um,  stretching 
down  the  thighs,  especially  on  the  right  side.  Pulse  90,  of  moderate  strength. 
Heart’s  sounds  feeble,  otherwise  normal.  Other  functions  natural.  The  bladder  was 
examined  by  Mr.  Syme,  and  a large  ulcer  was  detected,  occupying  the  base  and  neck 
of  the  bladder.  Tinct.  Hyoscyami  3 vi ; Tinct.  Opii  3 ij  ; Mucilaginis  et  Aquce  aa. 
3 vi.  Sumat  ter  indies. 

Progress  of  the  Case. — November  \%th. — Continues  much  in  the  same  state. 
Urine  presents  the  same  characters  as  before.  Omittatur  mistura  Hyoscyami, 

Potassce  Acetatis  § ss  ; 8p.  jEtheris  Nitrici  3 i'j  \ Mucilaginis  et  Aquce  aa  3 iij. 
M.  Sumat  3 j quartd  qudque  hord.  1^  Sol.  Mur.  Morphioe  3j  ; Mist.  Camphorce 
3 j.  M.  Sumat  dimidium  hora  somni  et  alterurn  post  koras  tres  si  opus  sit.  JVcmn 
fomentations  to  be  applied  to  the  loins.  Nov.  21  — The  w^arm  fomentations  were 

applied  as  ordered,  and  afforded  considerable  relief;  she  sleeps  well  at  night  after  tak- 
ing the  draught ; the  casts  have  now  disappeared  from  the  urine,  but  a few  granule 
cells  are  still  visible,  mixed  with  pus  corpuscles,  blood  globules,  and  some  crystals  of 
triple  phosphate.  Urine  still  of  specific  gravity  1010,  highly  albuminous,  and  of  a very 
putrid  smell  immediately  after  being  passed.  Nov.  IHh. — The  quantity  of  urine  is 
now  greatly  diminished  ; presents  the  same  characters  as  on  the  2ls^.  There  are  still 
pain  and  tenderness  in  right  lumbar  region  ; frequent  desire  to  pass  water,  the  first  half 
of  which  flows  with  comparative  facility,  but  the  remainder  comes  away  slowly,  requir- 
ing external  pressure  to  empty  the  bladder,  at  the  same  time  there  are  sharp  shooting 
pains  in  the  vulva,  and  the  inner  side  of  the  thighs,  extending  down  to  the  knees.  She 
appears  much  exhausted  ; pulse  weak,  96.  To  have  four  ounces  of  wine.  Nov.  28<^. 
— Is  much  in  the  same  state  ; the  urine  is  still  highly  coagulable  ; the  sediment  exam- 
ined by  the  microscope  presents  a large  number,  Is^,  of  finely  molecular  exudation 
casts  ; 2i//?/,  groups  of  broken  down  pus  cells  ; 3i/y,  crystals  of  triple  phosphate  ; Ulily., 
granular  cells  ; 5c4Zy,  blood  corpuscles.  December  ^th. — Is  now  passing  her  fasces  and 
urine  involuntarily  ; appetite  leather  improved  ; pulse,  85,  weak.  The  warm  fomenta- 
tions have  been  continued  since  the  18th  ult.  To  have  six  ounces  of  wine.  Dec.  %th. 
— Still  passes  everything  in  bed  ; complains  of  great  pain  and  tenderness  in  right  lum- 
bar region;  still  takes  food  well;  pulse  90,  of  better  strength.  Dec.  \bth — Appetite 
very  much  impaired  within  the  last  two  or  three  days ; still  complains  of  pain  over 
right  kidney,  and  passes  dejections  involuntarily.  Only  an  ounce  of  urine  could  be 
obtained  for  examination.  It  is  still  coagulable ; the  sediment  presenting,  under  the 
microscope,  the  same  characters  as  on  the  28th  ult.,  with  an  increase  in  the  number  of 
blood  corpu-scles  ; pulse  100,  very  weak.  Dec.  23  j. — Since  last  report  the  patient  has 
been  gradually  sinking,  and  she  died  this  morning. 

Sectio  Cadaveris. — Fifty  hours  after  death. 

Body  emaciated. 

Thorax. — Pericardium  contains  about  two  ounces  of  serum.  Heart  small,^presents 
a large  amount  of  fat  on  its  surface  ; valves  and  endocardium  perfectly  normal.  Left 
lung  slightly  adherent  at  apex  ; middle  and  lower  lobes  of  right  lung  strongly  adherent 
posteriorly ; both  lungs  were  crepitant  throughout,  with  the  exception  of  some  hard- 
ened deposits  at  apex  of  the  left,  which  look  like  old  tubercle.  Bronchi  contain  much 
frothy  mucus.  The  aorta  through  the.  whole  of  its  course  (and  both  iliac  arteries)  con- 
tained a large  amount  of  calcareous  deposit,  principally  seated  in  the  arch  of  the  aorta, 
and  the  thoracic  portion  of  that  vessel. 

Abdomen. — Stomach  and  intestinal  canal  normal ; pancreas  pale : spleen  very 
small ; liver  small,  congested,  firm,  and  dense.  Lumbar  glands  considerably  enlarged, 


NEPHEITIS  AND  PYELITIS. 


'^99 


and  contain  a very  great  amount  of  yellowish  opaque  juice,  evidently  purulent,  but  no 
distinct  abscesses.  Both  kidneiis  of  normal  size  when  viewed  externally ; the  ureters 
dilated  to  the  size  of  swan  quills  ; pelvis  of  both  kidneys  dilated  to  three  or  four  times 
the  normal  size  ; cortical  and  tubular  substance  correspondingly  small  in  volume  ; 
several  of  the  pyramids  distorted  and  crooked  in  direction,  but  their  basic  line  al- 
ways distinct ; cortical  substance  pale  ; malpighian  bodies  and  striae  destitute  of  blood  ; 
surface  smooth,  but  more  adherent  to  capsule  than  usual.  On  careful  examination 
with  the  naked  eye,  a considerable  number  of  cysts  from  the  smallest  visible  size  up 
to  ^ inch  diameter  are  observed  in  the  cortical  substance,  especially  near  the  surface. 
The  bladder  of  normal  size  ; all  its  walls  much  thickened  ; the  mucous  membrane 
presents  a soft  fungoid-looking  ulcerated  mass,  in  which  no  peculiar  or  character- 
istic structure  could  be  observed.  All  parts  of  the  mucous  membrane  were  equally 
diseased. 

Microscopic  Examination. — The  cysts  in  the  kidney  can  be  traced  down  to  very 
minute  sizes  (the  smallest  observed  was  about  the  600th  of  an  inch  in  diameter), 
having  the  usual  appearance  of  such  cyst  formations.  The  malpighian  bodies  shrunk, 
bloodless  and  opaque,  without  apparent  morbid  deposit,  but  with  thickening  of  their 
membrane  and  nuclei.  In  some  of  the  tubes  similar  thickening  and  epithelial  engorge- 
ment, producing  an  appearance  of  opacity  in  the  tubuli  without  any  recognisable  gran- 
ular deposit.  When  the  tubes  are  washed  out  and  examined  separately,  they  appear 
(most  of  them)  smooth.  Epithelium  small  and  compressed,  but,  generally,  regularly 
disposed  and  normally  developed.  In  a few  places,  traces  of  granular  and  molecular 
exudation,  but  to  an  insignificant  extent. 

Commentary. — The  complication  of  renal  and  vesical  disease  here  met 
with,  is  by  no  means  an  uncommon  one  in  aged  persons.  Its  existence 
leads  to  obstruction  of  the  ureter,  at  its  entrance  into  the  bladder,  disten- 
tion of  the  ureter  above,  accumulation  of  urine  in  the  pelvis  of  the  kidney, 
and,  as  a consequence,  inflammation  and  distention  of  its  mucous  lining 
walls,  pressure  on  the  secreting  portion,  and  atrophy  of  its  substance. 
Such  a lesion,  if  it  exist  in  both  kidneys,  must  necessarily  at  last  so  inter- 
fere with  their  functions,  as  to  be  incompatible  with  life.  The  chronic 
disease  of  the  bladder,  on  which  the  renal  disease  for  the  most  part  de- 
pends, only  admits  of  palliative  measures  for  its  relief. 

Cystic  disease  of  the  Iddney  may  originate  in  various  ways, — 1st,  From 
greater  or  less  obstruction  in  the  tubuli  uriniferi,  and  consequent  accumu- 
lation of  the  fluid  above,  forming  cystic  collections.  2d,  It  may  originate 
in  the  sacs  surrounding  the  malpighian  bodies,  the  fluid  accumulating  in 
them  producing  distention,  and  so  causing  cysts.  3d,  In  the  enlarge- 
ment of  the  secreting  cells  of  the  organ,  which  here,  as  in  the  ovary,  be- 
come distended  with  fluid,  and  by  pressing  upon,  compress  one  another. 

1.  The  obstructions  found  in  the  tubuli  uriniferi  are  of  various  kinds, 
and  may  consist  of  coagulated  exudation,  of  pus,  of  blood,  of  altered  epi- 
thelium cells,  or  of  different  salts,  such  as  urates,  carbonates,  phosphates, 
etc.  etc.  The  bloody  points  so  frequently  observed  on  the  surface  of 
diseased  kidneys,  most  frequently  arise  from  extravasation  of  blood  into 
the  convoluted  extremities  of  the  tubes.  Small  calculi  may  be  formed 
from  mineral  deposits,  but  more  commonly  the  tubular  cones  present  a 
diffused  white  appearance  from  their  occurrence.  That  such  a condition 
is  a frequent  source  of  cysts,  may  be  easily  proved  by  examination.  The 
cysts  so  formed  may  be  of  different  sizes,  varying  from  that  of  a millet 
seed  to  that  of  an  orange,  and  the  destruction  of  the  secreting  portion  of 
the  kidney  will,  of  course,  be  proportionate  to  their  volume  and  number. 
The  contents  of  such  cysts  are  also  of  various  kinds,  such  as  serum,  blood, 


800 


DISEASES  OF  THE  GENITO-UEINAET  SYSTEM. 


pus,  fibrous  exudation,  colloid  and  fatty  matter,  fluid  holding  various 
crystals  in  suspension,  whether  fatty  (cholesterine  or  margarine),  or  saline 
(phosphates,  urates,  etc.).  I have  frequently  seen  all  the  forms  in  the 
following  figure  (Fig.  474),  and  occasionally  the  radiated  bodies  repre- 
sented Fig.  321. 

2.  That  numerous  cysts  may  form  from  distention  of  the  minute  sacs 
surrounding  the  malpighian  body,  I have  satisfied  myself  of  by  careful 
examination,  and  possess  preparations  demonstrating  the  fact.  In  this 
case,  the  cysts  are  generally  numerous  and  scattered  through  the  cortical 
substance.  It  would  appear  to  arise  from  some  obstruction  at  the  com- 
mencement of  the  excreting  duct,  although  I have  never  been  able  to 
detect  any.  Fluid  collects  outside  the  membrane  in  immediate  con- 
tact with  the  tuft  of  vessels  constituting  the  malpighian  body,  and  inside 
another  membrane  continuous  with  the  basement  membrane  of  the  latter. 
Indeed,  it  is  in  cases  of  this  kind  that  we  may  satisfy  ourselves  that  the 


membrane  investing  the  tuft  of  vessels  is  really  double,  forming  a shut 
serous  sac,  in  the  cavity  of  which  the  fluid  accumulates.  This  fluid  is 
invariably  clear,  various  in  quantity,  but  each  cyst  seldom  exceeds  a small 
pea  in  size.  As  it  forms,  it  gradually  presses  on  the  vascular  tuft,  and 
causes  its  atrophy,  and  so  impedes  the  secretory  power  of  the  organ. 

3.  The  third  form  of  cystic  formation  in  the  kidney  evidently  ori- 
ginates in  the  secreting  cells  themselves,  as  they  may  be  seen,  on  a 
microscopic  examination,  to  exist  in  clusters,  varying  in  size  from  the 
600th  to  the  16th  of  an  inch  in  diameter.  In  such  a case,  the  paren- 
chyma of  the  organ  seems  to  be  inflltrated  with  them,  and  strongly 
reminds  the  observer  of  a section  of  the  ovary,  loaded  with  Graafian 
vesicles.  Many  still  retain  their  nucleus,  whilst  in  others  it  has  disap- 
peared. Mr.  Simon  of  London,  who  first  described  this  form  of  cystic 

Fig.  474.  Structures  occasionally  seen  in  cysts  of  the  kidney ; a and  h,  Structure- 
less transparent  colloid  masses ; c to  Colloid  bodies,  composed  of  one  or  more 
nuclei,  imbedded  in  albuminous  matter ; h to  Colloid  masses,  surrounded  by  con- 
centric laminae ; k,  A colloid  mass,  with  fatty  granules  arranged  in  an  areolar  manner. 
— {Wedl.)  350  dia^. 


bright’s  disease. 


801 


formation,  says,  as  explanatory  of  its  formation,  ‘‘  that  certain  diseases 
of  the  kidney  (whereof  subacute  inflammation  is  by  far  the  most  fre- 
quent)- tend  to  produce  a blocking  of  the  tubes ; that  this  obstruction, 
directly  or  indirectly,  produces  rupture  of  the  limitary  membrane  ; and 
that  then,  what  should  have  been  the  intra-tubular  cell-growth,  continues, 
with  certain  modifications,  as  a parenchytic  development.” 

One  or  all  of  these  forms  of  cystic  growth  in  the  kidney  may  be  as- 
sociated with  the  next  lesion  to  be  treated  of,  viz.,  Bright’s  disease. 

PERSISTENT  ALBUMINURIA,  OR  BRIGHT’S  DISEASE. 

That  albumen  in  urine  was  a symptom  of  certain  dropsies,  was  first 
noticed  by  Dr.  Wells  of  St.  Thomas’s  Hospital, f and  Dr.  Blackball  of 
Exeter ; that  it  indicated  especially  renal  dropsies,  was  the  discovery  of 
Dr.  Bright,  who  has  given  us  a careful  account  of  the  phenomena  which 
characterise  the  disease  that  has  since  borne  his  name,  as  well  as  of  the 
changes  observed  in  the  kidney  after  death.  The  subsequent  observa- 
tions of  Christison,  Martin,  Solon,  Rayer,  and  others,  as  well  as  the 
more  recent  investigations  of  Gluge,  Johnson,  Simon,  Frierichs,  and 
others,  have  rendered  it  certain  that  the  lesions  of  the  kidney  accom- 
panying albuminuria  are  various.  Some  are  dependent  on  what  may  be 
considered  an  acute  or  chronic  form  of  inflammation  (see  Nephritis), 
whilst  others  must  be  referred  to  what  we  now  call  the  fatty  and  waxy 
degenerations.  In  selecting  the  following  cases  as  illustrative  of  the 
disease,  I have  kept  in  view  its  natural  progress,  and  endeavored  to 
show  how,  by  judicious  treatment,  it  sometimes  terminates  in  recovery  ; 
how  at  other  times  it  frequently  becomes  obstinate,  and  in  'What  manner 
it  may  ultimately  cause  death.  Of  the  pathology  and  treatment  I shall 
speak  separately,  after  describing  the  facts  we  have  studied  at  the  bedside. 

Case  CLXXIX.;]; — Albuminuria — General  Anasarca — (Edema  of  Lung — 

Recovery. 

History. — Elizabeth  Brady,  set.  30,  cook,  married — admitted  March  19th,  1854. 
She  states  that  her  health  was  good  until  four  weeks  ago,  when,  after  exposure  to 
cold  and  wet,  she  was  seized  with  pains  in  the  chest,  and  cough,  but  without  shivering. 
Three  days  afterwards  her  feet  began  to  swell,  and  gradually  the  swelling  extended 
upwards,  involving  her  whole  body. 

Symptoms  on  Admission. — On  admission,  chest  well  formed ; breathing  slightly 
labored.  On  percussion,  unusual  resonance  is  perceived  over  the  upper  portion  of 
both  sides  anteriorly.  There  is  a marked  dulness  on  the  left  side  below  the  nipple 
and  lower  angle  of  scapula.  On  applying  the  stethoscope  over  the  portion  marked 
as  dull,  fine  crepitation  is  perceived.  Elsewhere  on  the  left  side,  the  inspiration  is 
harsh  and  the  expiration  prolonged  ; pulse  100,  small  and  hard ; cardiac  sounds 
normal ; tongue  covered  with  a brown  fur ; complains  of  nausea  and  disinclination 
for  food.  The  abdomen  is  distended  with  fluid,  and  she  has  pain  in  the  epigastric 
region  ; bowels  constipated;  urine  rather  scanty,  sp.  gr.  1028,  is  turbid  when  voided, 
and  on  standing  deposits  a copious  sediment,  which,  when  placed  under  the  micro- 
scope, presents  chiefly  amorphous  urate  of  ammonia,  with  a few  tube-casts.  On  the 
application  of  heat  and  nitric  acid  a large  coagulum  is  thrown  down.  Catamenia 
regular.  Her  skin  is  hot ; her  face  flushed  and  swollen ; she  suffers  from  general 

* Medico  Chirurgical  Transactions,  vol.  xxx.  p.  152. 

\ Trans,  of  a Society  for  promoting  Medical  and  Surgical  Knowledge,  vol.  iii.  pp. 
Ulj  16L 

\ Reported  by  Mr.  W.  W.  Clark,  Clinical  Clerk. 

51 


802 


DISEASES  OF  THE  GENITO-IJKINARY  SYSTEM, 


anasarca ; li  er  lower  extremities,  however,  being  especially  affected,  and  pitting  easily 
on  pressure. 

Progress  op  the  Case. — March  21s^. — Ordered  to  he  hied  at  the  arm  to  the  exterd 
of  timlve  ounces.  Pulv.  Doveri  Bi.  Tales  vi.  One  to  he  taken  at  hed-thne. 
March  ^‘Id. — Fifteen  ounces  of  blood  were  withdrawn  from  the  arm,  and  the  pulse 
shortly  fell  to  70.  She  expressed  herself  as  greatly  relieved.  After  taking  the 
Dover’s  powder  she  had  a short  sleep,  but  no  diaphoresis  was  produced.  The  blood 
withdrawn  presents  no  buffy  coat ; her  urine  is  voided  in  larger  quantity,  but  still 
deposits  a considerable  sediment;  pulse  90,  soft  and  weak.  Potass.  Acet.  3i; 

Sp.  MJth.  Nit.  3 vi  ; Syrup.  Aurantii  § i ; Aquce  § iv.  M.  One  ounce  to  he  taken 

three  times  a day.  Pulv.  Oamhogice  gr.  v ; Potass.  Bitart.  3 ij.  j\f.  To  he  taken 

at  hed-time.  March  23c?. — Her  bowels  have  been  well  opened,  and  her  general 
appearance  is  greatly  improved,  her  faee  being  much  less  swollen ; urine  less  turbid, 
and  in  larger  quantity.  Intermittatur  mist.  Pil.  Scillce  et  Digital,  xii.  One  to 
he  taken  every  sixth  hour.  March  ‘iAth. — Her  cough  has  abated  greatly,  and  she 

feels  herself  much  better.  Repetat.  Pidv.  Gamh.  et  Potass.  Bitart,  vespere.  Match 

2%ih. — Urine  deposits  very  little  sediment  on  standing ; and,  under  the  microscope, 
no  tube  casts  can  be  detected;  sp.  gr.  1018.  A slight  coagulum  is  produced  on 
applying  heat  and  nitric  acid.  Her  appetite  is  greatly  improved.  March  ^l^th. — 
On  examining  her  chest  to-day,  the  dulness  on  percussion,  which  previously  existed 
on  the  left  side,  cannot  now  be  detected,  and  on  auscultation  over  that  portion  the 
respiratory  murmur  is  heard  normal.  Under  the  right  clavicle  the  inspiration  appears 
unusually  harsh.  Her  urine  presents  the  same  character  as  at  last  report.  Rcpetan- 
tur  Pil.  ScilUe  et  Digital,  et  Pulv.  Potass.  Bitart.  3 ss  ter  indies.  April  3c?.  She  is 
now  nearly  convalescent,  and  has  taken  no  medicine  for  two  days.  To  have  steak 
diet.  May  8?A. — Complains  to-day  of  pain  in  the  epigastrium  and  of  vomiting ; 
bowels  constipated  ; pulse  natural ; urine  yields  no  coagulum  to  the  usual  re-agents ; 
sp.  gr.  1008  ; contains  no  tube-casts  on  microscopic  examination.  Menstruation 
rather  frequent,  and,  in  the  intervals  of  the  catamenial  periods,  she  is  subject  to  a 
leucorrhoeal  discharge.  U Naphthce  Medicinal.  3 i ; Tinct.  Cardam.  Co.  § i ; Aqtice 
3 V.  M.  A tahle-spoonful  to  he  taken  when  the  vomiting  is  trouhlesome.  IJ  Mo,g- 
nesice  Carh.  3 ss  ; Aq.  Cinnam.  § i ; Inf  us.  Sennce  Co.  3 ij ; M.  Ft.  haust.  hora 
somni  sumendus.  Intermittaniur  alia.  July  20?A. — Since  last  report  her  urine  has 
remained  entirely  free  of  albumen.  The  oedema  has  now  for  the  most  part  entirely 
disappeared,  but  still  returns  slightly  after  she  has  been  for  some  time  in  the  erect  po- 
sition. General  health  good.  Dismissed. 

Commentary . — On  succeeding  Dr.  Cliristison  in  the  charge  of  the 
clinical  wards  on  the  1st  of  May  1854,  I was  informed  that  this  was 
a case  of  Bright’s  disease.  On  the  8th  of  the  month,  however,  as  stated 
in  the  report,  on  examining  her  urine,  I found  it  to  contain  no  albumen 
on  the  addition  of  heat  or  nitric  acid,  while  the  sediment,  carefully 
collected,  exhibited  no  tube-casts  under  the  microscope.  On  looking 
into  the  history  of  the  case,  as  recorded  in  the  ward-book,  and  which 
is  given  above,  it  became  clear  that  the  woman  had  undoubtedly 
been  laboring  under  albuminuria  and  chronic  renal  disease,  which, 
well  pronounced  March  21st,  had  entirely  disappeared  at  the  beginning 
of  May.  But  the  oedema  of  the  feet  continued,  with  stomachic  derange- 
ments ; the  former  symptom  exhibiting  a tendency  to  return,  on 
assuming  the  erect  position  for  any  time ; and  in  consequence,  she  was 
not  dismissed  until  the  20th  of  July.  Before  saying  anything  with 
regard  to  the  treatment,  it  will  be  well  to  attend  to  the  facts  exhibited 
by  some  other  cases. 

Case  CLXXX.^ — Alhminuria — (Edema  of  loth  feet  and  legs.,  left  arm 
and  hand — Recovery. 

History. — Robert  Lindsay,  set.  62,  carder  of  wool — admitted  21st  Mai’ch  1854. 

Reported  by  Mi'.  Robert  Bird,  Clinical  Clerk. 


BRIGHT  S DISEASE. 


803 


States  that,  twenty-three  years  ago,  he  had  a violent  attack  of  rheumatism  which 
laid  him  up  for  ten  months.  After  his  recovery,  his  health  continued  good,  until 
ten  years  ago,  when  he  began  to  suffer  from  symptoms  of  stone  in  the  bladder.  He 
underwent  the  operation  of  lithotomy,  but  made  a tardy  recovery,  being  unable  to 
resume  his  work  until  upwards  of  twelve  months  afterwards,  and  for  two  or  three 
years  subsequently  he  was  subject  to  attacks  of  rigors,  which  compelled  him  to  keej) 
within  doors  for  several  days  at  a time.  He  then  became  tolerable  healthy,  and  con- 
tinued so  until  three  weeks  ago,  when  he  noticed  his  left  wrist  somewhat  swollen,  and 
in  the  course  of  two  days  his  lower  extremities  became  likewise  cedematous.  He  suf- 
fered from  a dull  heavy  pain  in  the  lumbar  region,  which  has  been  present  more  or 
less  ever  since  he  underwent  the  operation  ten  years  ago.  His  urine,  at  the  time  the 
swelling  commenced,  was  scanty  and  high  colored,  and  he  was  troubled  with  a slight 
cough.  He  says  that  about  the  time  when  his  illness  began,  he  was  engaged  in  clean- 
ing machinery,  and  may  have  caught  cold.  He  is  not  aware  of  any  other  cause  which 
might  have  brought  on  his  ailment.  He  acknowledges  that  formerly  he  was  a free 
liver,  but  since  the  operation  he  has  been  very  temperate. 

Symptoms  on  Admission. — On  admission,  both  feet  and  legs  are  oedematous,  pitting 
on  pressure.  There  is  also  slight  swelling  of  the  left  arm  and  hand.  He  comjilains 
of  a dull  pain  in  the  lumbar  region  on  both  sides,  but  that  on  tlie  left  is  most  severe. 
Micturition  frequent ; he  is  obliged  to  rise  several  times  in  the  course  of  the  night  for 
that  purpose.  It  is  not  attended  with  pain  or  difficulty.  Sp.gr.  of  urine  1011;  co- 
agulable  by  heat  and  nitric  acid.  He  complains  of  frontal  headache.  Sleeps  badly, 
being  much  disturbed  by  dreams  and  sudden  startings.  Tongue  moist  and  clean ; 
complains  of  great  thirst ; appetite  imjiaired  ; bowels  regular;  has  a slight  cough,  with 
very  little  expectoration  ; chest  everywhere  resonant  on  percussion.  At  the  apices  of 
both  lungs  anteriorly,  and  at  the  apex  of  the  left  posteriorly,  sibilant  rales  are  heard. 
He  has  suffered  from  palpitation  for  the  last  three  weeks,  but  the  cardiac  sounds  are 
normal.  I^  Tinct.  Ferri  Mur.  § i.  Ten  drops  to  be  taken  three  times  a-day. 

Pulv.  Doveri  gr.  x.  Mittant.  tales  vi.  One  to  be  taken  morning  and  night. 

Progress  of  the  Case. — March  T^d. — This  morning  he  had  violent  vomiting,  but 
it  has  now  abated,  and  he  complains  of  great  thirst.  March  2^th. — Ordered  pills  of 
digitaline,  each  containing  l-Hth  of  a grain.  One  to  be  taken  three  times  a-day. 
March  ^kth. — After  taking  the  pills  of  digitaline  twice,  excessive  purging  came  on ; 
their  further  use  was  therefore  abandoned.  The  urine  was  very  slightly  increased  in 
quantity.  April  Mh. — The  use  of  digitaline  was  resumed  four  days  ago,  and  now  the 
coagulability  of  the  urine  has  entirely  disappeared.  The  oedema  of  his  lower  extremi- 
ties has  abated  greatly.  The  purging,  caused  by  the  digitaline,  was  counteracted  by 
opium  pills..  May  2>d. — Since  last  report  the  urine  has  been  several  times  examined, 
and  has  been  always  found  to  be  free  of  albumen.  To-day  only  the  slightest  haze  is 
caused  by  heat  and  nitric  acid ; the  urine  is  pale  colored  ; sp.  gr.  1014,  transparent, 
and  without  sediment  on  standing ; 84  oz.  are  passed  in  the  twenty-four  hours. 
The  oedema  has  not  entirely  disappeared  from  the  feet  and  ankles.  He  continues  to 
take  the  digitaline  pills.  His  general  health  is  much  improved.  May  11th. — Two 
days  ago  he  was  ordered  the  following : — Tinct.  Ferri  Mur.  % i.  Fifteen  drops  to 
be  taken  thrice  a-day.  To-day  he  has  passed  54  oz.  of  urine.  The  oedema  of  his  feet 
and  ankles  is  abating.  A few  minute  flakes  are  produced  on  treating  the  urine  by 
heat  and  nitric  acid.  May  IMh. — 78  oz.  of  urine  were  voided  during  the  last  24 
hours.  1^  MEth.  Nit.  § iss  ; Aq.  Potass.  ; Tinct.  Digital,  aa  3 ij.  M.  A tea- 
spoonful to  be  taken  thrice  a-day.  Continue  Tinct.  Mur.  Ferri.  May  l^th. — Amount 
of  urine  passed  during  the  twenty-four  hours  is  100  oz.  June  %ld. — (Edema  of  legs 
almost  entirely  gone  ; 68  oz.  of  urine  passed  during  the  last  twenty-four  hours  ; sp. 
gr.  1014;  quite  unaffected  by  heat  and  nitric  acid.  June  ‘■lUh. — His  feet  and  ankles 
are  slightly  cedematous  at  night ; 60  oz.  of  urine  passed  during  the  last  twenty-four 
hours;  sp.gr.  1017.  No  coagulum  produced  by  heat  and  nitric  acid.  Jidy  ll^/<. — 
Dismissed  quite  well. 

Commentary. — In  this  case,  also,  we  can  have  no  doubt  of  the  exist- 
ence of  Bright’s  disease,  although  on  my  succeeding  Dr.  Christison  in 
the  clinical  wards  I found  no  albumen  in  the  urine,  and  that  the  patient 
was  rapidly  recovering.  Digitaline  had  been  tried,  with  the  efect  of 
producing  excessive  purging,  and  slight  increase  of  the  urine.  The 


804 


DISEASES  OF  THE  GENITO-UEINARY  SYSTEM. 


albumen  shortly  afterwards  disappeared  from  the  fluid,  but  here,  as  in 
the  last  case,  the  oedema  continued,  and  he  subsequently  became  quite 
well.  These  two  cases,  therefore,  indicate  that  purgatives  and  diuretics 
are  sometimes  very  efficient  in  entirely  removing  the  disease. 

Case  CLXXXI.* — Albuminuria — (Edema — Ascites  and  General  Ana- 
sarca — Coma  and  Convulsions — Recovery. 

History. — Alexander  Strachan,  aet.  36,  a joiner — admitted  October  26,  1858.  He 
enjoyed  good  health  up  to  the  2d  October  last,  when,  after  exposure  to  cold  and  wet, 
he  was  seized  with  a rigor,  followed  by  severe  cough  and  slight  expectoration.  On  the 
6th  he  first  remarked  swelling  of  the  lower  extremities,  and  in  the  evening,  on  trying 
to  make  water,  he,  with  some  difficulty,  passed  about  half  a pint  of  brown,  smoky- 
colored  urine.  On  the  following  morning  this  presented  a sediment  of  a light  color 
and  viscous  consistence.  He  at  this  time  suffered  from  constipation,  and  was  ordered 
a dose  of  castor-oil  by  his  medical  attendant.  On  the  7th  he  had  a copious  ev'icuation 
from  the  bowels,  but  his  legs  continued  to  swell.  On  the  8th  his  water  which  was 
small  in  quantity,  still  presented  a white,  viscous  sediment.  The  legs  became  more 
swollen,  the  abdomen  now  began  to  increase  in  size,  and  great  difficulty  of  breathing 
came  on.  He  continued  in  this  state  up  till  the  day  of  his  admission. 

Symptoms  on  Admission, — There  is  great  oedema  of  both  legs,  ascites,  and  general 
anasarca.  He  has  a good  deal  of  cough  and  frothy  expectoration  ; but,  with  the  ex- 
ception of  occasional  fine  moist  rale  and  sibilation  posteriorly,  the  lungs  are  healthy. 
Cardiac  dulness  and  sounds  normal.  Pulse  70,  of  moderate  strength.  He  complains 
of  a dull  pain  over  the  region  of  the  kidneys.  Urine  of  a dark,  smoky  color,  highly 
albuminous,  and  depositing  a whitish,  tenacious  sediment.  Tube-casts  and  blood  cor- 
puscles are  very  abundant,  as  determined  by  the  microscope.  Other  symptoms  nor- 
mal. To  he  dry  cupped  over  the  kidneys,  and  to  take  3 j doses  of  Pulv.  Jalapoi  Comp, 
three  times  a day. 

Progress  of  the  Case. — October  2^th. — The  cough  and  expectoration  have  greatly 
diminished  since  he  came  into  the  house,  but  little  impression  has  been  made  upon  the 
dropsy.  November  2d. — Ordered  Pit.  Digitalis  et  Scillce  xij  ; one  three  times  a-day,  in 
addition  to  the  powders.  November  ^th. — Has  passed  quantities  of  urine  varying  from 
20  to  44  oz.  daily,  although  generally  it  has  been  deficient  in  quantity.  The  dropsical 
symptoms  have  undergone  no  change.  This  morning  at  four  o’clock  he  was  seized 
with  convulsions  and  loss  of  consciousness.  Had  three  more  fits  at  intervals  during 
the  day.  Urine  of  a smoky  tint,  containing  tube-casts  and  blood  corpuscles.  Ordered 
to  be  cupped  to  5 ounces  over  the  region  of  the  kidneys.  To  have  1]  of  the  Bitartrate 
of  Potass  three  times  a-day.  November  %th. — Had  three  fits  to-day,  and  been  drowsy. 
November  ^th. — The  drowsiness  is  nearly  gone  to-day,  and  he  is  quite  sensible, 
though  complaining  of  an  intense  headache.  Pulse  108,  of  fair  strength.  Urine  40 
oz.,  sp.  gr.  1016,  albuminous  and  containing  blood  corpuscles.  Dropsy  of  the  legs  has 
nearly  disappeared,  and  the  abdomen  feels  softer.  It  measures  36  inches  round  the 
most  prominent  part.  November  \0th. — ffidema  of  legs  entirely  gone;  not  the  slight- 
est pitting  on  pressure.  Complains  of  seeing  objects  distorted,  and  sometimes  of  a 
haze  which  appears  before  his  vision.  He  continues  to  take  the  Squill  and  Digitalis 
pill,  one  four  times  a-day,  and  3 j doses  of  bitartrate  of  potash.  November  Wih. — 
Six  dry  cupping-glasses  were  applied  over  the  lumbar  region  this  evening.  The  pupil 
of  the  eye  was  observed  to  be  considerably  dilated.  November  \2th. — Passed  68  oz. 
of  urine  free  from  albumen.  November  \Zth. — Passed  42  oz.;  and  November  \Ath,  46 
oz.  of  urine.  To-day  the  left  pupil  was  observed  to  be  contracted,  the  right  dilated. 
Sees  whatever  object  he  has  been  looking  at  magnified  on  the  opposite  wall.  Novem- 
ber \Wi. — Since  last  report,  has  passed  on  the  different  days,  48,  60,  136,  132,  and  98 
oz.  of  urine.  To-day  it  shows  a mere  trace  of  albumen.  Abdomen  much  less  tense, 
measures  34  inches.  From  the  19th  to  the  27th  has  been  passing  about  90bz.  of  urine 
daily.  It  has  still  a dim,  smoky  tint,  reaction  acid,  sp.  gr.  1018.  Nitric  acid  imparts 
to  it  a red  tint,  and  after  boiling  flakes  of  albumen  appear.  From  this  time  he  gradu- 
ally recovered.  He  was  for  some  days  troubled  with  muscae  volitantes,  but  was  dis- 
missed on  the  1st  of  December  at  his  own  request,  the  dropsy  having  completely  dis- 
appeared, and  only  the  faintest  trace  of  albumen  existing  in  the  urine. 

^ Reported  by  Mr.  George  Shearer,  Clinical  Clerk. 


bright’s  disease. 


805 


Commentary . — In  this  case  the  amount  of  general  anasarca  was  very 
great,  and  purgatives  and  the  squill  and  digitalis  pill  produced  no  effect, 
so  that  poisoning  of  the  blood  with  urea  caused  coma  and  severe  con- 
vulsions. These  were  of  an  epileptiform  character,  with  foaming  at  the 
mouth,  each  paroxysm  being  of  about  ten  minutes’  duration.  From 
this  state  the  patient  was  roused  by  the  energetic  action  of  the  bitartrate 
of  potash,  which,  by  increasing  the  tlow  of  urine  from  the  kidneys, 
rapidly  diminished  the  head  symptoms,  and  completely  removed  the 
dropsy.  The  following  case,  which  is  the  most  remarkable  recovery  I 
ever  saw,  still  further  points  out  the  value  of  this  drug  in  Bright’s  dis- 
ease of  the  kidneys. 

Case  CLXXXII.'^ — Third  Attach  of  General  Anasarca  with  Albuminuria 
— Enormous  Dropsical  Distention  of  the  Abdomen^  Scrotum,  and 
Dferior  Extremities — Complete  Recovery  under  the  Action  of  Super- 
tartrate of  Potash. 

History. — William  Herdmann,  set.  49,  single,  a lithographer — admitted  March 
31st,  1855.  Patient  admits  that  he  has  been  a man  of  rather  intemperate  habits,  al- 
though this  has  not  been  the  case  of  late.  Twelve  years  ago,  without  any  premoni- 
tory symptoms,  he  was  suddenly  seized  with  general  anasarca  and  with  ascites.  For 
this  he  entered  the  Infirmary,  and  after  treatment  was  dismissed  “ Cured.”  Six  years 
after  the  first,  he  suffered  from  another  attack,  which  was  also  cured  in  the  Infirmary. 
Within  the  last  fortnight  he  has  been  again  attacked  by  “dropsy,”  which  has  been 
gradually  increasing. 

Symptoms  on  Admission. — On  admission,  the  quantity  of  urine  passed  is  small, 
but  he  is  not  obliged  to  rise  during  the  night  to  pass  his  water.  No  pain  in  the  loins, 
or  tenderness  on  pressure.  Abdomen  is  considerably  swollen,  especially  at  the  lower 
part.  Circular  measurement  below  umbilicus,  30^  inches.  When  he  lies  on  his 
back,  the  anterior  part  of  the  abdomen  is  tympanitic,  and  the  flanks  dull  on  percus- 
sion. On  turning  him  to  either  side,  the  one  which  is  uppermost  becomes  clear  on 
percussion,  and  the  undermost  remains  dull.  There  is  slight  oedema  of  the  ankles, 
but  he  notices,  every  morning,  some  puffiness  in  the  cheeks,  especially  on  the  righf 
side  (that  on  which  he  usually  lies).  Bowels  rather  costive ; appetite  very  bad  ; tongue 
foul,  and  covered  with  thick  brown  fur ; considerable  thirst ; complains  of  cough  and 
shortness  of  breath ; expectorates  a little  frothy  mucus.  Percussion  of  chest  anteri- 
orly resonant  on  both  sides.  On  auscultation  in  front,  there  is  heard  on  both  sides 
harsh  inspiration,  attended  with  very  prolonged  expiration.  Posteriorly,  at  both 
bases,  there  are  loud  sibilant  and  crepitating  rales.  Heart  sounds  indistinct ; no  mur- 
mur ; pulse  68,  of  good  strength  ; sleeps  well ; has  complained  a little  of  drowsiness 
for  the  last  few  days ; skin  dry  and  harsh.  very  scanty ; has  only  passed  12 

oz.  since  admission.  The  application  of  heat  converts  the  whole  quantity  in  the  test- 
tube  into  a firm  coagulum  ; sp.  gr.  1024.  Casts  of  tubes  and  oil  globules  are  found  in 
the  sediment.  Descendat  in  balneum  calidum  vespere.  Sumat.  Pit.  Scillce  et  Digita- 
lis j.  ter  in  die.  I^  Tr.  Opii  Ammoniatce  ; Sp.  Lavendulee  Co.  aa  § ss  ; Mist.  Scillce 
§ V.  M.  Sumat  § j ter  in  die. 

Progress  op  the  Case. — April  ^th. — Has  passed  16  oz.  of  urine  during  the  last 
twenty-four  hours.  Swelling  of  abdomen  increased  ; it  measures  below  umbilicus  33 
inches.  He  is  very  thirsty.  April  Mh. — Only  9 oz.  of  urine  passed  since  last  report ; 
sp.  gr.  1018  ; highly  coagulable  ; bowels  costive  ; tongue  dry  and  furred  ; cough  still 
present,  with  expectoration  of  tough  frothy  mucus ; sibilant  and  crepitating  rales  still 
heard  at  bases  of  both  lungs  posteriorly.  Repeat  the  warm  baths.  Injiciatur  enema 
foetidum.  Habeat  Pule.  Ipecac.  Co.  gr.  x.  hac  nocte  et  repetatur  eras  mane.  April 
%th. — Obtained  little  relief  from  the  injection  ; skin  of  chest,  abdomen,  and  loins,  pits 
upon  pressure.  Abdomen  measures  34f  inches  in  circumference  ; passed  only  9 oz.  of 
urine  since  last  report,  of  same  character  as  before.  Breath  has  a urinous  odor, 
Contimient.  Pil.  Scillce  et  Digitalis  et  sumat  Potass.  Bitart.  3 j ter  in  die.  Repetatut 


Reported  by  Mr.  Robert  Byers,  Clinical  Clerk. 


806 


DISEASES  OF  THE  GENITO-UEIXAET  SYSTEM. 


Pulv.  Doveri.  April  \bth. — Urine  passed  daii}’’  has  been  from  8 to  15  oz.,  of  sp.  gr, 
about  1020,  and  highly  coagulable.  O^nittantur  Pil.  Scillce  et  Digitalis.  To  appl^ 
spongio  piline  constantly  to  the  abdo^nen,  sat^irated  with  a strong  solution  of  In  fus. 
Digitalis.  April  22(/. — Urine  not  increased  in  quantity,  varies  from  9 to  15  oz.  per 
diem  ; abdomen  measures  37^  inches.  The  Inf.  Digitalis  has  produced  a rash  of  a 
papular  character  over  the  surface  of  the  abdomen.  5 ^P-  -^th.  Nitrici  3 vj ; Aq. 
Oiniiamomi  ^ vss.  M.  Habeat  | j ter  in  die.  April  2bth. — Says  that  the  last  mix- 
ture has  given  him  great  relief ; has  passed  26  oz.  of  urine  after  it.  The  spongio- 
piline  to  be  removed,  owing  to  irritation  which  it  has  caused  in  the  skin  of  abdomen. 
J/ay  2d. — Base  of  left  lung  dull  on  percussion  posteriorly ; no  rale ; a good  deal 
of  pain  in  abdomen ; bowels  costive ; skin  dry ; has  passed  25  oz.  of  urine  to- 
day. May  Sd. — Urine  24  oz  ; Habeat  Potass.  Bitart.  Dj  ter  in  die.  Omittantur  alia. 
May  bth. — Urine  18  oz.  ; swelling  of  abdomen  much  increased  ; thighs  and  legs 
greatly  distended.  Abdomen  measures  forty  inches  in  circumference.  Had  Pil.  Rhei 
Co.  gr.  X.  last  night.  To  take  Gin  § j daily.  May  ^ih. — Urine  20  oz.  ; sp.  gr.  1018  ; 
his  condition  at  present  seems  almost  hopeless.  The  abdomen  is  enormously  distend- 
ed, with  a peculiar  diffuse  indurated  feel  over  the  region  of  the  epigastrium,  which, 
however,  is  tympanitic  on  percussion.  The  scrotum,  thighs,  and  legs  are  greatly  en- 
larged ; appetite  impaired  ; the  pulse  86,  weak.  To  be  dry  cupped  over  the  loins. 
To  have  Gin  ? ij  daily.  May  9th. — No  change.  Habeat  Potass.  Bitart.  1 ter  in  die. 
May  Wth. — Urine  34  oz,  ; sp.  gr.  1015;  still  highly  coagulable;  numerous  casts  of 
tubes  are  seen  in  the  urine  under  the  microscope.  3Iay  Ibth. — Urine  38  oz.  ; sp.  gr. 
1014;  is  less  coagulable;  complains  of  severe  frontal  headache.  To  continue  with 
the  Bitartrate  of  Potass.  3Iay  16///. — Urine  64  oz.  ; sp.  gr.  1010.  Alay  Vlth. — Urine 
58  oz. ; sp.  gr.  1013;  no  headache;  bed-sore  on  sacrum;  right  side  more  swollen 
than  left  (he  lies  on  his  side) ; bowels  costive.  Habeat  J^il.  Cotocynth.  Co.  gr.  x hord 
somni.  3Iay  IS/A. — Urine  67  oz.  ; oedema  of  limbs  v'ery  much  diminished;  swelling 
of  abdomen  less.  Alay  2\st. — Urine  68  oz. ; sp.  gr.  1010  ; appetite  good  ; pulse  96, 
full  and  strong,  31ay  22d. — Urine  1 20  oz,  31ay  23c/. — Urine  128  oz.  ; sp.  gr.  1014  ; 
it  still  contains  albumen  in  considerable  quantity  ; the  abdomen  has  greatly  dimin- 
ished in  size,  and  the  thighs  and  legs  are  of  natural  appearance,  though  there  is  some 
pitting  on  pressure  at  the  ankles  ; every  second  day  of  late  he  has  been  attacked  about 
noon  with  a severe  frontal  headache,  B Quince  Sul fihatis  gr.  iij  ter  die  sumend.  3Iay 
2\th. — Urine  107  oz.  ; sp.  gr.  1018;  still  contains  much  albumen;  no  headache. 
3Iay  2bth. — Urine  126  oz.  ; sp.  gr.  1016;  very  slight  headache  to-day;  has  taken 
four  of  the  quinine  powders.  Still  takes  the  Bitartrate  of  Potash.  May  28///. — Urine 
100  oz.  ; sp.  gr.  1020.  3lay  30/A. — Urine  50  oz.  May  31.s/. — Urine  80  oz. ; sp.  gr. 
1014;  perf^ectly  fiee  from  all  trace  of  albumen  ; oedema  of  legs  and  ascites  have  com- 
pletely disappeared ; no  headache  ; appetite  good.  June  %th. — No  return  of  the  albu- 
men in  urine  ; quantity  varies  from  60  to  114  oz.  daily.  June  9th. — A slight  trace 
of  albumen  in  the  urine  to-day,  and  feet  slightly  cedematous.  June  16/A. — Still  a 
faint  trace  of  albumen  in  the  urine  ; his  ankles  become  cedematous  if  he  sits  up  long. 
June  \9th. — Urine  100  oz.  in  twenty-four  hours;  sp.  gr.  1010;  contains  an  exceed- 
ingly faint  trace  of  albumen.  June  27/A. — The  quantity  of  urine  passed  in  twenty- 
four  hours  averages  100  oz.  ; sp.  gr.  varies  from  1010  to  1015 ; his  ankles  after  he  has 
been  long  up  pit  slightly  on  pressure.  July  2d. — Albumen  has  quite  disappeared ; 
bandaging  prevents  his  ankles  from  swelling.  He  sits  up  the  entire  day.  The 
appetite  is  good.  Urine  passed  daily  about  40  oz.  In  fact  he  is  quite  well.  July  3c?. 
— Dismissed  cured. 

Commentary. — In  this  case  the  man  described  his  dropsy  as  being  the 
third  attack  of  the  kind  he  had  experienced,  although  it  was  by  far  much 
more  severe  than  the  preceding  ones.  I found  him  in  the  ward  at  the 
same  time  with  Cases  CLXXIX  and  CLXXX.,  but  unlike  them,  the 
treatment  seemed  to  have  been  of  no  avail.  The  abdomen  was  enor- 
mously distended  from  fluid  collected  in  the  peritoneum  and  the  scrotum  ; 
the  thighs  and  legs  were  also  so  greatly  swollen  from  dropsy,  that  to  all 
appearance  the  case  was  hopeless.  The  urine,  when  heated,  presented 
almost  a solid  mass  of  albumen,  as  if  it  had  been  serum  of  the  blood,  and 


bright’s  disease. 


807 


the  sediment  exhibited,  under  the  microscope,  numerous  fatty  cells  and 
casts  of  the  tubes,  proving  the  disease  to  be  renal.  A singular  circum- 
stance is,  that  from  his  admission  in  March,  until  May  11th,  notwith- 
standing a diaphoretic,  purgative,  and  diuretic  treatment  had  been  em- 
ployed, he  continued  to  get  worse,  and  the  anasarca  increased.  In  April, 
also,  he  had  taken  the  bitartrate  of  potash  in  drachm  doses  without  benefit. 
But  after  I resumed  the  same  remedy  in  May,  in  half  drachm  doses,  its 
diuretic  effect  was  extraordinary.  From  the  11th  to  the  28th  of  May,  the 
quantity  of  urine  was  greatly  increased,  and  I ordered  it  to  be  measured 
daily.  On  some  occasions  126  oz.  of  fluid  were  voided,  and  coincident  with 
this  diuretic  effect,  the  enormously  swollen  abdomen,  scrotum,  and  inferior 
extremities  diminished  in  size,  and  gradually  returned  to  their  normal 
condition.  On  the  31st  of  May  there  was  no  albumen  in  the  urine. 
The  ankles  still  remained  puffy,  especially  after  sitting  up  for  any  time, 
but  on  the  3d  of  July  he  was  dismissed  perfectly  well. 

The  anasarca  in  this  case  had  reached  its  ultimate  limits,  the  scrotum 
was  as  large  as  an  adult  head,  the  prostration  of  the  patient  was  extreme, 
and  we  daily  feared  the  coming  on  of  coma  and  sloughing  sores  on  the 
back.  Although  dry  cupping  was  tried  over  the  loins  on  the  7th  of 
May,  I have  m^’-self  no  doubt  that  the  good  effects  are  entirely  to  be  at- 
tributed to  the  diuretic  ordered  on  the  9th,  and  the  increased  discharge 
of  fluid  from  the  kidneys  which  followed. 

The  cases  now  recorded,  in  which  advanced  Bright’s  disease  was  per- 
fectly cured,  exhibit  the  groundlessness  of  the  fears  entertained  by  some 
as  to  the  use  of  diuretics  in  that  disease.  In  all  they  were  freely  em- 
ployed, and  it  may  be  observed  that  improvement  invariably  coincided 
with  the  coming  on  of  the  increased  flow  of  urine.  The  case  of  Herdmann 
(Case  CLXXXII.)  is  extraordinary  in  this  respect.  Case  CLXXIX. 
also,  in  which  there  was  a permanent  cure  of  albuminuria  in  connection 
with  hepatic  disease,  may  be  consulted  with  advantage. 

Case  CLXXXIII."^ — Second  Attack  of  Alhuminuria  with  Anasarca — Dis- 

missed  relieved. 

tliSTORY. — Mary  Donaghan,  set.  43 — admitted  July  12tli,  1854,  out  worker.  She 
states  that  about  three  weeks  ago,  she  came  home  from  her  usual  employment  in  the  open 
fields  in  good  health,  but  awoke  next  morning  with  pain  in  the  epigastric  region,  and 
found  her  legs,  arms,  body,  and  face,  much  swollen.  She  was  not  aware  of  having 
been  exposed  to  unusual  cold  or  wet  previously,  and  had  no  shivering.  She  had  no 
pain  in  the  loins,  and  passed  her  urine  in  usual  quantity.  Two  years  ago,  she  was  ad- 
mitted into  this  hospital,  suffering  in  the  same  way  as  at  present.  The  swelling  of  her 
body  at  that  time,  however,  was  much  greater. 

Symptoms  on  Admission. — On  admission,  her  lower  extremities  only  are  oedema- 
tous,  pitting  on  pressure.  Her  skin  is  moist,  and  she  perspires  moderately.  Urine 
passed  in  normal  quantity.  On  standing,  a thick  white  deposit  subsides,  which,  under 
the  microscope,  is  seen  to  consist  of  epithelial  scales,  numerous  tube-casts  filled  with 
oily  globules,  and  compound  granular  bodies.  Urine  deposits  a considerable  coagu- 
lum  by  heat  and  nitric  acid,  also  an  abundant  precipitate  of  chlorides  by  nitrate  of 
silver;  sp.  gr.  1012.  She  complains  of  pain  on  pressing  firmly  the  left  lumbar  region. 
Her  tongue  is  moist  at  the  edges,  and  furred  in  the  centre.  She  complains  of  thirst, 
and  bad  appetite.  Epigastric  region  somewhat  tender  on  pressure.  Bowels  consti- 
pated. B Pnlv.  Potass.  Bitart.  | ss ; in  pulv.  xii  divid.  One  to  be  taken  three 
limes  a-day. 

Progress  of  the  Case. — July  23c?. — Conjunctivae  somewhat  inflamed.  Two  leech- 
es to  be  applied  to  external  angles  ot  both  eyes,  26i!A.— Conjunctivitis  less  acute. 

* Reported  by  Mr.  James  Thorburn,  Clinical  Clerk. 


808 


DISEASES  OF  THE  GENITO-URINARY  SYSTEM. 


Nit.  Argent,  gr.  ij  ; Aguce  ^ i ; Nt.  Collyrium.  August  Id. — Her  eyes  are  now  .learly 
well.  Urine  still  very  coagulable,  and  its  general  characteristics  are  much  the  same  as 
on  admission.  The  oedema  of  the  legs  is  abating  a little.  August  \Mh. — She  has  been 
sweating  profusely  for  the  last  few  days.  The  characters  of  the  urine  are  much  the 
same  as  last  report.  The  oedema  disappears  almost  entirely  when  she  retains  the  re- 
cumbent posture  for  some  time,  but  returns  again  wh.en  she  walks  about.  She  con- 
tinues to  use  the  powders  of  Potass.  Bitart.  August  21s^. — Urine  pale  colored;  sp. 
gr.  1012.  Yields  a considerable  coagulum  on  the  application  of  heat  and  nitric  acid. 
The  swelling  of  her  legs  has  abated  very  much.  Scarcely  any  pitting  can  be  produced, 
except  after  she  has  been  walking  about  a good  deal.  Her  general  health  is  very  good. 
She  is  able  to  be  out  of  bed  during  the  whole  day,  and  is  now  anxious  to  be  dismissed. 
August  21s^. — Dismissed  relieved. 

Commentary. — In  this  case  the  same  diuretic  treatment  we  have 
previously  seen  to  be  so  beneficial,  produced  great  relief  and  rapid  dis- 
appearance of  the  anasarca.  No  doubt  every  symptom  would  have 
soon  disappeared,  had  she  not  insisted  on  leaving  the  Infirmary. 

Case  CLXXXIV.* — Second  Attack  of  Albuminuria  after  an  interval  of 
twenty-nine  years.,  with  Anasarca — Bronchitis — Dismissed  relieved. 

History. — James  M‘Kay,  ast,  62,  armorer — admitted  January  6th,  1853.  He  states 
that  he  enjoyed  excellent  health  till  twenty-nine  years  ago,  when  he  was  admitted  to 
the  Royal  Infirmary  under  Dr.  Spens,  for  swelling  of  the  limbs,  trunk,  and  face,  super- 
vening after  exposure  to  cold  and  wet.  He  continued  under  treatment  for  nine  days, 
when  he  was  dismissed  cured,  and  since  then  he  continued  free  from  any  complaint, 
till  about  five  weeks  ago,  when  he  observed  that  his  urine  was  diminished  in  quantity, 
was  of  a high  color,  and  deposited  a thick  white  sediment.  A few  days  after,  he  was 
exposed  to  cold,  while  perspiring,  having  freely  indulged  in  spirituous  liquors.  This 
was  followed  by  distinct  rigor,  lasting  for  a short  time,  and  followed  by  general  uneasi- 
ness and  feverishness,  with  headache  and  feeling  of  soreness  in  the  loins.  Ten  days 
after  the  rigor,  swelling  appeared  in  the  feet  and  gradually  increased,  extending  to  the 
legs,  thighs,  and  scrotum,  but  during  the  last  few  days  the  oedema  has  considerably 
diminished.  He  has  been  a good  deal  addicted  to  the  use  of  ardent  spirits  for  the 
greater  part  of  his  life. 

Symptoms  on  Admission. — On  admission  the  skin  is  soft  and  dry ; the  legs  are 
somewhat  oedematous,  and  pit  on  pressure.  The  urine  is  passed  more  frequently  than 
usual,  and  in  small  quantities  at  a time ; the  whole  amount  of  urine  voided  is  con- 
siderably under  the  normal  standard ; it  is  of  a pale  color ; sp.  gr.  1012 ; highly  coagu- 
lable with  heat  and  nitric  acid  ; no  distinct  sediment  is  deposited  on  standing.  He  has 
no  pain  at  present  in  the  situation  of  the  kidneys  or  bladder ; tongue  dry  ; has  no 
appetite,  but  troublesome  thirst ; bowels  regular ; pulse  96,  natural ; heart’s  sounds 
normal ; he  has  some  cough  and  dyspnoea  on  exertion,  but  the  chest  is  otherwise  ’nor- 
mal ; other  functions  natural.  To  have  warm  bottles  applied  to  the  limbs  and  feet., 
with  twelve  grains  of  Dover's  powder  at  nighty  followed  by  a draught  of  twenty-five 
minims  of  Morphia  if  he  does  not  sleep. 

Progress  of  the  Case. — January  2th. — Slept  towards  morning  after  the  morphia ; 
no  sweating;  urine  coagulable  as  before;  sp.  gr.  1018;  passed  without  pain  or  diffi- 
culty, and  in  good  quantity,  viz.,  48  ounces.  The  oedema  has  quite  disappeared  from 
the  limbs  ; bowels  costive.  Ordered  two  Colocynth  and  Hyoscyamus  pills.  Jan.  12^A. — 
On  the  10th,  he  was  much  in  the  same  state  ; no  sweating ; appetite  bad ; great  thirst, 
for  which  he  was  ordered  milk  and  lime  water.  Being  no  better  last  night,  he  was 
ordered  the  warm  bath,  followed  by  fifteen  grains  of  Dover's  powder.  To-day  he  states 
that  he  felt  more  weak  after  the  bath,  had  slight  perspiration,  which  was  confined  to 
the  face  and  legs.  To  have  twelve  grains  of  Dover's  powder,  with  six  of  James'  powder 
at  bed-time.  Jan.  \4:ih. — The  diaphoretic  has  been  continued  since  last  report,  but  no 
sweating  has  been  produced ; passed,  during  the  last  twenty-four  hours,  58  oz.  of  urine  ; 
bowels  are  rather  costive.  Bitart.  Potass.  3 iss  ; Pulv.  Gambog.  gr.  iv.  M.  To  be 
taken  immediately,  and  repeated  in  six  hours  if  necessary.  Jan.  ifith. — The  bowels 
were  well  opened  on  the  15th,  the  stools  being  of  thin  consistence  after  the  second 
powder,  which  afforded  considerable  relief ; but  they  have  not  been  opened  since ; ap- 
petite still  bad,  but  less  thirst.  The  urine  to-day  is  of  nearly  natural  color ; sp.  gr. 
1022  ; quite  as  coagulable  as  before ; the  quantity  passed  in  the  last  twenty-four  hours  is 

* Reported  by  Mr.  Wm.  Calder,  Clinical  Clerk. 


BRIGHT  S DISEASE. 


809 


68  oz.,  with  a slight  sediment  of  urate  of  ammonia.  Ordered  a scruple  of  Bitartrate 
of  Potass  three  times  a-day.  Jan.  \^th. — The  quantity  of  urine  passed  yesterday  was  60 
oz.,  but  to-day  it  has  diminished  to  36  ; he  complained  of  much  thirst,  and  was  ordered 
cream  of  tartar  water  as  a drink ; he  did  not  sleep  well  during  the  night,  and  is 
somewhat  incoherent  in  his  remarks  to-day,  though  quite  sensible  when  promptly 
spoken  to ; bowels  still  costive ; repeat  the  powder  of  Bitartrate  of  Potass  and  Gam- 
boge ; to  have  ten  grains  of  DovePs  powder  after  the  bowels  have  been  well  opened. 
Jan.  20</i. — Was  a good  deal  better  last  night,  felt  himself  warm  and  comfortable 
after  the  Dover’s  powder,  but  he  did  not  sweat ; he  has  had  three  loose  stools  since  ; 
the  quantity  of  urine  is  now  60  oz.;  sp.  gr.  1020;  still  highly  coagulable;  his  thirsi 
is  considerably  diminished.  Jan.  22d. — The  urine  examined  under  the  microscope 
yesterday  exliibited  a few  pale  casts  of  the  urinary  tubes,  which  are  also  present  to- 
day ; during  the  last  two  days  he  has  passed  about  58  oz.  of  urine  in  the  twenty-four 
hours,  and  he  states  that  altogether  he  feels  much  better.  March  ^th. — Since  last 
report  has  gradually  improved  in  health.  To-day  wishes  to  go  out,  as  he  now  has  no 
complaint  but  weakness ; voids  from  60  to  60  oz.  of  urine  daily.  It  is  of  rather  pale 
color  ; sp.  gr.  1020  ; about  one-sixth  coagulable.  A few  sibilant  rales  are  heard  occa- 
sionally over  the  chest,  but  otherwise  the  systems  are  healthy.  Is  dismissed  accordingly 
much  relieved. 

Commentary. — In  this  case  the  diaphoretic  plan  of  treatment  was 
tried  at  first,  but  with  inconsiderable  successi  It  is  true  the  oedema 
disappeared  from  the  legs,  a result  probably  as  much  owing  to  the 
recumbent  position  and  general  comforts  of  the  hospital  as  to  the  medi- 
cines employed.  When  the  bi tartrate  of  potash  was  administered,  after- 
wards combined  with  purgatives,  the  effects  were  more  rapid,  and  the 
anasarca  soon  disappeared.  The  coagulability  of  the  mriiie,  however, 
still  continued,  though  in  a diminished  degree,  when  he  left  the  house. 

Case  CLXXXV.* — Third  Attack  of  Albuminuria  with  Anasarca — 
Dismissed  relieved. 

History. — James  Smith,  get.  38 — admitted  25th  November,  1852.  States  that  he 
enjoyed  good  health  till  about  three  and  a half  years  ago,  when  after  exposure  to  a 
draught  of  cold  air,  his  ankles  began  to  swell,  which  swelling  in  four  days  extended  up 
to  the  thighs,  and  induced  him  to  apply  for  admission  to  the  hospital,  where  he  remained 
three  weeks  and  was  dismissed  cured.  The  same  symptoms  reappeared  in  twelve 
months,  and  he  was  again  admitted  a patient,  remained  for  a few  weeks,  and  went  out, 
feeling  quite  well.  He  continued  in  excellent  health  till  four  months  ago,  when  he 
began  to  complain  of  shortness  of  breath  and  palpitation  when  at  work  ; the  palpitation 
was  reduced  by  cupping,  but  the  dyspnoea  continued  upon  taking  exertion.  Four 
weeks  ago  the  swelling  at  the  ankles  returned,  and  he  was  again  admitted  into  the 
hospital,  ward  6,  where  he  has  been  under  treatment  till  the  date  of  his  admission 
into  the  clinical  ward.  His  habits  were  rather  intemperate  previous  to  his  lirst  attack, 
but  since  then  he  has  never  indulged  in  any  kind  of  intoxicating  liquors. 

Symptoms  on  Admission. — On  admission,  there  is  some  oedema  of  the  limbs  and 
trunk,  which  pit  slightly  on  pressure  ; the  skin  generally  is  very  dry,  but  of  the  usual 
iemperature.  The  quantity  of  urine  voided  in  the  twenty-four  hours  is  66  oz. ; it  is 
of  a pale  straw  color,  slightly  turbid,  and  highly  coagulable;  sp.  gr.  1014,  depositing  a 
slight  sediment  like  thin  whey.  Viewed  under  the  microscope,  it  presents  numerous 
fragments  of  desquamative  casts  ; some  very  long,  some  containing  nuclei  and  granular 
cells  more  or  less  fatty,  and  some  filled  with  minute  fatty  molecules.  There  are  nume- 
rous DUS  cells ; some  epithelium  cells,  isolated  and  in  groups,  from  the  ureter  or 
bladdei’.  There  are  numerous  columnar  crystals  of  uric  acid,  and  some  mineral  salts 
aggregated  in  masses  of  minute  angular  crystals.  Tongue  clean  and  moist ; appetite 
good  ; bowels  regular  ; pulse  68,  of  moderate  strength.  There  is  slight  irregularity  of 
the  heart’s  action ; first  sound  prolonged,  and  accompanied  with  a soft  blowing  mur- 
mur heard  loudest  at  the  apex.  Other  functions  normal. 

Progress  of  the  Case. — He  was  dismissed  at  his  own  desire  on  the  2Mh  of  No- 
vember., but  returned  with  all  his  foi-mer  symptoms  aggravated  on  the  27^A  of  December. 

* Reported  by  Mr.  Alexander  T.  Macarthur,  Clinical  Clerk. 


810 


DISEASES  OF  THE  GEXITO-UEINAKY  SYSTEM. 


He  states  tliat  after  leaving  the  hospital  he  returned  to  his  usual  enifdoyment  for  abour 
a week,  when  he  caught  cold,  and  he  has  been  confined  to  the  house  ever  since.  The 
cough  became  very  severe,  with  dyspnoea  and  great  debility  after  passing  his  urine. 
On  examination,  the  quantity  of  urine  excreted  is  50  oz. ; it  is  passed  without  pain  ; is 
of  pale  color  resembling  whey,  is  slightly  turbid,  and  deposits,  on  standing,  a small 
quantity  of  white  sediment,  which,  on  examina  tion  by  the  microscope,  presents  nume- 
rous casts,  as  before  noticed,  but  no  crystals ; sp.  gr.  10]  3,  highly  coagulable.  On 
auscultation,  sibilant  rales  are  heard  all  over  the  chest,  expiration  prolonged,  but  no 
dulness  on  percussion.  He  has  a frequent  cough,  with  frothy  mucous  expectoration, 

Sol.  Antim.  3 ii ; Camph.  § iv  ; Misce.  Sumat  § ss  quartd  qndque  hord. 

Descendat  in  bcdneum  calidum  secundd  qudque  node.  Dec.  1'^th. — Still  rather  feverish, 
complains  of  intense  thirst,  constant  craving  for  drink,  which  is  unrelieved  by  water.  To 
have  as  drink  ? xij  of  milk  mixed  with  § vj  of  lime  water.  January  Is^. — Cough  much 
the  same  as  on  admission  ; oedema  of  legs  much  diminished,  but  the  skin  is  still  dry, 
diaphoresis  never  having  been  induced.  About  90  oz.  of  urine  are  passed  in  the  twenty- 
four  hours,  still  very  coagulable  with  heat  and  nitric  acid  ; slight  deposit,  still  contain- 
ing granular  casts  of  the  urinary  tubes.  Jan.  Qth. — Cough  much  relieved  ; pulse  68, 
of  good  strength ; swelling  of  the  legs  now  quite  gone ; urine  passed  in  large  quantity  ; 
still  complains  of  great  thirst.  Continuenter  medicamenta.  Jan.  \2>th. — Voided  130 
oz.  of  urine  during  the  last  twenty-four  hours ; has  still  considerable  thirst ; pulse  80, 
of  good  strength.  Expresses  himself  as  feeling  quite  well.  On  standing  for  twenty- 
four  hours,  the  urine  deposits  a slight  sediment,  in  which  casts  of  the  urinary  tubes  are 
still  visible,  crowded  with  fatty  granules.  Jan.  llth. — Feels  better  than  he  has  done  for 
several  years,  and  wishes  to  return  home.  He  is  accoi-dingly  ordered  to  be  dismissed. 

Commentary. — In  this  case  it  was  evident  that  improvement  had 
commenced  on  his  entering  the  clinical  ward,  the  urine  was  passing 
copiously,  and  diuretics  were  not  directly  indicated.  Under  these  circum- 
stances the  diaphoretic  plan  of  treatment  was  persevered  in,  and  although 
not  with  the  result  of  entirely  freeing  his  urine  of  all  trace  of  albumen, 
yet  with  such  good  efiect,  that  he  insisted  on  leaving  the  house,  which 
he  did  nearly  well. 

In  the  last  three  cases  it  will  be  observed  that  great  relief  was 
experienced,  although  perfect  recovery  was  not  established.  The  dropsi- 
cal symptoms  were  removed,  whilst  the  albuminuria  remained,  a condi- 
tion which  constitutes  the  majority  of  those  cases  which  enter  into  the 
hospital,  and  are  dismissed  as  “ relieved.” 

Case  CLXXXVI.* — Albuminuria^  with  general  Anasarca.,  terminating 
fatally — Waxy  Kidneys,  Spleen,  and  Liver,  with  Extensive  Deposition 
of  Tuhercle. 

History. — Sarah  Wilson,  set.  7 — admitted  November  11th,  1853.  Three  years  ago 
she  suffered  from  scarlatina,  and  has  ever  since  been  a weakly  child,  with  a capricious 
appetite.  In  the  course  of  last  summer,  oedema  of  the  feet  and  legs  was  first  observed, 
together  with  diarrhoea,  which  has  continued  more  or  less  ever  since. 

Symptoms  on  Admission. — On  admission,  her  countenance  is  puffy  and  pallid,  and 
the  whole  surface  blanched.  Her  feet  and  legs  are  oedematous,  pitting  on  pressure. 
The  urine  is  of  a pale  color ; sp.  gr.  1006.  On  applying  heat,  and  adding  nitric  acid, 
a coagulum  is  thrown  down,  which  occupies  a space  in  the  test-tube  equal  to  that  of 
half  the  quantity  of  urine.  She  has  never  felt  any  pain  in  the  lumbar  region.  Tongue 
moist,  and  covered  by  a slight  fur  ; no  thirst ; appetite  good.  The  abdomen  is  greatly 
distended,  and  there  is  distinct  fluctuation.  Pulse  86,  weak  and  compressible ; cardiac 
sounds  normal.  She  has  no  headache  and  sleeps  well  at  night.  Acet.  Potass.  3 i; 
yEth.  Nit.  3 ij ; Syrupi  3 i ; Aquce  § v.  M.  A table-spoonful  to  be  taken  three 
times  a-day. 

Progress  of  the  Case. — November  l^ith. — Diarrhoea  continues  and  she  lies  in  a very 
weak  state.  .8^  Alist.  Cretce  3 iv.  An  ounce  to  be  taken  three  or  four  times  a-day.  To 
have  1 oz.  of  gin  daily.  Nov.  25^/i. — Urine  passed  in  great  quantity  ; sp.  gr.  1002  ; 


* Reported  by  Mr.  Peter  W.  Wallace,  Clinical  Clerk. 


bright’s  disease. 


811 


not  eo  coagulable.  The  diarrhoea,  which  abated  for  a few  days  after  last  report,  has 
again  returned.  Ordered  an  astringent  mixture.  Nov.  2>0th. — The  puftiness  of  the 
face, -which,  on  some  days  after  her  admission,  abated  considerably,  is  now  as  bad  as 
ever.  Her  urine  has  been  passed  involuntarily  for  the  last  three  days ; the  diarrhoea 
is  less  severe.  Dec.  l^th. — Since  last  report,  the  oedema  has  wholly  disappeared. 
The  faeces  and  urine  are  both  passed  invokintarily.  The  constant  dribbling  of  the 
latter  over  the  labia  and  nates  has  produced  excoriation.  She  takes  her  food  pretty 
well,  but  vomits  it  occasionally.  Her  pulse  is  very  feeble,  and  her  strength  much  im- 
paired. She  is  at  present  taking  2 oz.  of  gin,  and  an  equal  quantity  of  wine  daily.  For 
the  last  five  or  six  days  she  has  been  very  drowsy,  sleeping  almost  constantly,  although 
she  can  easily  be  aroused,  and  answers  questions  readily.  Dec.  IMh. — The  oedema 
has  not  returned,  but  the  drowsiness  gradually  increased  until  this  morning,  when  she 
expired. 

Sectio  Cadaveris. — Forty  hours  after  death. 

Body  greatly  emaciated  ; slight  oedema  of  feet. 

Thorax, — The  lungs.,  which  looked  quite  healthy,  presented  to  the  touch  some 
indurated  points ; these,  on  being  cut  into,  were  found  to  consist  of  clusters  of  minute 
grey  granulations,  generally  about  the  size  of  small  marbles.  At  the  apex  of  tlie  right 
lung  was  a small  cretaceous  conci'etion.  The  heart  weighed  3 oz.,  and  was  quite  healthy. 

Abdomen. — There  were  adhesions  between  the  upper  surface  of  the  liver  and  the 
diaphragm.  The  liver  weighed  4 lb.  There  was  a little  hepatic  congestion,  but  the 
intervening  tissue  was  pale ; the  whole  presented  the  usual  appearance  of  the  waxy 
degeneration.  The  spleen  weighed  2A  ounces,  specific  gravity  1054.  It  felt  firm,  and 
presented  on  section  a waxy  appearance.  Throughout  its  substance  were  numerous 
enlarged  semi-translucent,  grey  malpighian  bodies,  closely  aggregated  together.  Their 
average  diameter  was  about  the  16th  of  an  inch.  The  kidneys  enlarged,  weighing 
each  6 1 oz.  On  stripping  off  the  capsule  they  presented  a mottled  appearance  from 
the  presence  of  irregular  vascularity,  contrasting  with  the  pale  cortical  substance.  On 
section  they  presented  a well-marked  waxy  appearance ; the  cortical  portion  was  of  a 
pale  yellowish  color  ; the  striae  generally  absent  or  indistinct.  At  some  places  there 
was  a number  of  minute  opaque  yellowish  spots.  On  opening  the  intestines,  tubercular 
ulcers  were  found  ; they  occurred  in  the  lowmr  third  of  the  small  intestine,  presented 
the  usual  characters,  and  occupied  the  whole  circumference  of  the  gut.  The  mesenteric 
glands  were  much  enlarged,  and  were  infiltrated  with  tubercle. 

Microscopic  Examination. — The  liver  was  found  to  contain  much  fatty  matter, 
both  free  and  contained  in  the  hepatic  cells.  But  the  majority  of  the  cells  were  pale 
and  very  indistinct  (see  Fig.  295,  p,  230),  Thin  sections  of  the  cortical  substance  of 
the  kidneys  presented  a very  transparent  appearance,  particularly  the  malpighian  bodies. 
At  some  places,  there  were  collections  of  fatty  granules,  but  this  did  not  occur  very 
frequently,  and  only  in  isolated  points.  The  enlarged  malpighian  bodies  in  the  spleen 
contained  a translucent  matter,  closely  resembling  colloid,  and  which  presented  the 
blue  reaction  of  cellulose  on  the  application  of  iodine  and  sulphuric  acid. 

Commentary. — This  case  presented  all  the  symptoms  of  Bright’s 
disease,  in  a young  girl  who  had  been  in  a state  of  ill  health  for  three 
years,  in  consequence  of  an  attack  of  scarlatina.  On  dissection  after 
death,  the  kidneys,  liver,  and  spleen  were  found  to  have  undergone  that 
chronic  condition  now  known  as  waxy,  and  which  is  very  commonly 
associated,  as  in  this  case,  with  tubercle.  The  nature  of  the  morbid 
alteration  has  been  previously  referred  to  (see  p.  249), 

Case  CLXXXVII.* — Albuminuria — Excessive  amount  of  Urine — Phthisis 
Pulmonalis — Waxy  Liver.,  Kidneys.,  and  Spleen. 

History. — Thomas  Keegan,  set.  40 — admitted  December  13th,  1848.  Patient  states 
that  he  was  in  the  enjoyment  of  good  health  till  last  May,  when  he  first  experienced 
intense  thirst,  and  began  to  drink  large  quantities  of  water.  At  the  same  time  he 
observed  that  his  urine  became  very  much  increased  in  quantity,  and  he  required  to 
get  up  three  or  four  times  in  the  course  of  the  night  to  micturate.  He  had  no  pain 
in  the  region  of  the  kidneys  or  on  making  water.  This  polydipsia  and  excessive  mictu- 


* Reported  by  Mr.  George  Shearer,  Clinical  Clerk. 


812 


DISEASES  OF  THE  GEXITO-UEINARY  SYSTEM. 


rition  continued  undiininished  till  five  months  ago,  when  he  experienced  a dull  aching 
pain  in  the  small  of  the  back.  This  pain  in  the  loins  afterwards  degenerated  into  a 
feeling  of  weakness,  which  has  continued  ever  since.  On  the  29th  October  he  went 
into  the  Glasgow  Infirmary,  complaining  of  loss  of  appetite,  great  thirst,  weakness,  and 
loss  of  flesh.  He  remained  in  this  Institution  for  six  weeks,  and  took  several  remedies 
without  any  benefit.  During  the  last  fortnight  his  appetite  has  returned,  and  he  has 
been  much  better. 

Symptoms  on  Admission. — There  was  dulness  on  percussion,  and  cracked-pot  sound 
over  the  upper  third  of  left  lung  in  front.  Over  this  part  there  was  heard  tubular 
breathing  and  loud  mucous  rales ; over  the  right  apex  prolonged  expiration.  Posteri- 
orly percussion  equal  on  both  sides.  Crepitation  and  sibilant  rales  on  left  side.  There 
is  frequent  cough,  with  copious  muco-purulent  expectoration.  Tongue  dry,  clean,  red, 
and  tremulous.  Appetite  good  but  thirst  excessive.  Drinks,  as  nearly  as  can  be  ascer- 
tained, a gallon  of  water  daily.  Bow-els  regular.  He  is  much  emaciated ; skin  dry.  He 
has  not  perspired  any  for  several  weeks.  No  oedema  or  ascites.  The  urine  acid,  unu- 
sually transparent,  sp.  gr.  1010,  shows  a considerable  quantity  of  albumen,  chlorides 
abundant,  no  sugar.  Large  waxy  tube  casts  were  detected  in  the  urine,  under  the  mi- 
croscope. There  is  slight  tenderness  on  pressing  firmly  over  the  region  of  the  kidneys. 

Progress  of  the  Case. — December  15?A. — He  passes  from  100  to  130  oz.  of  urine 
daily.  Has  expectorated  a considerable  quantity  of  muco-purulent  matter.  His  mouth 
and  fauces  were  so  dry  this  morning  that  blood  fowled  on  dragging  the  tongue  from 
the  palate,  to  which  it  adhered  by  clammy  glutinous  secretion.  There  w’as  a slight 
discharge  of  blood  after  blowing  his  nose  also.  December  \ Wi. — Passed  I'lG  oz.  of  urine 
on  the  16th,  128  oz.  on  the  iVth,  to-day  82  oz.,  and  drinks  large  quantities  of  water. 
Ordered  to  be  dry-cupped  over  the  kidneys.  To  drink  soda-water^  and  milk  and  water 
instead  of  simple  water.  December '2S.dk. — Urine  112  oz.  Ordered  a table-spoonfd 
of  Oleum  Morrhuce  three  times  a-da]p  and  the  following  mixture  : — B Spt.  jDtheris 
Nitrici  3 i ; Sol.  Mur.  Morph.  3 ss  ; Mist.  Camphorce  § ij.  M.  Half  the  mixture  at 
bed-time  and  the  other  half  in  three  hours  if  the  cough  is  troublesome.  December  2\st. — 
Had  a good  sleep  after  the  mixture,  but  felt  drowsy  and  siek  all  day.  Pupils  contracted 
at  morning  visit.  Passed  112  oz.  of  urine.  22(7. — Feels  very  well  to-day.  Passed  a good 
night.  Urine  64  oz.  December  267A. — Has  still  a feeling  of  weakness  and  heaviness 
in  the  loins,  and  breathes  heavily  and  with  some  difficulty.  Expectoration  purulent 
and  considerable  in  quantity.  Slight  oedema  of  left  foot  observed  this  morning.  Urine 
diminished  to  54  oz.  in  the  twenty-four  hours.  December  26^A. — Passed  48  oz.  of 
urine  since  yesterday.  Has  had  no  stool  daring  last  tw'cnty-four  hours.  Complains 
of  great  sickness  to-day,  and  vomited  his  dinner.  Ordered  Naphthce  Medicin.  ^ ss ; 
Tr.  Card.  Co.  ? i ; M.  A tea-spoonful  occasionally  in  a glass  of  water.  B Pulv. 
Jnlapce  Co.  3 ss  ; mitte  tales  xij  ; one  three  times  a day.  Ordered  also  4 oz.  of  gin  daily. 
December  2Slth. — Passed  a very  uncomfortable  night,  wdth  frequent  moaning  and  sterto- 
rous breathing.  At  1 p.  m.  his  respiration  became  very  slow  and  labored,  a mucous 
rattle  was  heard  in  his  throat,  and  at  forty-five  minutes  past  one  he  expired. 

Seeffo  Cadaveris. — Forty-eight  hours  after  death. 

Body  a good  deal  emaciated. 

Thorax. — Very  dense  adhesions  at  the  ap?ees  of  both  lungs.  The  upper  lobe  of 
each  lung  felt  firm  and  dense.  In  the  upper  lobe  of  the  left  lung  there  was  a cavity  of 
tolerably  regular  oval  form,  and  nearly  the  size  of  a hen’s  egg.  The  lower  extremity 
communicated  wdth  a smaller  one  of  an  irregular  form.  These  cavities  were  linecl  by 
a well-organized  lining  membrane,  having  a cheesy-looking  matter  adherent  to  it  at 
many  places,  and  here  and  there  the  cavities  were  crossed  by  bands  of  condensed  fibrous 
tissue.  The  imlmonary  tissue  around  them  w as  greatly  condensed.  There  was  much 
yellow  tubercle  scattered  through  the  remainder  of  the  lung,  and  several  vomica?.  One 
or  two  small  cavities  and  a good  deal  of  tubercle  were  found  scattered  through  the 
upper  lobe  of  the  right  lung.  About  two  inches  below  the  apex,  and  nearly  in  the 
centre  of  the  organ,  was  a cretaceous  concretion,  about  the  size  of  a pea,  enclosed  in 
a capsule  of  dense  fibrous  tissue.  About  an  inch  below  this  there  was  a second  concre- 
tion. The  middle  and  loxver  lobes  contained  little  tubercle.  Bronchial  glands  enlarged^ 
indurated,  and  loaded  with  black  pigment.  Heart  healthy. 

Abdomen. — The  liver  was  much  enlarged,  and  was  of  unusual  firmness  and  density. 
On  section  it  presented  the  waxy  degeneration,  xvell  marked-,  the  surface  of  section 
being  dry,  of  a somewhat  mottled  yellowish-red  color,  with  a peculiar  translucent 
appearance ; lobular  structure  very  indistinct.  The  organ  weighed  6 lbs.  6 oz.  The 


bright’s  disease. 


813 


spleen  was  enlarged,  8^  oz.,  and  felt  somewhat  dense.  On  section  it  was  found  to  be 
pretty  abundantly  studded  with  clear  Malpighian  bodies,  resembling  grains  of  boiled 
sago.*  The  kidneys  were  enlarged,  weighing  15^  oz.  On  stripping  off  the  capsule, 
the  surface  of  the  gland  was  found  quite  smooth,  very  pale,  of  a whitish-yellow  color, 
and  of  unusual  density.  The  surface  was  somewhat  mottled,  owing  to  some  patches 
of  vascuhuity,  contrasting  strongly  with  the  generally  anaemic  condition.  On  section 
the  cortical  substance  was  found  hypertrophied,  and  had  a pale,  translucent  appear- 
ance. The  medullary  portion  was  moderately  congested.  Almost  all  the  branches  of 
the  renal  artery  in  each  kidney  contained  whitish  clots ; some  of  them  were  firm,  others 
partially  softened.  Some  chronic  tubercular  ulcers  were  found  in  the  lower  part  of  the 
small  intestine,  and  in  the  upper  part  of  the  large  intestine. 

Microscopic  Examination. — On  examining  microscopically  a little  of  the  softened 
portions  of  the  clots  in  the  renal  arteries,  it  was  seen  to  consist  chiefly  of  granular 
matter  with  a comparatively  small  number  of  cells,  having  the  character  of  pus 
globules.  When  a section  of  the  kidney  vms  examined,  the  minute  arteries  were  found 
to  be  much  thickened.  The  cells  and  other  structures  of  the  kidney  presented  the 
usual  characters  of  waxy  degeneration. 

Comnientarij . — After  death  both  kidneys,  the  liver,  and  spleen 
exhibited  a chronic  state  of  waxy  degeneration.  Death  was  occasioned 
by  exhaustion  from  the  pulmonary  disease,  vomiting,  and  impeded 
nutrition.  This  case  was  published  in  the  last  edition  under  the  head 
of  Polydipsia,  and  was  the  first  in  which  the  passage  of  a large  amount 
of  urine  during  the  progress  of  Bright’s  disease  attracted  my  attention. 
In  the  previous  case,  however,  it  will  be  observed  that  the  urine  also  was 
passed  in  great  quantity.  Many  other  such  cases  have  since  entered  the 
clinical  wards,  three  of  which  follow. 

Case  CLXXX  VIII.'^ — Albuminuria  with  great  increase  of  Urine-^ 
Waxg  Kidneys^  Spleen^  and  Liver. 

History. — Mary  Muirhead,  set.  lY — admitted  March  3,  1860.  She  states,  that  at 
the  age  of  five  she  lost  the  power  of  her  lower  limbs,  and  that  shortly  afterwards  an 
abscess  formed  on  her  back,  between  the  shoulders,  and  ultimately  burst,  when  she 
recovered  the  use  of  her  limbs.  Her  spinal  column  is  bent  outwards,  at  an  acute  angle, 
opposite  the  second  dorsal  vertebra.  She  states  that,  excepting  this  abscess  and  the 
discharge  from  it,  which  continued  nearly  to  the  date  of  her  admission,  she  has  enjoyed 
general  immunity  from  disease.  Four  years  ago  she  had  scarlatina,  but  has  since  been 
in  her  usual  health.  Her  respiration  was  always  difficult  on  exertion,  and  this  has 
increased  during  the  last  three  months,  since  which  time  she  has  had  cough,  at  first 
short  and  dry,  but  more  recently  accompanied  by  sputum.  The  patient  states  that 
since  January  she  has  been  subject  to  lumbar  pains,  at  times  so  severe  as  to  prevent 
her  working.  A month  after  this,  or  three  weeks  previous  to  admission,  she  observed 
that  she  was  passing  a much  larger  amount  of  urine  than  was  natural,  and  at  the  same 
time  her  ankles  became  oedematous,  and  her  face  at  times  puffy.  Her  weakness  in- 
creasing, she  applied  for  and  obtained  admission  to  the  Infirmary. 

Symptoms  on  Admission. — On  admission  heart  sound  healthy ; pulse  100,  small 
and  feeble.  There  was  considerable  harshness  of  respiratory  murmurs  all  over  the 
chest.  Tongue  clean,  but  rather  dry ; thirst  great;  appetite  good  ; bowels  regular; 
slight  ascites  ; the  liver  and  spleen  not  enlarged  ; legs  slightly  oedematous;  skin  pale 
and  dry.  Urine  was  copious,  about  50  to  *70  oz.  per  diem  ; sp.  gr.  1005  ; containing 
much  albumen  and  few  chlorides.  A sediment  was  deposited  on  standing,  which  con- 
tained numerous  hyaline  tubecasts,  involving  here  and  there  a cell  which  had  under- 
gone fatty  degeneration.  Habeat  Tr.  Ferri  Mur.  tt^xv  ter  die.  Steak  diet.  Milk. 

Progress  of  the  Case. — Patient  remained  under  observation  without  much  change 
for  two  months,  during  which  time  her  urine  ranged  from  50  to  150  oz.  daily.  On 
only  two  occasions  during  these  two  months  did  it  fall  below  50  oz.  Tlu.  ascites  grad- 
ually increased.  About  the  beginning  of  May  she  was  seized  with  diarrhoea,  which 
continued  notwithstanding  the  employment  of  various  astringents.  The  cough  and 
dyspnoea  increased,  with  advanced  dropsy  of  the  legs  and  abdomen.  The  daily  amount 

* Reported  by  Mr.  Wm.  Ward  Leadham,  Clinical  Clerk. 


814 


DISEASES  OF  THE  GENITO-URIXAEY  SYSTEM. 


of  urine  fell  to  30  or  40  oz.,  continued  albuminous,  and  contained  casts  w th  more 
fatty  renal  cells  than  formerly.  She  died  exhausted  May  20th. 

lectio  Cadaver  is. — Thirty  hours  after  death. 

The  lungs  were  found  free  from  tubercle,  but  the  bronchi  congested  and  full  of 
mucus.  Heart  small,  weighing  less  than  four  oz.  ; spleen  large  and  waxy  ; liver  large 
and  waxy,  weighing  1 lb,  15  oz, ; kidneys  large,  weighing  together  13-|  oz.  The  cor- 
tical substance  was  very  pale,  and  presented  all  the  characters  of  the  waxy  degenera- 
tion, There  was  no  ulceration  of  the  intestines. 

Commentary. — In  this  case  it  will  be  observed,  that  as  a result  of 
chronic  spinal  disease,  followed  by  scarlatina,  Bright’s  disease  appeared, 
accompanied  by  frequent  desire  to  pass  water,  and  that  from  70  to  80 
oz.  of  urine,  which  she  voided  daily  on  coming  into  the  house,  it  subse- 
quently increased  to  150  oz.  I was  much  struck  with  this  circumstance, 
and  at  once  recognised  its  similitude  to  that  of  Keegan,  previously 
reported,  who  died  from  waxy  degeneratk)n  of  the  kidneys  and  other 
organs.  Although  the  notes  of  the  examination  after  death  are  meagre,, 
the  existence  of  the  lesion  cannot  be  doubted. 

Case  CLXXXIX."^ — Albuminuria — Syphilitic  Ulcerations  of  Throat — 
Enlarged  Spleen  and  Liver — Leucocythemia — Waxy  Degeneration  of 
Kidneys.^  Liver,  and  Spleen. 

History. — Edward  Burns,  a laborer,  set,  30,  married — admitted  January  12,  1860. 
Patient  states  that  he  has  had  very  little  sickness,  and,  in  particular,  never  had  syphilis ; 
but  he  confesses  to  have  suffered  fri^ii  buboes,  resulting  from  a strain.  The  prepuce 
is  remarkably  contracted,  and  his  throat  presents  syphilitie-looking  ulcerations. 

Symptoms  on  Admission. — His  throat  was  ulcerated,  his  voice  was  husky,  and  he 
had  a harsh  cough,  with  occasional  muco-purulent  expectoration.  At  the  apex  of  the 
right  lung  there  was  harshness  of  respiration,  but  no  increase  of  vocal  resonance ; cardiac 
sounds  normal;  pulse  80,  small  and  feeble.  Blood  poor  in  corpuscles;  the  white  rela- 
tively more  numerous ; the  red  pale  and  flabby,  with  a tendency  to  tail,  and  form  into 
rows  like  a string  of  beads  rather  than  a rouleau  of  eoins.  Tongue  clean;  appetite 
pretty  good  ; bowels  open.  Hepatic  dulness  extends  from  the  sixth  rib  to  the  umbilicus. 
The  spleen  is  also  considerably  enlarged.  The  urine  is  highly  albuminous,  of  low  spe- 
cific gravity,  and  contains  a few  waxy  tube  casts.  Patient  stated  that  he  never  observed 
anything  particular  about  his  urine ; but  on  its  being,  by  Hr.  Bennett’s  direction, 
measured,  it  was  found  to  amount  to  upwards  of  160  oz.  daily.  It  was  always  of  low 
sp.  gr.,  iuid  contained  no  trace  of  sugar.  There  was  no  oedema  of  the  legs,  unless  oc- 
casionally, when  he  had  been  working  hard,  and  then  his  ankles  became  swollen  at 
night.  During  the  four  months  he  I’emained  in  the  house  his  general  health  improved, 
and  his  liver  diminished  slightly  in  size.  The  amount  of  urine  varied  from  140  to  230 
oz.  daily,  and  he  drank  from  60  to  120  oz.  of  fluids.  Latterly  the  quantity  discharged 
was  from  90  to  120  oz.  daily,  and  his  blood  presented  a more  healthy  appearance. 
The  treatment  consisted  of  astringents  and  Argent.  Nit.,  to  the  ulcerating  of  the  fauces, 
wdiich  healed,  and  of  Tr.  Ferri  Mur.  and  lodid.  Potassii  internally,  and  oecasional  dry 
cupping  over  the  loins.  He  was  dismissed,  at  his  own  request,  April  30th. 

Presented  himself  Fh  April  1861. — His  general  appearance  is  better  than  it  was 
last  year.  He  states  that  he  is  quite  well,  but  that  the  daily  amount  of  urine  has  not 
further  diminished.  It  is  highly  albuminous,  of  low  specific  gravity,  and  contains 
casts.  His  tongue  is  clean  ; his  appetite  good  ; his  bowels  are  moved  twice  a-day.  The 
liver  is  much  enlarged,  measures  eight  inches  vertically,  and  extends  eonsiderably 
across  the  epigastrium  to  the  left  side.  The  spleen  is  also  enlai’ged.  The  blood  con- 
tains an  excess  of  white  corpuscles.  Expiration  is  harsh  and  prolonged  at  the  apices 
of  both  lungs.  The  heart-sounds  are  altered  in  tone,  but  not  of  a blowing  charaeter. 

13^/i  Jiugust  1862. — The  patient  again  presented  himself.  He  is  more  emaciated. 
States  that  from  increasing  debility  he  has  been  unable  to  work  for  a month  past. 
He  still  makes  large  quantities  of  urine,  which  is  albuminous,  but  not  so  intensely  as 
before.  It  deposits  a sediment  containing  hyaline  tube  casts,  with  oil-granules  here 

* Reported  by  Mr.  Colville  Browm,  Clinical  Clerk. 


height’s  disease. 


815 


and  there  arranged  in  groups,  as  if  resulting  from  disintegration  of  cells.  There  has 
been  no  dropsy  of  late.  The  liver,  though  still  enlarged,  is  decidedly  diminished  since 
last  report.  He  complains  much  of  his  breathing. 

22(^  September  1863. — He  complains  much  of  difficulty  of  breathing,  and  of  cough 
and  headache  when  he  attempts  to  stoop ; he  has  also  dropsy ; and  from  all  these 
symptoms  feels  himself  unable  to  follow  his  usual  work.  The  amount  of  urine  is  still 
large.  He  is  obliged  to  rise  three  or  four  times  every  night  in  order  to  micturate. 
The  urine  is  albuminous,  and  contains  waxy  casts. 

lie-cdmitted  November  1863,  complaining  of  a further  aggravation  of  his 
symptoms,  and  died  on  the  9th,  under  the  care  of  Dr.  Sanders. 

Sectio  Cadaveris. — Twenty-eight  hours  after  death. 

The  body  was  somewhat  emaciated. 

Chest. — The  heart  was  enlarged.  The  aorta  was  very  atheromatous.  The  lungs 
were  cedematous,  and  the  bronchi  congested  and  full  of  mucus. 

Abdomen. — The  liver  was  about  the  natural  size.  On  its  surface  were  a number 
of  nodples  and  cicatrices.  At  the  bottom  of  some  of  the  latter  nodules  of  a pale  color 
were  visible.  On  section,  numerous  nodules  were  found  scattered  throughout  the 
organ ; they  were  pale,  dense,  and  had  an  appearance  exactly  resembling  bees-wax ; 
their  structure  was  much  denser  than  that  of  the  surrounding  tissue.  In  some  nodules 
there  were  streaks  of  fibrous  tissue  throughout  the  substance  and  round  the  margin, 
and  the  greater  the  proportion  of  that  tissue  the  deeper  were  the  cicatrices.  In  the 
nodules  elevated  above  the  surface  there  were  no  such  streaks,  or  very  few.  In  those 
situated  at  the  bottom  of  deep  cicatrices,  the  fibrous  element  was  abundant,  or  even 
in  excess  of  the  glandular.  On  applying  iodine  to  these  masses,  the  whole  of  the 
waxy-looking  material  assumed  a brownish-red  color,  but  the  fibrous  streaks  simply 
assumed  a yellow  tinge. 

Microscopic  Examination. — Microscopically,  the  masses  were  found  to  present 
exactly  the  characters  of  waxy  hepatic  cells.  They  were  composed  entirely  of  these 
cells,  enlarged,  transparent,  and  finely  granular.  In  some  parts  the  cell  elements  were 
broken  down,  and  a finely  granular  material  containing  some  oil-globules  was  present. 
The  fibrous  tissue  in  the  masses  presented  the  characters  of  dense  white  areolar  tissue ; 
and  where  it  was  most  abundant  the  cells  were  most  atrophied.  Throughout  the  rest 
of  the  organ  the  cells  were  little  affected  with  the  waxy  degeneration,  but  some  of  the 
small  vessels  showed  it  distinctly.  The  kidneys  were  somewhat  contracted  in  the 
cortical  substance,  and  presented  a very  well-marked  instance  of  the  waxy  degeneration 
of  the  vessels  and  Malpighian  bodies.  There  was  some  degree  of  waxy  degeneration 
of  the  villi  of  the  small  intestine ; the  bowels  were  otherwise  natural. 

Commentary. — In  this  case,  similar  phenomena  were  observed  as  in 
the  former  cases,  the  amount  of  urine  passed  daily  having  increased  to 
the  extent  of  230  oz.  daily.  A careful  examination  after  death  revealed 
the  waxy  degeneration. 

Case  CXC."^ — Enlarged  Liver  and  Spleen — Leucocythemia^  and  Fihrinosis 
of  the  Hood — Albuminuria — Waxy  Kidneys. 

History. — Archibald  March,  set.  29,  a shoemaker,  married — admitted  February 
15,  1860.  In  April  1859,  patient  was  in  the  Infirmary  on  account  of  enlargement 
of  the  liver  and  spleen,  with  slight  leucocythemia.  He  was  dismissed  considerably 
Teheved ; but  having  felt,  of  late,  great  oppression  on  taking  food,  with  occasional 
bloody  vomitings  and  increasing  general  debility,  he  was  readmitted.  States  that, 
some  years  since,  he  had  syphilis,  which  was  followed  by  eruptions,  nodes,  etc.,  and 
ultimately  by  the  symptoms  of  which  he  now  complains. 

Symptoms  on  Admission. — His  general  appearance  is  cachectic  and  sallow;  his 
chest  covered  with  brownish  patches  of  pityriasis  nigra,  which  have  existed  for  some 
years.  There  is  no  oedema.  Pulse  is  full,  82  per  minute.  Cardiac  dulness  2y  inches 
transversely.  There  is  a soft  blowing  murmur,  with  the  first  sound,  loudest  at  the 
biise.  There  is  a slight  relative  increase  of  the  colorless  corpuscles  of  the  blood, 
and  the  red  corpuscles  have  a tendency  to  tail.  (See  Fig.  60,  taken  from  this  case  ) 
Tongue  is  moist;  appetite  not  good;  thirst  great.  He  vomits  occasionally  after 
eating.  Bowels  constipated.  The  liver  measures  nine  inches  in  a line  vertical  to  the 

* Reported  by  Messrs.  Thos.  Annandale  and  P.  M.  Braidwood  Clinical  Clerks. 


816 


DISEASES  OF  THE  GENITO-UEINARY  SYSTEM. 


nipple ; and  there  is  great  tenderness  on  pressure  over  the  whole  area  of  dulne*,s.  The 
splenic  dulness,  laterally,  is  6^  inches  from  above  downwards.  Urine  was  of  a pale 
amber  color ; specific  gravity  i009  ; no  albumen.  March  2>d. — It  was  ascertained  that 
his  urine  amounted  to  110  ounces  daily,  and  it  continued  at  a similarly  high  standard, 
sometimes  falling  as  low  as  90  and  rising  as  high  as  130  ounces.  March  lO^A. — A 
trace  of  albumen  was  observable.  It  steadily  increased  in  amount ; and,  soon  after 
its  appearance,  a very  few  waxy  or  hyaline  casts  were  to  be  detected  by  the  microscope. 
Notwithstanding  the  increased  flow  of  albumen,  the  patient,  under  a tonic  treatment, 
with  liberal  diet,  so  far  improved  as  to  be  able  to  leave  the  hospital,  to  resume  work, 
on  March  26th.  He  has  been  seen  at  intervals  since.  December  3c?. — His  complexion 
sallow  and  cachectic  as  before ; abdomen  free  from  tenderness ; liver  measures,  in  line 
of  right  nipple,  7^  inches,  and  the  spleen  barely  5 inches  at  the  side.  He  does  not 
know  exactly  how  much  water  he  makes  daily ; but  thinks  it  is  less  than  when  he  was 
in  the  Infirmary.  It  is  distinctly  albuminous.  No  dropsy.  The  glands  of  the  neck 
on  both  sides  have  become  enlarged  within  the  last  ten  days.  The  blood  is  in  the  same 
condition  as  formerly.  4dh  February  1861. — The  liver  and  spleen  have  further  dimin- 
ished in  size.  His  appearance  is  somewhat  less  cachectic.  For  some  days  he  has  had 
a pain  in  the  neighborhood  of  the  umbilicus,  and  along  the  margin  of  the  liver,  aggra- 
vated on  movement  or  on  pressure,  and  after  eating.  The  stools  are  of  a dark  color, 
and  contain  some  bright  red  blood.  He  has  no  piles.  The  amount  of  urine  continues 
high,  about  120  oz.  daily,  and  is  albuminous.  Sth  October  1861. — The  patient  again 
presented  himself ; his  cachectic  appearance  is  increased ; he  complains  of  a severe 
pain  in  the  lumbar  region,  and  along  the  spermatic  cords.  His  renal  symptoms  con- 
tinue unchanged,  and  the  liver  is  still  distinctly  enlarged.  Since  that  time  he  has  re- 
peatedly been  an  inmate  of  the  Royal  Infirmary ; has  occasionally  worked  at  his  occu- 
pation of  shoemaking,  and  has  of  late  acted  pretty  constantly  as  cook  to  the  Mid- 
Lothian  Militia  stationed  at  Dalkeith.  March  21s<,  1864. — He  continues  to  make  large 
quantities  of  water  daily,  usually  upwards  of  120  oz.  It  is  still  albuminous,  but  no 
tube  casts  have  been  discovered  for  some  time.  The  hepatic  dulness  is  diminished  to 
about  six  inches ; the  organ  is  still  painful  on  pressure.  He  has  no  nausea,  and  his 
Dowels  are  regular ; but  on  several  occasions  lately  he  has  had  intense  diarrhoea,  some- 
times with  bloody  stools,  and  has  vomited  blood-colored  matters.  November  2c?,  1864. — 
Presented  himself  at  the  Royal  Infirmary,  saying,  that  he  was  greatly  improved  in 
health,  and  has  been  able  to  work  continuously  for  some  months  past.  The  liver  and 
spleen  are  still  further  diminished  in  size,  the  excess  of  colorless  cells  in  the  blood  has 
disappeared,  while  the  colorless  corpuscles  are  healthy.  In  other  respects  the  same. 

Commentary. — This  man,  who  is  still  living,  and  who  has  been 
under  my  observation  for  upwards  of  five  years,  presented  all  the 
phenomena  described  in  previous  cases  of  waxy  degeneration  of  the 
kidneys,  liver,  and  spleen.  The  condition  of  his  blood  was  very  pecu- 
liar, not  only  presenting  all  the  characters  of  leucocytheinia,  but  an 
amount  of  fibrin  so  great  as  to  be  deposited  in  fibres  the  moment  it  was 
placed  on  a glass  side,  and  examined  with  the  microscope — the  colored 
corpuscles  of  the  blood  also  were  altered  in  form,  presenting  an  oval 
shape,  tails,  etc.,  as  previously  figured.  (See  Fig.  60.)  At  one  period, 
also,  he  probably  had  waxy  degeneration  of  the  intestinal  mucous 
membrane.  In  1860  we  saw  the  albuminuria  appear — the  amount  of 
urine  passed  daily  increased  to  130  oz.  daily — and,  from  all  the  circum- 
stances of  the  case,  there  could  be  no  doubt,  that  a most  extensive  waxy 
degeneration,  with  enlargement  of  the  kidneys,  liver,  and  spleen,  existed. 
Notwithstanding  the  profound  cachexia,  weakness,  and  prolonged  symp- 
toms which  were  unusually  severe,  he  has  latterly  become  much  better. 
The  liver  and  spleen  have  diminished  one-third  of  their  previous  bulk, 
and  he  has  so  much  improved  in  health  as  not  only  to  declare  himself 
well,  but  to  continue  his  daily  occupation  without  fatigue.  The  future 
progress  of  this  interesting  case  will  be  watched  with  unceasing  interest. 

The  three  previous  cases  strongly  attracted  ray  attention,  and  that 


BRIGHT  S DISEASE. 


817 


of  the  class,  during  the  spring  of  1860,  in  consequence  of  their  simi- 
larity to  that  of  Keegan,  in  which  I first  noticed  the  great  increase 
of  albuminous  urine,  in  connection  with  waxy  degeneration  of  the 
kidneys  and  other  organs.  Dr.  Grainger  Stewart,  who  was  my  resident 
physician  at  the  time,  has  since  then  taken  great  pains  to  collect  a con- 
siderable number  of  these  cases,  which  he  has  published.*  From  many 
well-marked  examples  of  waxy  degeneration  of  the  kidneys  I have  since 
examined,  there  can  be  no  doubt  that  an  increase  of  albuminous  urine 
is  a diagnostic  symptom  of  great  importance.  A study  of  the  five  cases 
I have  detailed  will  be  seen  to  agree  with  the  following  description 
of  the  symptoms  of  this  lesion  by  Dr.  Stewart: — 

“An  individual  who  has  long  sufifered  from  wasting  disease,  such  as  scrofula, 
caries,  necrosis,  or  syphilis,  or  who,  though  without  palpable  disease,  is  of  a feeble 
constitution,  feels  an  increasing  weakness,  and  begins  to  pass  large  quantities  of 
urine,  and  to  drink  largely.  He  is,  contrary  to  his  usual  custom,  obliged  to  rise 
repeatedly  during  the  night  to  make  water,  and  on  each  occasion  passes  a considerable 
quantity.  The  amount  of  urine  varies  from  50  to  upwards  of  200  oz.  daily,  always 
bearing  a relation  to  the  amount  of  fluid  drunk,  generally  nearly  equalling  it  in  amount, 
or  sometimes  even  exceeding  it.  The  feet  and  ankles  become  cedematous  after  a hard 
day’s  work,  but  return  to  their  natural  condition  during  the  night’s  repose.  In  many 
cases  there  is  observed  a hardness  and  swelling  in  the  hepatic  and  splenic  regions,  de- 
pendent on  an  increase  of  bulk  of  the  liver  or  spleen.  The  patient  feels  a constant 
lassitude  and  unfitness  for  exertion.  His  urine  gradually  becomes  albuminous,  and  a 
few  waxy  or  hyaline  tube  casts  are  to  be  found  in  the  very  scanty  sediment  which  it 
throws  down.  It  is  of  low  specific  gravity — 1005  to  1015.  The  blood  presents  some 
peculiarities  microscopically ; the  white  corpuscles  being  somewhat  increased  in  num- 
ber, and  the  red  presenting  a flabby  appearance,  with  a marked  tendency  to  tail, — 
that  is  to  say,  instead  of  forming  into  rouleaux,  like  healthy  corpuscles,  they  become 
stretched  out  into  long,  spindle-shaped  bodies.  The  blood  changes  I have  observed 
only  when  the  degeneration  affected  the  lymphatic  or  blood  glands.  The  patient  may 
continue  in  this  state  for  months,  or  even  years — may,  indeed,  undergo  a temporary 
improvement — the  liver  and  spleen  becoming  diminished  in  bulk,  and  the  blood  resum- 
ing a more  healthy  character ; but,  sooner  or  later,  for  the  most  part,  ascites  or  general 
dropsy  gradually  supervene,  accompanied  frequently  by  diarrhoea,  which  is  at  times 
found  quite  uncontrollable.  The  urine,  now  very  albuminous,  diminishes  in  quantity, 
so  as  at  times  to  be  almost  or  altogether  suppressed  ; effusions  into  the  serous  cavities 
or  severe  bronchitis  ensues ; the  patient  becomes  exhausted  and  sinks,  or  drowsiness 
comes  on,  and  the  disease  terminates  amid  coma  and  convulsions.” 

I would  refer  you  to  the  excellent  remarks  of  Dr.  Stewart  as  to  the 
individual  symptoms  and  pathology  of  this  disease,  only  begging  you  to 
avoid  the  word  amyloid  as  indicative  of  the  lesion,  for  reasons  detailed 
at  length,  p.  250. 

Case  CXCI.f — Albuminuria^  with  Phthisis  Pulmonalis^  terminating 
fatally — Extensive  Deposition  of  Tubercle  and  Colliquative  Diarrhoea — 
Atrophied  Fatty  Kidney — Ulcerated  Intestines, 

History. — John  Montgomery,  aet.  60,  weaver — admitted  November  19th,  1852. 
States  that  for  several  years  past  he  has  been  exposed  to  great  privations,  and  that  he 
has  been  frequently  troubled  with  bowel  complaint  during  that  time.  The  attacks 
have  sometimes  been  severe,  and  of  long  duration,  but  have  generally  lasted  for  a few 
days  only.  About  a month  before  admission,  the  diarrhoea  became  much  aggravated, 
there  having  been  sometimes  as  many  as  twelve  stools  in  twenty-four  hours.  This  has 
continted  more  or  less  since  that  time,  reducing  him  greatly  in  flesh  and  strength.  As 
far  as  he  has  observed,  he  has  never  passed  blood  by  stool.  He  has  also  had  a short 

* Edinburgh  Medical  Journal,  1861,  p.  740;  and  1864,  p.  97. 
f Reported  by  Mr.  W.  M.  Calder,  Clinical  Clerk. 

62 


818 


DISEASES  OF  THE  GENITO-UEINARY  SYSTEM. 


dry  cough,  but  ouly  for  a few  weeks  past,  and  unaccompanied  with  expectoration  or 
dyspnoea.  He  was  brought  into  the  hospital  in  a state  of  great  weakness  and  ex- 
haustion, having  fallen  down  in  the  street,  supposed  to  be  in  a state  of  intoxication. 
He  states  that  he  has  not  taken  any  spirits  for  some  days  past,  although  he  has  been 
much  addicted  to  intemperance  during  the  greater  part  of  his  life. 

Symptoms  on  Admission. — On  admission,  the  tongue  is  very  dry,  but  not  furred  ; 
but  there  are  some  sordes  on  the  teeth  and  gums.  He  experiences  difficulty  in  deglu- 
tition, as  if  there  was  some  obstruction  about  upper  part  of  sternum ; appetite  bad ; 
troublesome  thirst;  no  sickness  or  vomiting;  no  pain  in  epigastrium,  but  frequent 
griping  pains  in  abdomen.  Bowels  are  very  loose : much  straining  and  great  tenesmus 
when  at  stool ; evacuations  of  an  almost  watery  consistence  and  reddish-brown  color. 
They  present  no  appearance  of  blood,  but  contain  a few  shreds  of  mucus.  Occasion- 
ally he  passes  nothing  but  a small  quantity  of  frothy  slime ; no  haemorrhoids.  On 
physical  examination  of  the  abdomen,  the  parietes  are  tense  and  retracted.  The  liver 
is  slightly  enlarged,  the  dulness  measuring  five  inches  from  above  downwards.  Chest 
appears  contracted,  and  does  not  expand  freely.  There  is  no  comparative  dulness  on 
percussion.  The  respiration  is  feeble  and  the  expiration  prolonged;  under  the 
right  clavicle  it  is  of  a somewhat  tubular  character.  Vocal  resonance  is  also  increased 
over  the  same  part.  At  the  lower  part  of  right  side  anteriorly,  there  is  a fine  fric- 
tion sound.  Sputum  in  very  small  quantity;  muco-purulent,  untinged  with  blood. 
Pulse  124,  small  and  feeble ; heart  sounds  normal ; urine  sp.  gr.  1012,  becomes  slightly 
clouded  with  heat  and  nitric  acid,  but  no  distinct  coagulum  is  formed ; other  functions 
normal.  H Mur.  Morph.  3 ij  ; Tinct.  Catechu  3 vj  ; Mist.  Cretce  § vj.  M.  Su~ 
mat  § j tertid  qudque  hard.  Ordered  to  have  6 oz.  of  wine  and  steak  diet. 

PnoGRESS  OF  THE  Case. — November  2Qth. — Wandered  a good  deal  during  the  night; 
is  exceedingly  weak  to-day,  but  the  diarrhoea  is  less  severe.  Nov.  22d. — Complains 
more  of  cough  and  pain  in  right  side,  striking  across  the  chest  to  the  left ; no  dulness 
on  percussion ; still  friction  on  right  side  with  fine  moist  rales  ; marked  increase  of 
vocal  resonance ; urine  diminished  in  quantity ; of  natural  color,  with  slight  floccu- 
lent  precipitate  on  the  application  of  heat  and  nitric  acid.  Diarrhoea  stopped ; pulse 
112,  small  and  weak.  Nov.  24th. — Was  much  weaker  yesterday,  and  evidently 
sinking;  too  weak  for  examination  of  the  chest;  bowels  were  once  opened;  no  urine 
voided  since  last  report.  Died  this  morning  at  four  o’clock,  comatose. 

Sectio  Cadaveris. — Fifty-six  hours  after  death. 

Body  somewhat  emaciated  ; very  little  subcutaneous  fat ; muscles  well  nourished. 

Thorax. — Heart  normal ; adhesions  of  both  pleurae  over  limited  space  of  upper 
lobes.  Both  lungs  contained  many  scattered  groups  of  tubercle,  chiefly  miliary ; some 
fewT  of  them  softened,  and  wdth  small  dry  excavations  at  the  apices;  the  pulmonary 
tissue  around  the  tubercles  mostly  indurated  and  dark  colored  from  carbonaceous  in- 
filtration ; the  bronchial  glands  dark  and  enlarged. 

Abdomen. — Stomach  and  jejunum  and  upper  two-thirds  of  ileum  normal.  In  lower 
third  several  scattered  ulcers,  not  exceeding  eight  or  tw’elve  in  number,  from  one- 
quarter  to  three-quarters  of  an  inch  in  diameter ; some  of  them  slightly  congested  at 
edges ; their  characters  in  all  respects  those  of  tubercular  ulcers.  Colon  contracted 
at  lower  part.  In  the  ascending  portion,  there  are  four  or  five  small  tubercular  ulcers ; 
the  largest  half  an  inch  in  diameter,  edges  pale  and  slate-colored,  the  floor  somewhat 
indurated.  Spleen  pale,  peritoneal  capsule  thickened,  the  organ  rather  small,  no  dis- 
tinct morbid  appearance.  Liver  slightly  enlarged,  presenting  very  distinctly,  and  in 
a considerable  degree,  the  fatty  degeneration.  Kidneys  unusually  small  (dimension  of 
right  three  and  a half  inches  long,  one  and  three-quarter  inches  broad,  three-quarters 
of  an  inch  thick,  left  kidney  of  nearly  the  same  size,  weight  not  ascertained) ; capsule 
easily  stripped  off ; surface  slightly  uneven,  not  distinctly  tuberculated ; venous  vas- 
cularity of  surface  considerable  but  irregular;  on  section,  cortical  substance  much 
diminished  (average  three-eighths  of  an  inch  in  diameter  from  base  of  pyramids); 
limiting  line  of  pyramids  tolerably  distinct ; faint* appearance  of  opaque  granulations. 
On  examination  w ith  a lens,  many  very  minute  cysts  were  discovered  in  cortical  sub- 
stance ; most  of  them  required  a power  of  half  an  inch  focal  distance  to  bring  them 
into  view.  A similar  powder,  or  even  the  naked  eye,  distinguished  easily  a number  of 
opaque  light  gamboge  yellow  points  in  the  cortical  substance ; the  largest  w^as  about 
one-fiftieth  of  an  inch  in  diameter,  accurately  limited,  and  yielding,  on  being  punctured, 
a fluid  of  the  same  color.  In  the  cortical  substance  there  were  also  some  minute 
haemorrhagic  petechiae,  having  the  usual  appearance  of  extravasation. 


bright’s  disease. 


819 


Microscopic  Examination. — With  high  magnifying  powers,  the  tubuli  uriniferi 
were  seen  in  some  places  to  be  of  normal  character,  with  the  exception  of  a very  few 
granules  in  the  epithelium ; on  the  contrary,  in  others,  the  tubes  were  crowded  with 
fatty  granules.  The  epithelium  generally  was  normal  in  form  and  appearance  in  the 
tubes  which  had  fewest  granules.  In  many  places  the  cortical  substance  of  the  kid- 
ney was  studded  with  minute  cysts,  constituting  the  third  form  which  they  present 
(see  p.  800),  In  the  fluid  squeezed  from  the  yellow  points,  in  the  cortical  substance, 
there  was  an  immense  number  of  fatty  granules,  partly  loose,  partly  agglomerated  into 
amorphous  collections,  partly  composing  distinct  rounded  granular  masses  up  to  the 
one-ninetieth  of  an  inch  in  diameter,  and  partly  contained  in  cells  of  a very  fine  deli- 
cate transparent  character,  presenting  much  of  the  appearance  of  a tesselated  epithe- 
lium. The  cells  of  this  epithelium  were  more  transparent,  and  generally  one-third 
smaller  than  those  usually  found  in  renal  tubules. 

Commentary. — In  this,  as  in  some  former  cases,  the  renal  disease 
was  associated  with  phthisis,  but  was  more  chronic,  further  advanced,  and 
exhibited  the  ultimate  eifects  of  the  fatty  rather  than  of  the  waxy  de- 
generation, The  report  states  that  the  urine  was  not  highly  coagulable, 
presenting  only  a slight  cloud  on  the  addition  of  heat  and  nitric  acid. 
The  fluids  of  the  body,  however,  seemed  to  have  been  discharged  to  a 
great  extent  by  means  of  stool.  Before  death,  the  urine  was  suppressed, 
causing  coma.  Drs.  Christison  and  Peacock  have  pointed  out  how  fre- 
quently Bright’s  disease  is  a complication  of  phthisis,  and  I have  not 
only  confirmed  that  observation,  but  observed  that  this  is,  in  most  cases, 
connected  with  the  waxy  degeneration  of  the  renal  organs. 

In  the  cases  previously  given,  we  have  seen  various  examples  of  the 
inflammatory,  waxy,  and  fatty  forms  of  Bright’s  disease.  It  would  be 
easy  to  multiply  instances  where,  on  dissection,  all  kinds  of  intermediate 
conditions  of  the  kidneys  had  been  observed ; but  those  now  recorded, 
together  with  such  as  recovered  or  were  relieved,  present  the  leading 
characters  illustrative  of  the  pathology,  diagnosis,  and  treatment  of 
Bright’s  disease.  A few  words  on  each  of  these  topics  may  now  be  added 
with  propriety. 

Pathology  of  Bright'’ s Disease. 

Many  names  have  been  proposed  by  various  pathologists  for  the  dis- 
ease called  after  Dr.  Bright.  Up  to  the  present  time,  however,  none  of 
them  has  been  sufficiently  good  to  comprehend  all  those  lesions  which 
occasion  renal  dropsy,  with  persistent  albuminuria.  Hence  we  still 
retain  the  designation  it  has  so  appropriately  borne,  to  express  a disorder 
characterized  by  more  or  less  dropsy,  caused  by  obstruction  to  the  renal 
functions,  and  accompanied  by  the  presence  of  albumen  in  the  urine. 

The  nature  of  the  obstruction  to  the  renal  function  differs  under  a 
great  variety  of  circumstances,  but  such  as  occasion  dropsy,  with  per- 
sistent albuminuria,  it  appears  to  me  may  now  be  classified  under  three 
heads — 1st,  Inflammation,  acute  or  chronic;  2d,  Waxy  degeneration; 
3d,  Fatty  degeneration. 

1.  The  Inflammatory  Form. — This  may  be  acute  or  chronic;  the  first 
is  generally  induced  by  all  those  causes  which  excite  inflammation  in 
other  internal  organs,  and  is  ushered  in  by  rigors  and  febrile  symptoms, 
and  accompanied  by  pains  in  the  lumbar  region,  and  the  phenomena 
generally  described  as  those  peculiar  to  nephritis.  (See  Nephritis.)  The 
chronic  disease  may  follow  the  acute,  may  come  on  more  slowly,  as  the 


820 


DISEASES  OF  THE  GENITO-TJEINARY  SYSTEM. 


result  of  the  same  causes,  or  proceed  so  imperceptibly  from  causes  which 
have  escaped  observation,  that  the  occurrence  of  dropsy,  more  or  less 
extensive,  may  be  the  first  symptom  which  excites  attention.  On  testing 
the  urine  chemically,  it  is  found  to  be  albuminous,  and  on  examining  the 
sediments  microscopically,  various  kinds  of  casts,  with  epithelial  cells, 
blood  corpuscles,  different  salts,  and  other  morbid  products,  may  be  seen. 
These  casts  of  the  uriniferous  tubes  are  finally  molecular  and  fibrinous 
{exudative  casts),  or  mingled  with  the  fibrinous  matter,  there  are  epithelial 
cells  and  free  nuclei  of  the  tubes  {desquamative  casts).  Other  products, 
which  vary  according  to  the  period  of  the  disorder  and  the  tissues  in- 
volved, may  also  be  present,  to  which  we  shall  allude  under  the  head  of 
diagnosis. 

On  examining  the  kidneys  of  individuals  who  have  labored  under 
this  form  of  the  disease,  we  find  that  in  the  acute  stage  they  are  more 
or  less  congested  and  tinged  of  various  colors,  from  a bright  red  to  a 
dusky  brown.  The  surface  is  not  unfrequently  covered  over  with  minute 
ecchymotic  spots,  dependent  on  the  extravasation  of  blood  into  the  tubes, 
in  their  convoluted  portions.  The  excessive  congestion  and  extravasation 
of  blood,  by  obstructing  the  tubes  and  interfering  with  the  secreting 
function  of  the  organ,  form  the  chief  source  of  danger  in  these  cases. 
There  may  also  be  frequently  observed  a fibrinous  exudation  filling  the 
tubes,  in  which  are  intermixed  the  epithelial  cells,  and  here  again  the 
extent  of  the  obstruction  so  occasioned  is,  sometimes  without  much  con- 
gestion (Case  CLXXL),  commensurate  with  the  danger  of  the  case.  As 
the  disease  becomes  more  chronic,  the  intense  uniform  coloration  dimi- 
nishes, leaving  irregular  arborizations,  which  mottle  the  surface — the 
blood  extravasated  is  absorbed — the  exudation,  if  not  dislodged  and 
passed  in  fragments  by  the  urine,  gradually  disintegrates,  and  may  or 
may  not  undergo  the  purulent  or  fatty  transformation.  This,  by  long- 
continued  pressure,  causes  permanent  obstruction  of  the  tubes  and 
atrophy  of  the  renal  structure,  so  that  at  last  the  organ  becomes  smaller 
and  smaller,  less  and  less  able  to  perform  its  functions,  and  ultimately 
causes  death  (Case  CXCI.) 

2.  The  Waxy  Form. — This  form  of  the  disease  is  generally  chronic, 
and  for  the  most  part  accompanies  scrofulous,  syphilitic,  and  other 
cachectic  complications.  Dropsy,  and  a peculiarly  sallow  and  emaci- 
ated look,  constitute  its  chief  symptoms ; and  the  urine,  as  the  disease 
slowly  progresses,  becomes  first  increased  in  quantity,  and  then  more  and 
more  suppressed,  death  taking  place  by  exhaustion  or  coma.  The  urinary 
sediment  is  usually  small,  and  presents  hyaline  casts  of  the  tubes  {waxy 
casts)  ^ with  a few  epithelial  cells,  unusually  colorless  and  transparent. 
Not  unfrequently,  however,  at  an  early  period,  desquamative  casts,  with 
little  fibrin,  and  composed  of  closely  aggregated  cells,  of  the  tubes,  may 
be  seen.  This  form  of  the  disease,  though  mixed  up  with  the  various 
other  lesions  which  usually  accompany  it,  may  now  in  the  majority  of 
cases  be  distinctly  determined,  the  description  given  by  Dr.  Stewart 
serving  for  the  most  part  to  render  it  recognizable  (p.  817). 

On  examining  kidneys  which  have  undergone  the  waxy  degeneration, 
we  generally  find  that  they  are  more  dense  to  the  feel  than  natural,  some- 
times smaller,  at  others  larger  than  usual,  and  of  a color  resembling 


height’s  disease. 


821 


various  shades  of  dirty  bees’  wax,  or  of  a light  fawn  tint.  On  section 
the  surface  is  smooth,  and  the  edges 
more  or  less  translucent ; a circumstance 
dependent  on  the  diminished  vascularity 
which  everywhere  prevails,  and  a pecu- 
liar transparency  which  all  the  struc- 
tures of  the  organs  have  undergone.  A 
thin  slice,  when  magnified  under  a 
power  of  250  diam.  linear,  exhibits  the 
vessels  of  the  Malpighian  bodies  more 
transparent  and  refractive  than  usual 
(Fig.  475).  The  tubules  are  colorless^ 
often  destitute  of  epithelium,  and  of  a 
peculiar  whiteness.  Such  cells  as  are 
discovered  have  their  nuclei  more  or 
less  atrophied,  and  closely  resemble  475. 

those  seen  in  the  liver  when  similarly  affected  (see  Fig.  319,  p. 
249),  Indeed,  this  change  in  the  kidney  is  frequently  associated  with  a 
similar  transformation  of  the  liver,  spleen,  and  intestinal  mucous  mem- 
brane. The  nature  of  this  waxy  degeneration  of  tissue  is  unknown, 
although  probably  it  is  some  change  in  the  chemical  composition  of  the 
structure  affected,  whereby  it  is  rendered  albuminoid.  It  is  in  no  way 
amyloid,  as  previously  pointed  out  (p.  250).  But  whatever  be  the  es- 
sential nature  of  this  peculiar  degeneration,  there  can  be  little  doubt  that 
the  waxy  tissues  are  rendered  more  permeable  by  fluids,  and  hence  the 
excessive  discharge  of  urine  and  of  matter  from  the  intestinal  mucous 
membrane  when  so  affected.  (Cases  CLXXXVI.  to  CXC.) 

The  Fatty  Form. — This,  as  we  have  seen,  may  be  a result  of  in- 
flammation, but  it  is  not  unfre- 
quently  produced  independent 
of  it.  Here,  again,  the  progress 
of  the  disease  is  chronic,  is  not 
so  frequently  associated  with 
scrofula  and  tubercle,  but  occurs 
rather  in  individuals  more  ad- 
vanced in  life,  suffering  from 
cardiac  and  bronchitic  disorders, 
or  who  are  addicted  to  intem- 
perance. It  is  also  frequently 
associated  with  fatty  degenera- 
tion of  the  heart  and  liver. 

Dropsy  and  persistent  albuminuria 


Fig.  476, 

are  constant  symptoms,  and  the 
sediment  is  ’.oaded  with  casts  of  the  tubes  containing  oil  granules 
{fatty  casts)  and  granule  cells. 

Fig.  475.  Waxy  degeneration  of  a Malpighian  body,  with  a few  granule  cells.— 
( Wedl.)  300  dtam. 

Fig.  476.  Structures  in  a fatty  kidney,  a and  6,  Tubes  filled  with  fatty  granules, 
having  in  one  of  them  the  transparent  basement  membrane  visible,  c.  Transverse 
section  of  a similar  tube,  d.  Fatty  epithelium  of  the  tubes,  e,  Amorphous  fatty 
matter  in  the  tube.s.  f Crystals  of  uric  acid  in  a tubule. — ( Wedl.)  350  diain. 


822 


DISEASES  OF  THE  GENITO-URINAEY  SYSTEM. 


On  examining  the  kidneys  of  individuals  who  have  died  of  this 
form  of  the  disease,  we  observe  the  tubes  more  or  less  obstructed  by  fatty 
granules,  which  have  gradually  accumulated  in  the  epithelial  cells  of 
the  tubes.  These  separate,  and  even  burst,  liberating  their  contents, 
and  in  this  way  obstruct  the  tubes,  and  compress  the  secreting  and 
surrounding  textures  (Fig.  476,  a and  1).  Gradually  the  vessels 
are  so  compressed,  that  the  organ  afiected  looks  bloodless,  and  though, 
on  the  whole,  enlarged,  is  of  a light  fawn  or  dirty  white  color. 
The  fibrous  texture  is  occasionally  hypertrophied,  causing  contractions 
round  the  convoluted  tubes,  thus  producing  irregularities  on  the  surface. 
Occasionally,  also,  large  accumulations  of  the  fatty  granules  take  place, 
causing  the  tubes  to  burst,  and  presenting  to  the  naked  eye  light  fawn- 
colored  spots  or  granulations,  more  or  less  numerous,  which  are  scattered 
over  and  through  the  cortical  substance.  It  is  easy  to  conceive  how  such 

accumulations  of  fat,  and  consequent  pressure 
and  obstruction,  must  at  length  so  interfere 
with  the  kidneys,  as  to  be  incompatible  wdth 
the  performance  of  their  functions  (Case 
CXCI.) 

On  scraping  the  surface  of  a fatty  kidney, 
and  adding  a drop  of  water,  we  are  enabled 
to  see,  under  a magnifying  power,  fragments 
and  cells  such  are  given  Figs.  476,  477.  The}’’ 
exhibit  portions  of  uriniferous  tubes  loaded 
with  free  fat  granules  and  epithelial  cells, 
also  containing  similar  fat  granules.  On 


Fisr.  477. 


making  a thin  section  of  a fatty  kidney,  we  not  unfrequently  see  the 


Fig  478.  Fig.  479. 

tubes  in  situ  loaded  with  similar  granules,  and  the  fibrous  tissue  so  in- 


477.  Portion  of  fatty  tube,  with  fatty  epithelial  cells,  scraped  from  the  sur- 
face of  a fatty  kidney. 

Fig.  478.  Longitudinal  section  of  a fatty  kidney,  showing  the  tubes  loaded  with 
fatty  granules. 

Fig.  479.  Transverse  section  to  the  former  one,  (i.)  Malpighian  body.  — 
son.)  260  diam. 


bright’s  disease. 


823 


creased  and  thickened  between  them,  as  to  occasion  a lesion  identical 
in  many  respects  with  the  so-called  cirrhosis  of  the  liver,  to  which  an 
atrophied  and  granular  kidney  is  strictly  analogous.  Sections  of  the 
cortical  substance  of  such  kidneys  are  represented  Figs.  478,  479. 

The  above  is  a condensed  description  of  what  appears  to  me 
the  three  pathological  forms  of  Bright’s  disease  of  the  kidney.  These 
lesions,  although  they  are  met  with  separately  and  distinct,  may, 
however,  be  more  or  less  conjoined.  One  part  of  a kidney  may  be 
congested  or  inflamed,  whilst  another  is  fatty ; or  we  may  have  the  fatty 
and  waxy  conditions  united  together.  It  is  only  in  this  way  that  we 
can  account  for  the  various  shades  of  alteration  which  the  kidney  may 
at  different  times  present  during  the  continuance  of  persistent  albumin- 
uria with  dropsy.  All  these  alterations,  by  interfering  with  the  secret- 
ing functions  of  the  cells,  more  or  less  disorder  the  excretory  power  of 
the  kidneys,  and,  if  continued,  ultimately  tend  to  overload  the  blood 
with  the  effete  elements  which  ought  to  be  discharged  with  the  urine. 
At  the  same  time,  by  causing  more  or  less  congestion  of  the  vessels,  or 
by  pressure  on  the  Malpighian  bodies,  and  obstruction  of  the  tubules,  a 
serous  effusion  takes  place,  the  albumen  of  which,  passing  into  the  urine, 
communicates  to  it  that  property  of  coagulability  which  constitutes  its 
pathognomonic  character. 


Diagnosis  of  Brighfs  Disease. 

The  diagnosis  of  Bright’s  disease  of  the  kidney  is  dependent  on 
three  kinds  of  observation: — 1st,  Symptoms;  2d,  Chemical — and  3d, 
Microscopical — examination  of  the  urine. 

1.  Diagnostic  Symptoms. — In  the  acute  forms,  pain  in  the  lumbar 
regions,  high-colored  urine,  and  other  indications  of  nephritis,  followed 
by  dropsy ; and  in  the  more  chronic  forms,  the  occurrence  of  dropsy, 
frequently  without  the  local  renal  symptoms,  are  the  chief  diagnostic 
symptoms.  A constant  desire  to  pass  urine,  and  the  passage  of  a large 
quantity  of  that  fluid  should  also  excite  apprehension.  But  these 
symptoms  must  always  be  very  vague  until,  by  a chemical  examination 
of  the  urine,  the  presence  of  albumen  is  determined. 

Chemical  Examination  of  the  Urine. — In  testing  the  urine,  you 
should  be  careful  to  employ  both  heat  and  nitric  acid.  Heat  alone 
frequently  separates  earthy  salts,  which  to  the  eye  may  resemble  a slight 
cloud  of  albumen;  and  nitric  acid  alone  frequently  throws  down  a 
precipitate  of  uric  acid,  where  urate  of  ammonia  is  in  excess.  But  if 
the  coagulum  produced  by  heat  also  resist  the  action  of  nitric  acid,  we 
may  be  pretty  sure  that  the  urine  contains  albumen.  The  mere  presence 
of  albumen  in  the  urine  does  not  constitute  Bright’s  disease.  It  may 
accompany  cystitis  or  haematuria — may  follow  the  action  of  a blister 
affecting  the  kidneys,  or  result  from  mercurialism,  errors  in  diet,  or  con- 
firmed dyspepsia.  In  all  such  cases,  however,  it  is  temporary,  and  does 
not  present  the  diagnostic  character  of  persistence. 


824 


DISEASES  OF  THE  GENITO-UEINAKY  SYSTEM. 


Microscopical  ^Examination  of  the  Urine,  — The  method  I have  found 
best  for  determining  the  form  and  structure  of  the  organic  matter  dis- 
charged in  the  urine,  is  to  allow  the  fluid  to  repose  for  twelve  hours, 
then  pour  ofi'  the  supernatant  liquid,  and  put  the  turbid  sediment  into 
a test-tube.  Allow  this  to  repose  for  another  twelve  hours,  when  the 
concentrated  precipitate  containing  the  organic  matters  collects  at  the 
bottom,  and  can  now  easily  be  brought  into  the  field  of  the  microscope. 
Or  some  ounces  of  the  urine  may  be  put  into  a conical  glass,  like  an 
ale  glass,  and  the  precipitate  allowed  to  deposit  itself,  as  recommended 
by  Dr.  Johnson.  From  thence  it  can  easily  be  obtained  by  pouring 
off  the  supernatant  fluid,  or  by  removing  the  sediment  with  a pipette 
for  microscopic  examination.  The  objects  so  brought  into  view  are 
various,  comprising  different  salts,  cells,  fungi,  and  casts  of  tubes  (see 
pp.  103  to  107,  and  Figs.  102  to  114),  the  discrimination  of  which 
necessitates  a knowledge  of  histology.  The  diagnostic  elements,  however, 
in  Bright's  disease,  may  be  considered  to  be  the  separated  casts  of  the 
tubuli  uriniferi.  These  are  of  four  kinds. 

1.  Exudative  Casts, — These  casts  consist  of  the  coagulated  exuda- 
tion, or  fibrin,  which,  in  the  inflammatory  form,  is  poured  into  the  tubes, 
so  as  to  present  a mould  of  their  interior.  They  are  analogous  to  similar 
casts  which  occur  in  the  minute  bronchi,  in  all  cases  of  pneumonia,  and 
are  recognised  under  the  microscope  by  their  uniform 
molecular  structure.  They  mostly  occur  in  acute  cases, 
are  frequently  associated  with  blood  corpuscles,  and  not 
unfrequently  with  desquamative  casts  and  epithelial  cells. 
Figs.  108  Z>,  and  480. 

2.  Desquamative  Casts. — These  casts  consist  of  mass- 
es of  the  epithelium  lining  the  tubules,  sometimes 
closely  aggregated  together  side  by  side,  at  others  ag- 
glutinated by  means  of  the  molecular  exudation  former- 
ly alluded  to.  They  result  from  a separation  of  the 
lining  cell  membrane  from  the  interior  of  the  tube,  in  patches  of  greater 
or  less  extent  and  may  be  associated  in  acute  cases  with 
exudations,  and  in  chronic  cases  with  the  fatty  or  waxy 
transformations  next  to  be  mentioned. — See  Figs.  108 
rt,  p.  105,  and  481. 

3.  Fatty  Casts. — These  casts  consist  also  of  patches 
of  epithelium,  which,  however,  have  previously  under- 
gone the  fatty  transformation,  by  the  accumulation  of  a 
greater  or  less  number  of  fatty  granules  in  their  cells. 

Occasionally  the  cells  burst  and  fill  the  tubes  with  fatty 
granules,  among  which  no  epithelium  can  be  distin- 
guished.— (See  Fig.  109,  p.  105,  and  Fig.  476.)  At 
others  the  cells  are  less  changed,  the  fatty  accumulation  as  it  were  only 
commencing,  as  in  Fig.  482.  These  fatty  casts  are  often  associated  with 
fragments  of  desquamative  ones,  with  a few  cells,  more  or  less  fatty,  and 
frequently  with  the  next  kind  of  cast  to  be  noticed  (Fig.  482). 

Waxy  Casts. — These  casts  present  an  exceedingly  diaphanous  and 

Fig.  480.  Exudative  casts  with  epithelial  cell  and  mass  of  coagulated  exudation. 

Fig.  481.  Desquamative  casts  with  blood  corpuscles,  naked  nuclei,  and  cells. 


Fig.  480. 


Fig.  481. 


bright’s  disease. 


825 


Fig.  483. 


structureless  substance,  which,  according  to  Dr.  Johnson,  is  secreted  by 
the  basement  membrane, 
after  the  destruction  of  its 
epithelial  cells.  But  may  it 
not  consist  of  the  basement 
membrane  itself  which  has 
undergone  some  chemical 
transformation,  the  nature 
of  which  has  yet  to  be 
ascertained  ? The  waxy  are 
frequently  associated  with 
the  two  kinds  of  casts  last 
described,  but  especially  with  the  fatty  ones  (Figs.  482,  483).  Not 
unfrequently  all  stages  of  transformation  may  be  seen  in  the  same 
demonstration,  between  one  tube  containing  epithelial  cells,  more  or 
less  fatty,  and  another,  which  being  empty,  presents  the  translucent  or 
waxy  appearance.  (Figs.  476,  483.) 

The  exact  signification  of  all  these  various  kinds  of  casts  has  yet  to 
be  fully  determined  by  clinical  investigation.  But  it  appears  to  me  that 
the  exudative  casts  indicate  the  most  acute  form  of  lesion — the  desqua- 
mative a sub-acute,  the  fatty  a chronic  lesion,  and  the  waxy  a lesion 
destructive  of  the  tubular  textures.  But  as  all  these  difierent  changes 
may  be  going  on  in  the  kidney  at  the  same  moment,  so  we  may  find 
these  various  casts  mingled  with  one  another  in  various  proportions, 
combined  with  other  structural  elements.  The  predominance  in  number 
of  one  kind  of  cast  over  another,  will,  however,  serve  to  indicate  to  the 
pathologist,  with  tolerable  correctness,  the  nature  of  the  change  which 
is  going  on  in  the  renal  organs.  They  undergo  great  variety  in  size, 
often  being  much  smaller  than  any  kind  of  uriniferous  tubes,  a circum- 
stance indicating  considerable  contraction  of  their  calibres. 


Treatment  of  Bright's  Disease. 

The  acute  forms  of  Bright’s  disease  should  be  combated  externally 
by  cupping  over  the  loins,  and  warm  fomentation.s — internally  by 
diaphoretics,  and  later  by  diuretics.  I have  seldom  found  it  necessary 
to  have  recourse  to  general  bleeding,  and  then  only  as  a palliative  to 
relieve  pulmonary  congestion.  The  chronic  forms,  in  addition  to  appro- 
priate remedies,  require  attention  to  diet  and  exercise.  A non-fatty  diet 
is  evidently  indicated  in  the  fatty  degeneration  of  the  kidney.  Fixercise, 
change  of  air,  and  sea  voyages  are  also  beneficial.  Care  also  should  be 
taken  that  the  surface  be  kept  warm,  and  cutaneous  transpiration 
favored.  The  complications  and  sequelae  must  be  managed  according 
to  circumstances,  and  the  general  indications  special  to  individual 
diseases.  In  this  place  I shall  only  allude  to  the  effects  of  two  classes 
of  remedies,  namely,  diaphoretics  and  diuretics. 

Diaphoretics. — The  connection  which  necessarily  exists  between  the 
kidneys  and  the  skin  as  excretory  organs,  is  well  known.  In  health. 

Fig.  482.  Fatty  casts  with  granule  cell. 

Fig.  483.  Waxy  casts  of  various  sizes. 


826 


DISEASES  OF  THE  GENITO-URINAIIY  SYSTEM. 


impeded  function  in  the  one,  is  to  a certain  extent,  compensated  for  by 
increased  function  in  the  other  ; and  diseases  in  the  skin,  especially  scar- 
latina, or  other  causes  which  tend  to  check  cutaneous  transpiration,  are 
peculiarly  liable  to  induce  renal  disorders.  Such  being  the  case,  it 
seems  highly  judicious,  in  our  efforts  to  cure,  to  excite,  by  all  means 
in  our  power,  the  functions  of  the  skin  in  cases  of  Bright’s  disease 
of  the  kidney  ,*  and  with  this  view,  Dover’s  powder,  keeping  the  surface 
warm,  hot  air  baths,  warm  water  baths,  and  a warm  climate,  are  among 
the  means  which  have  been  proved  to  be  most  useful.  They  are  more 
especially  indicated  in  the  waxy  form  of  the  urine  with  increased 
amount  of  urine  and  slight  dropsy.  When,  however,  the  urine  is 
diminished,  and  dropsy  a leading  symptom,  it  frequently  happens  that 
these  remedies  are  of  no  avail,  and  then  we  must  have  recourse  to  the 
next  class  of  remedies. 

Diuretics. — It  has  been  thought  that  in  the  acute  inflammatory  cases, 
where  the  kidney  is  more  or  less  congested  and  loaded  with  exudation, 
diuretics,  by  stimulating  the  organs  and  exciting  them  to  increased 
action,  would  add  to,  rather  than  diminish,  the  excitement.  But  when 
it  is  considered  that  the  dropsy  is  induced  by  obstruction  in  the  secreting 
tubes,  which  presents  a mechanical  obstacle  to  the  outward  flow  of  fluid, 
it  seems  probable  that,  by  increasing  that  flow,  the  accumulations  pro- 
ducing the  obstruction  may  be  washed  out.  Besides,  by  augmenting  the 
amount  of  fluid  from  the  Malp)ighian  bodies  through  such  tubes  as  still 
remain  pervious,  a compensation  is  frequently  to  be  found  for  the  dimin- 
ished flow  which  takes  place  in  the  obstructed  ones.  Certain  it  is,  that 
1 have  given  diuretics  in  all  stages  of  the  disease  with  the  best  effects, 
as  soon  as  it  became  manifest  that  the  remedies  formerly  alluded  to 
were  of  no  avail.  Nor  have  I seen  any  bad  results  from  the  practice. 
Besides,  in  acute  cases  with  diminution  of  urine  and  rapid  dropsy,  no 
other  course  is  left  open  to  us,  as  diaphoretics  under  such  circumstances 
are  seldom  effectual. 

The  whole  class  of  diuretics  may  be  tried  in  Bright’s  disease,  in  com- 
bination with  other  remedies ; but  the  most  valuable,  so  far  as  I have 
been  able  to  determine,  is  the  bitartrate  of  potass,  which  I have  fre- 
quently seen  to  produce  a most  powerful  effect,  when  every  other  had 
failed.  The  spongio-piline,  saturated  in  a strong  solution  of  infusion  of 
digitalis  applied  externally,  and  digitaline  administered  internally  in 
minute  doses,  botli  recommended  by  Dr.  Christison,  are  useful.  But  here 
again  I have  seen  the  cream  of  tartar  operate  after  both  these  had  failed. 
Sometimes  also,  after  it  has  been  given  without  effect  at  an  early  period 
of  the  disease,  it  has  succeeded  remarkably  well  at  a later  one.  Of  this, 
the  case  of  Ilerdmanu  (Case  CLXXXII)  is  a remarkable  example,  which 
warrants  our  having  recourse  to  the  remedy  again  and  again  after  certain 
intervals,  should  it  not  act.  It  is  very  possible  that  the  casts  which 
obstruct  the  tubes  may  be  more  loosened  at  one  time  than  at  another, 
and  that  a powerful  diuretic  may,  in  consequence,  have  a greater  effect 
in  washing  out  the  obstructions  and  restoring  the  functions  of  the  organs. 
At  all  events,  I have  rarely  seen  other  diuretics  succeed,  when  repeated 
attempts  by  means  of  the  bitartrate  of  potass  had  failed. 


SECTION  IX. 


DISEASES  OF  THE  INTEGUMENTARY  SYSTEM. 

Notwithstanding  the  great  advances  which  have  been  made  in  our 
knowledge  of  diseases  of  the  skin,  it  cannot  be  denied  that  very  inexact 
notions  prevail  regarding  this  class  of  disorders.  I do  not  here  allude  to 
the  eruptive  fevers  which,  from  their  frequency  and  danger,  necessarily 
demand  the  attention  of  every  professional  man,  so  much  as  to  the  lighter 
and  more  chronic  disorders  to  which  the  skin  is  subject.  Ignorance, 
however,  here,  although  it  seldom  occasions  danger  to  human  life,  pro- 
duces great  inconveniences,  exasperates  the  progress  of  other  maladies, 
renders  life  miserable,  and  frequently  destroys  those  social  relations  and 
ties  which  constitute  happiness. 

A lady  was  seized  with  an  eruption  on  the  genital  organs,  which 
rendered  the  slightest  contact  unbearable.  Her  husband  suspected  that 
she  labored  under  syphilis,  and  accused  her  of  infidelity.  A medical 
man,  who  was  consulted,  pronounced  her  disease  venereal — a separation 
took  place  between  the  parties ; the  lady  always  maintaining  her  inno- 
cence, but  anxious  to  escape  the  unfounded  suspicions  and  ill-treatment 
of  her  husband.  Mercury  and  an  anti-venereal  treatment  was  continued 
for  some  time,  but  the  disease  increased  in  intensity.  At  length  another 
physician,  skilled  in  the  diagnosis  of  skin  diseases,  was  consulted,  who 
pronounced  it  to  be  an  ec%ema  rubrum^  quite  unconnected  with  syphilis ; 
and  on  the  application  of  appropriate  remedies,  a speedy  cure  confirmed 
his  diagnosis. 

A lady  in  the  country  sent  one  of  her  servants  into  town,  to  obtain 
advice  for  an  eruption  which  had  broken  out  on  her  body,  and  which  she 
was  afraid  might  be  communicated  to  her  children.  The  practitioner 
consulted  was  much  puzzled,  and  asked  me  to  see  the  patient,  who,  ac- 
cording to  him,  was  laboring  under  a rare  form  of  skin  disease.  I 
found  a herpes  zoster  extending  round  one  half  the  trunk,  and  told  him  it 
would  disappear  spontaneously  in  a few  days,  which  it  did. 

Nothing  is  more  common  in  practice  than  to  meet  with  cases  among 
servants,  where  prurigo  has  been  mistaken  for  itch,  causing  great  alarm 
to  the  family,  and  much  injury  to  the  servant.  The  various  diseases  of 
the  scalp  also  are  continually  confounded  together.  Indeed,  examples 
might  easily  be  accumulated,  proving  the  inconvenience  which  an  un- 
acquaintance with  skin  diseases  may  occasion  both  to  patient  and  practi- 
tioner. A young  medical  man  is  especially  liable  to  be  consulted  in 
cases  of  trifling  skin  eruptions ; and  nothing  is  so  likely  to  establish  his 
credit,  as  the  ready  diagnosis  and  skilful  management  of  such  disorders, 


828 


DISEASES  OF  THE  INTEGUMENTARY  SYSTEM. 


especially  when  (as  frequently  happens)  they  have  been  of  long  standing, 
and  baffled  the  efforts  of  older  practitioners.  Conceiving,  then,  that  this 
subject  deserves  more  careful  consideration  than  it  usually  meets  with  in 
a clinical  course,  I propose  directing  your  attention  to  the  classification, 
general  diagnosis,  and  treatment  of  these  disorders  as  an  introduction  to 
the  study  of  individual  cases  in  the  wards. 


CLASSIFICATION  OF  SKIN  DISEASES. 

Skin  diseases  are  so  various  in  appearance  and  in  their  nature,  that 
many  experienced  practitioners  have  endeavored  to  facilitate  their  study 
by  arranging  them  in  groups. 

There  are  three  kinds  of  classifications  which  deserve  notice — 1st, 
The  artificial  classification  of  Willan,  Bateman,  and  others;  2d,  The 
natural  arrangement  of  Alibert  and  others;  and  3d,  A pathological 
arrangement  founded  on  the  supposed  morbid  lesions. 

Of  these,  the  best,  and  the  one  which  most  facilitates  the  study  of 
cutaneous  diseases,  is  certainly  that  of  Willan.  No  doubt  it  has  its  faults 
and  inconveuiences,  but  many  of  them  have  been  removed  by  Biett. 
This  classification  is  founded  upon  the  character  presented  by  the  erup- 
tion, which,*  when  once  known,  determines  the  disease.  It  is  an  old 
saying,  that  it  is  much  easier  to  play  the  critic  and  to  find  fault,  than  to 
construct  something  better.  This  remark  may  be  well  applied  to  those 
who  have  ventured  to  set  aside  the  principles  on  which  Willan’s  arrange- 
ment is  founded,  and  to  bring  forward  others.  No  natural  classification 
can  ever  be  followed  by  the  student,  as  it  presupposes  a considerable 
knowledge  of  the  subject.  The  pathological  arrangement  again  is  decidedly 
faulty.  The  morbid  anatomy  and  pathology  of  many  skin  diseases  are 
unknown  ; how,  then,  can  we  found  a classification  upon  them  ? Indeed, 
the  very  foundation  on  which  such  classifications  are  based,  is  continually 
undergoing  changes  as  pathology  advances. 

On  the  whole,  therefore,  the  arrangement  best  suited  to  the  student 
and  for  practical  purposes  is  that  of  Willan  and  Bateman,  with  the  modi- 
fications subsequently  to  be  noticed. 

Definitions. — Before  we  can  proceed  to  refer  any  particular  disease 
to  its  appropriate  class,  we  must  be  acquainted  with  the  characteristic 
appearances  which  distinguish  the  different  orders.  They  are  as  fol- 
lows : — 

1.  Exanthema  (Bash). — Variously-formed,  irregular-sized,  superficial 
red  patches,  which  disappear  under  pressure,  and  terminate  in  des- 
quamation. 

2.  Vesmila  (Vesicle). — A small,  acuminated,  or  orbicular  elevation 
of  the  cuticle,  containing  lymph,  which,  at  first  clear  and  colorless,  be- 
comes often  opaque  or  pearl-colored.  It  is  succeeded  either  by  scurf  or 
a laminated  scab. 

3.  BuUa  (Bleb). — This  differs  from  the  vesicle  in  its  size,  a large 
portion  of  the  cuticle  being  detached  from  the  skin  by  the  interposition 
of  a watery  fluid,  usuall}^  transparent. 

4.  P'ustula  (Pustule). — A circumscribed  elevation  of  the  cuticle,  con- 


CLASSIFICATION  OF  SKIN  DISEASES. 


829 


taining  pus.  It  is  succeeded  by  an  elevated  scab,  which  may  or  may  not 
be  followed  by  a cicatrix. 

5.  Papula  (Pimple). — A small,  solid,  acuminated  elevation  of  the 
cuticle,  in  appearance  an  enlarged  papilla  of  the  skin,  commonly  termi- 
nating in  scurf,  and  sometimes,  though  seldom,  in  slight  ulceration  of  its 
summit. 

6.  Squama  (Scale). — A lamina  of  morbid  cuticle,  hard,  thickened, 
whitish,  and  opaque,  covering  either  small  papular  red  elevations,  or 
larger  deep-red,  dry  surfaces. 

7.  Tuherculum  (Tubercle). — A small  hard,  indolent,  primary  eleva- 
tion of  the  skin,  sometimes  suppurating  partially,  sometimes  ulcerating 
at  its  summit. 

8.  Macula  (Spot). — A permanent  discoloration  of  some  portion  of 
the  skin,  often  with  a change  of  its  structure.  These  stains  may  be 
white  or  dark-colored. 

The  different  appearances  thus  described  characterise  the  eight  orders 
of  Willan  and  Bateman — viz.,  1.  Exanthemata;  2.  Vesiculm;  8.  Bullae; 
4.  Pustulae;  5.  Papulae;  6.  Squamae;  7.  Tubercula;  8.  Maculae.  The 
principal  modifications  made  by  Biett  consist  in  removing  from  these 
groups  certain  diseases  which  have  no  affinity  with  them,  and  forming 
them  into  extra  orders  of  themselves.  Thus  he  makes  altogether  fifteen 
orders,  as  seen  in  the  following  classification  given  by  his  pupils  Schedel 
and  Cazenave,  which  also  indicate  the  subdivisions  into  which  each  order 
is  divided  : — 


Order  I. — Exanthemata. 

Vaccinia. 

Framboesia. 

Rubeola. 

Ecthyma. 

Cheloidea. 

Scarlatina. 

Impetigo. 

Order  VIII. — Maculce. 

Erythema. 

Acne. 

Lentigo. 

Erysipelas. 

Mentagra. 

Eph  elides. 

Roseola. 

Porrigo. 

Naevi  and  Vintiligo. 

Urticaria. 

Equinia. 

Order  IX. — Purpura. 

Order  II. — VesiculcB. 

Order  V. — Papulce. 

“ X. — Pellagra. 

Eczema. 

Lichen. 

“ XI. — Radesyge. 

Herpes. 

Prurigo. 

“ XII. — Lepra  Astra- 

Scabies. 

Order  VI. — Squamce. 

chanica. 

Miliaria. 

Psoriasis. 

« XIII.— TAe  Aleppo 

Varicella. 

Pityriasis. 

Evil.,  or  Malum 

Order  III. — Bailee. 

Ichthyosis. 

Alepporuyn. 

Pemphigus. 

Order  VII. — Tubercula. 

“ XIV. — Elephantiasis 

Rupia. 

Lepra  Tuberculosa, 

Arahica. 

Order  IV. — Pustulce. 

Lupus. 

“ XV. — Syphilidee  or 

Variola. 

Molluscum. 

Syphilitic  Erup- 

tions. 


Even  this  classification  is  very  complicated,  and  appears  to  me  to 
admit  of  still  further  modifications,  which  will  render  the  subject  more 
simple  and  practical  at  the  bed-side.  I shall  point  out  to  you,  in  the 
first  instance,  the  reasons  which  have  induced  me  to  make  these  modifi- 
cations, and  then  give,  in  a tabular  form,  the  classification  which  we 
shall  in  future  adopt. 

In  the  orders  Exanthemata  and  Pustulce  we  find  several  diseases 
which  are  characterised  by  excessive  fever,  so  that  they  have  long  been 
spoken  of  under  the  term  of  eruptive  fevers,  as  well  as  under  that  of 
febrile  eruptions.  With  them,  in  short,  fever  is  the  characteristic,  and 


830 


DISEASES  OF  THE  INTEGUMEXTAKY  SYSTEM. 


they  are  influenced  by  laws  of  a peculiar  character,  altogether  different 
from  those  which  regulate  the  production  of  other  cutaneous  affections. 
I propose,  then,  to  remove  these  disorders  from  the  category  of  skin  dis- 
eases altogether,  and  to  leave  only  three  in  the  first  order,  namely,  ery- 
thema, roseola,  and  urticaria.  I am  aware  that,  strictly  speaking,  these 
may  be  accompanied  by  slight  fever,  which  may  also  occur  in  several 
other  skin  diseases.  But  I do  not  pretend  to  form  a classification  which 
is  perfect,  or  even  pathological,  but  one  which  some  experience  in  the 
teaching  of  these  diseases  has  convinced  me  is  useful  and  practical  for  the 
student. 

In  the  order  Vesiculm  we  find  five  diseases.  I propose  cutting  out 
miliaria,  as  being  very  unimportant,  and  a trifling  sequela  of  fevers. 
Varicella  I believe  to  be  a modified  small-pox,  and  I omit  it  for  the  same 
reasons  as  I do  variola.  Scabies,  on  the  other  hand,  though  dependent 
upon  the  presence  of  an  insect,  the  Acarus  Scahiei,  presents  such  distinct 
characters  as  to  warrant  its  retention. 

I propose  expunging  the  order  Bnllce  altogether.  "We  find  in  it  two 
diseases.  The  first  of  these,  pemphigus  or  pompholyx,  is  a vesicular  dis- 
ease in  every  point,  appearing  sometimes  in  successive  crops,  and  form- 
ing a laminated  scab.  Kupia,  on  the  other  hand,  is  evidently  a pustular 
disease,  forming  a prominent  scab,  producing  ulceration,  and  leaving  a 
cicatrix.  I shall  therefore  add  pemphigus  to  the  order  vesiculge,  and 
rupia  to  that  of  the  pustulm. 

From  the  for  the  reasons  formerly  stated,  I expunge  variola, 

vaccinia,  and  equinia.  Mentagra,  so  far  as  I have  been  able  to  study  it 
in  this  country,  has  always  consisted  of  eczema  or  impetigo  on  the  chin 
of  the  male.  In  syphilitic  cases  it  is  more  or  less  tubercular,  and  it  has 
been  described  also  as  consisting  of  a vegetable  parasite.  Although  I 
have  never  seen  the  appearance  figured  % Cazenave  (Plate  1C),  I can 
understand  that  such  a mentagra  might  really  consist  of  vegetable  fungi. 
At  all  events,  mentagra  is  not  a special  pustular  disease.  Porrigo  means 
any  eruption  on  the  head,  whether  vesicular,  pustular,  or  squamous. 
Favus,  to  which  it  has  long  been  applied,  is  undoubtedly  a parasite,  and 
ought,  with  others  of  a like  nature,  to  constitute  a distinct  class.  More- 
over, it  is  neither  vesicular  nor  pustular.  Hence  the  class  of  pustulac 
will  with  us  contain  only  impetigo,  ecthyma,  acne,  and  rupia. 

The  orders  Papulm  and  Squamm  remain  the  same.  The  strophulus 
of  many  English  writers  is  certainly  only  lichen  occurring  in  the  child ; 
and  what  has  been  called  lepra,  as  distinguished  from  psoriasis,  is  the 
latter  disease  presenting  an  annular  form. 

From  the  class  Tubercuh  I cut  out  framboesia,  as  being  a disease  un- 
known in  this  country,  together  with  cheloidea,  which,  as  I understand  it, 
means  either  cancer  or  tubercle  of  the  skin. 

As  regards  the  order  Maculcd^  I place  purpura  in  it,  as  did  M illan, 
because,  although  sometimes  it  may  depend  on  constitutional  causes  of 
an  obscure  nature,  and  at  others  be  allied  to  scurvy,  it  still,  in  an  arbi- 
trary classification  of  this  kind,  constitutes  an  undoubted  spot  or  macula. 

All  the  other  orders  of  Biett  I shall  take  the  liberty  of  expunging— 
pellagra,  lepra  Astrachanica,  and  malum  Alepporura,  are  unknown  in  this 
country.  I agree  with  Hebra,  in  thinking  that  Radesyge  is  only  a modi- 


DIAGNOSIS  OF  SKIN  DISEASES. 


831 


fied  form  of  lupus.  The  elephantiasis  Arabica  is  an  hypertrophy  of  the 
areolar  tissue  or  chorion,  and  belongs  more  to  the  subject  of  fibrous 
growths  than  that  of  skin  diseases.  Syphilitic  diseases  I do  not  regard 
as  a distinct  order,  but  as  any  of  the  ordinary  skin  alfections,  more  or 
less  modified  by  a peculiar  state  of  the  constitution. 

Whilst  I have  cut  out  many  diseases  from  the  eight  orders  originally 
established  by  Willan,  and  subsequently  modified  by  Biett,  I find  it  ne- 
cessary to  add  two  orders,  which  the  advance  of  pathology  and  histology 
shows  ought  to  be  considered  apart.  I allude  to  those  which  depend  on 
the  presence  of  parasitic  animals  and  plants,  and  which  may  be  called 
respectively  Dermatozoa  and  Dermatophyta.  It  has  now  been  shown  by 
M.  Boiirguignon,  that  scabies  is  dependent  on  the  presence  of  an  acarus, 
but  that  the  insect  is  only  indirectly  the  cause  of  the  eruption.  Hence 
I put  acarus  among  the  dermatozoa,  although  it  certainly  forms,  when 
present,  a constituent  of  itch.  Among  the  dermatophytes  will  be  placed 
favus  and  mentagra — both  removed  from  the  class  pustulae.  Other  dis- 
eases, such  as  plica  Polonica,  and  pityriasis,  have  been  considered  as 
parasitic ; but  the  former  is  unknown  in  this  country,  and  the  latter, 
when  it  presents  epiphytes  among  the  scales,  constitutes  a form  of  favus. 

The  classification,  then,  we  shall  in  future  adopt  is  as  follows: 


Order  I. — Exanthemata. 
Erythema. 
Roseola. 
Urticaria. 

Order  II. — Vesiculce. 
Eczema. 

Herpes. 

Scabies. 
Pemphigus. 
Order  III. — PustulcB. 
Impetigo. 
Ecthyma. 

Acne. 

Rupia. 


Order  IV. — Papulce. 
Lichen. 

Prurigo. 

Order  V. — Equaince. 
Psoriasis. 

Pityriasis. 

Ichthyosis. 

Order  VI. — Tabercula. 

Lepra  Tuberculosa. 
Lupus. 

Molluscum. 

Order  VI. — Maculae. 
Lentigo. 

Ephelides. 


Ngevi. 

Purpura. 

Order  VIII. — Dermatozoa. 
Entozoon  folliculo- 
rum. 

Acarus. 

Pediculus. 

Order  IX, — Dermatophyta. 
Achorion  Schonleinii 
(Favus). 

Achorion  Grubii 
(Mentagra).* 


DIAGNOSIS  OF  SKIN  DISEASES. 

The  recognition  of  skin  diseases,  and  the  separating  of  one  class  from 
another,  is  of  essential  importance  to  a proper  treatment.  On  this 
point  I fully  agree  with  a w^riter,  who  says,  “ The  treatment  of  a great 
many  cutaneous  diseases  is  but  of  secondary  importance  compared  with 
their  differential  diagnosis.  Many  of  them  will  get  well  without  any  treat- 
ment, provided  they  are  allowed  to  pursue  their  natural  course ; and,  on 
the  contrary,  a mild  and  simple  eruption,  by  being  mi.staken,  from  a 
similarity  of  external  appearance,  for  one  of  a severe  or  rebellious  char- 

* It  has  been  objected  to  the  words  porrigophyte  and  mentagraphyte,  introduced 
by  Gruby,  that  they  are  unclassical ; and  as  the  celebrated  botanist  Link,  after  care- 
fully examining  these  vegetations,  has  described  the  former  as  a new  genus,  under  the 
head  of  Achorion  (from  acAor,  the  old  term  given  to  a favus  crust  by  Willan),  I have 
tUought  it  best  to  adopt  that  term.  To  mark  the  variety  in  favus,  he  has  added  the 
name  of  its  discoverer,  Schonlein  ; and  I have  ventured,  at  all  events  provisionally,  to 
distinguish  the  one  described  as  existing  in  mentagra,  by  adding  to  it  also  that  of  its 
discoverer,  Gruby. 


832 


DISEASES  OF  THE  INTEGUMENTARY  SYSTEM. 


acter,  and  treated  accordingly,  may  be  aggravated  and  prolonged  for  an 
indefinite  period.’’ — (Burgess.)  This  diflerential  diagnosis,  however,  to 
the  inexperienced,  is  a matter  of  great  difficulty,  because  not  only  is  con- 
siderable tact  generally  necessary  to  discover  the  original  element  each 
disease  presents,  such  as  rash,  vesicle,  pustule,  scale,  and  so  on ; but 
often  this  is  impossible.  Under  such  circumstances  the  diagnosis  is  fre- 
quently derived  from  the  scab,  or  other  appearances  presented,  such  as 
the  cicatrix.  The  whole  subject  has  been  rendered  very  confused  and 
complicated  by  systematic  writers,  who  have  often  given  different  names 
to  the  same  disease,  or  unnecessarily  divided  them  into  forms  and  va- 
rieties. I advise  you  not  to  pay  any  attention  to  these  forms  and  varie- 
ties for  the  present,  and  to  confine  your  efforts  only  to  the  detection  of  the 
diseases  enumerated  in  the  table  under  each  order;  and  with  a view  of 
facilitating  your  endeavors,  the  following  short  diagnostic  characters  and 
definitions  should  be  attended  to. 

I.  Exanthemata. 

1.  Erythema. — A slight  continuous  redness  of  the  skin  in  patches 
of  various  shapes  and  sizes. 

2.  Boseola. — Circumscribed  rose-red  patches,  of  a circular,  serrated, 
or  annular  form. 

3.  Urticaria. — Prominent  red  patches  of  irregular  form,  the  centre 
of  which  is  often  paler  than  the  surrounding  skin. 

II.  Vesiculje. 

Eczema. — Very  minute  vesicles  in  patches,  presenting  a shining  ap- 
pearance, yielding  a fluid  which  dries  into  a laminated  or  furfuraceous 
crust.  The  skin  is  a bright  red  color. 

Herpes. — Clusters  of  vesicles,  varying  in  size  from  a millet  seed  to 
that  of  a pea,  surrounded  by  a bright  red  areola.  They  yield  a fluid 
which  dries  into  a thin  incrustation,  that  drops  off  between  the  eighth 
and  fifteenth  day. 

Scabies. — Isolated  vesicles  of  an  acuminated  form,  commonly  seated 
between  the  fingers  and  flexor  surfaces  of  the  arms  and  abdomen — never 
on  the  face. 

Pemphigus. — Large  vesicles  or  blebs  (bullae)  surrounded  by  an  ery- 
thematous circle,  the  fluid  of  which  forms,  when  dry,  a laminated  crust. 
When  chronic,  they  appear  in  successive  crops,  and  the  disease  is  called 
pompholyx. 


III.  Pustule. 

Impetigo. — Small  pustules,  commonly  occurring  in  groups,  and  form- 
ing an  elevated  crust. 

Ecthyma. — Large  isolated  pustules,  depressed  or  umbilicated  in  the 
centre,  and  leaving  a cicatrix. 

Acne. — Isolated  pustules  situated  on  a hardened  base,  which  form 
and  disappear  slowly.  They  only  occur  on  the  face  and  shoulders. 

Pupia. — Large  pustules,  followed  by  thick  prominent  crusts,  and  pro- 
ducing ulcerations  of  various  depths. 


DIAGNOSIS  OF  SKIN  DISEASES. 


833 


IV.  Papula. 

ZicJien. — Minute  papulae  occurring  in  clusters  or  patches. 

Prurigo. — Larger  and  isolated  papulae  generally  seated  on  the  exten- 
sor surfaces  of  the  body. 


V.  Squamje. 

Psoriasis. — Whitish  laminated  scales  slightly  raised  above  the  red- 
dened surface  of  the  skin.  Lepra  is  poriasis  occurring  in  rings. 

Pityriasis. — Very  minute  scales,  like  those  of  bran,  seated  on  a red- 
dened surface. 

Ichthyosis. — Induration  of  the  epidermis,  and  formation  of  square  or 
angular  prominences,  not  seated  on  a reddened  surface. 

VI.  Tubercula. 

Lepra  Tuberculosa. — (Elephantiasis  of  the  Greeks). — Tubercles  vary- 
ing in  size,  preceded  by  erythema  and  increased  sensibility  of  the  skin, 
and  followed  by  ulceration  of  their  summits. 

Lupus. — Induration  or  tubercular  swelling  of  the  skin,  which  may  or 
may  not  ulcerate.  In  the  former  case,  ulceration  may  occur  at  the  sum- 
mit or  at  the  base  of  the  tubercles,  and  frequently  extends  in  the  form 
of  a circle  more  or  less  complete. 

Molluscum. — Pedunculated,  globular,  or  flattish  tubercles,  accom- 
panied by  no  erythema  or  increased  sensibility,  occurring  in  groups. 
They  are  filled  with  atheromatous  matter. 

VII.  Macula. 

Lentigo  or  Frechle. — Brownish-yellow  or  fawn-colored  spots  on  the 
face,  bosom,  hands,  or  neck. 

Ephelis. — Large  patches  of  a yellowish-brown  color,  accompanied  by 
slight  desquamation  of  the  cuticle. 

Nceci  or  Moles. — Spots  of  various  colors  or  forms,  sometimes  elevated 
above  the  skin.  They  are  congenital. 

Purpura. — Bed  or  claret-colored  spots  or  patches,  which  do  not  dis- 
appear under  pressure  of  the  finger. 

VIII.  Dermatozoa.. 

These  minute  animals  require  a lens  of  considerable  power  to  ascer- 
tain their  characters,  which  need  not  be  particularised  here,  as  they  will 
be  subsequently  described  and  figured.  (See  p.  830,  et  seq.) 

IX.  Bermatophyta. 

These  minute  plants  require  a high  magnifying  power  to  distinguish 
them  with  exactitude.  But  they  communicate  peculiar  characters  to 
certain  cutaneous  diseases,  as  follows  • 

Favus. — Bright  yellow,  umbilicated  crusts,  surrounding  individual 
53 


834 


DISEASES  OF  THE.  INTEGUMENTARY  SYSTEM. 


hairs,  which  agglomerate  together  to  form  an  elevated  friable  crust,  of  a 
peculiar  musty  or  mousey  smell. 

Mentagra. — Grayish  or  yellowish  dry  crusts,  of  irregular  form,  origi- 
nating in  the  hair  follicles  of  the  beard. 

In  forming  your  diagnosis,  therefore,  you  will  be  guided  principally 
by  three  characters  : — 1st,  The  primitive  and  essential  appearance — that 
is,  whether  a rash,  vesicle,  pustule,  and  so  on.  2d,  The  crust — whether 
laminated  or  prominent,  composed  of  epidermis  only,  etc.  8d,  Ulcera- 
tion,— whether  present  or  absent;  and  if  so,  the  kind  of  cicatrix.  These 
and  other  characters  I shall  point  out  at  the  bed-side,  so  as  to  familiarise 
you  with  their  appearances. 

You  will  remember  that  the  classification  formed  by  Willan  is  wholly 
artificial.  It  is  like  the  Linnsean  classification  of  plants.  The  difiiculty 
for  the  learner  is  to  recognise  the  essential  character,  the  more  so  as  many 
diseases  pass  through  various  stages  before  this  is  formed.  Thus  herpes 
presents — 1st,  a rash;  2d,  papules  ; 3d,  vesicles  ; 4th,  pustules;  yet  the 
disease  is  considered  vesicular.  Ecthyma  passes  through  the  same 
stages,  yet  it  is  considered  pustular.  In  the  vesicular  disease,  however, 
the  crust  is  laminated, — in  the  pustular,  it  is  more  or  less  prominent. 

Again,  it  not  unfrequently  happens  that  two  or  more  diseases  are 
combined  together  in  one  eruption.  Thus  it  is  very  common  to  meet 
eczema  and  impetigo  combined,  when  the  disease  is  called  Eczema  im'peti- 
ginodes.  Favus  occasionally  causes  considerable  irritation,  producing  a 
pustular  or  impetiginous  margin  around  it.  The  vesicles  of  scabies  are 
often  accompanied  by  the  pustules  of  ecthyma,  and  so  on. 

In  very  chronic  skin  diseases,  it  may  happen  that  it  is  impossible  to 
say  what  the  original  disorder  was,  whether  vesicular,  pustular,  scaly,  or 
papular.  In  such  cases  the  skin  assumes  a red  color,  the  dermis  is 
thickened,  the  epidermis  rough  and  indurated,  and  a morbid  state  is  oc- 
casioned, in  which  all  trace  of  the  original  disease  is  lost,  and  what  remains 
is  a condition  common  to  various  disorders. 

As  regards  varieties,  little  need  be  said,  and  as  I formerly  stated,  I 
advise  you  to  postpone  their  study  until  you  are  acquainted  with  the 
diseases  themselves.  Even  then  an  acquaintance  with  them  is  of  secon- 
' dary  importance.  These  varieties  have  been  formed  on  account  of  the 
most  varied  circumstances,  such  as, — 1st,  Duration,  most  of  them  may 
be  acute  or  chronic  ; 2d,  Obstinacy,  the  terms  inveterata^  acrius^ 

etc.;  3d,  Intensity,  hence  the  terms  mitis^  maligna^  etc.;  4th,  SrruA- 
TiON,  hence  the  terms  capitis,  facialis,  lahialis,  pafmaris,  etc. ; 5th, 
Form,  hence  the  terms  circinatus,  scutulata,  iris,  gyrata,  larvalis,figu- 
rata,  tuherosa,  guttata,  etc.;  6th,  Consittution,  hence  the  terms  cachec- 
tica,  scorbutica,  syphilitica,  etc.;  7th,  Age,  hence  the  terms  inf antilis, 
senilis,  etc. ; 8th,  Color,  hence  the  terras  album,  nigrum,  rubrum, 
versicolor,  etc  ; 9th,  Density,  hence  the  terms  sparsa,  diffusa,  concen- 
iricus,  etc. ; 10th,  Feel,  hence  the  terms  Iccve,  indurata  ; 11th,  Sensa- 
tion PRODUCED,  hence  the  terms  formicans, pruritus,  uriicans,  etc. ; 12th, 
Geographical  distribution,  hence  the  terms  tropicus,  Mgyptiana,  Nor- 
wegiana,  etc. 


DIAGNOSIS  OF  SKIN  DISEASES. 


835 


PORRIGO. 

There  was  a period  in  the  history  of  skin  diseases  when  they  were 
arranged  in  two  great  divisions — viz.,  those  affecting  the  scalp,  and  those 
affecting  the  rest  of  the  cutaneous  surface.  All  the  disorders  compre- 
hended ill  the  hrst  of  these  divisions  received  the  name  of  Porrigo,  a 
word  said  by  some  to  be  derived  from  jporrum,  on  account  of  the  scales 
or  concretions  of  the  scalp  resembling  the  layers  of  an  onion ; by  others  it 
is  derived  from  porrigo^  to  spread.  Willan  described  six  kinds  of  Por- 
rigo, viz.,  P.  larvaXis,  P.  furfurans,  P.  scutulata^  P.  favosa^  P.  lupi- 
nosa^  and  P.  deoalvans.  It  is  now  ascertained  that  none  of  these  dis- 
eases are  necessarily  peculiar  to  the  scalp, — and  that,  although  they  are 
more  or  less  modified  by  being  connected  with  and  affecting  the  hairs  of 
that  region,  they  may  also  occur  on  other  parts  of  the  skin.  There  can 
be  little  doubt,  however,  that  the  employment  of  the  term  Porrigo,  as 
well  as  the  corresponding  word  Teigne  in  France,  has  thrown  great  con- 
fusion over  the  subject  of  eruptions  on  the  scalp.  But,  as  this  term  is 
still  in  pretty  general  use,  it  will  be  well  to  explain  to  you  what  diseases 
these  different  kinds  of  Porrigo  really  are. 

Porrigo  larvalis  (larva,  a mask)  is  really  Impetigo,  or  Eczema  impe- 
tiginodes,  of  the  scalp.  The  former  is  recognised  by  crusts  more  or  less 
prominent  or  nodulated ; the  latter,  by  the  circumstance  that,  in  addition 
to  these  nodules,  there  is  between  them  a laminated  or  brittle  crust, 
spread  more  or  less  equally  over  the  surface.  They  are  both  ver}^  com- 
mon in  infants  and  children and  the  disease  sometimes  extends  over  the 
face,  concealing  the  features,  hence  the  term  larvalis.  A very  charac- 
teristic representation  of  Impetigo  capitis  is  given  in  Willan  and  Bate- 
man, Plate  xli.,  erroneously  called  Porrigo  favosa.  (See  also  the  disease 
on  the  face,  ibid.,  Plate  xxxvii.  ; Alihert,  Planches  13  and  15.) 

Porrigo  furfurans  (furfur,  bran)  is  really  Pityriasis  of  the  scalp, 
although  Psoriasis  of  that  region  has  also  received  the  same  appellation. 
There  is  also  a peculiar  form  of  Eczema,  or  Eczema  impetiginodes,  in 
which  the  crust  is  friable,  and  breaks  up,  or  crumbles  into  minute  frag- 
ments, to  which  the  term  furfurans  has  been  erroneously  applied.  The 
true  Porrigo  furfurans  (Pityriasis)  is  well  represented,  Willan  and  Bate- 
man, Plate  xxxviii. ; Alihert,  Planches  14  and  15.  It  is  often  a form 
of  favus.  (See  Favus.) 

Porrigo  scutulata  (scutulum,  a small  shield). — The  nature  of  this  dis- 
ease has  been  much  disputed.  By  some  it  is  said  to  be  Favus  (Erasmus 
Wilson),  by  others  a form  of  Herpes  (Cazenave).  The  disease  is  de- 
scribed by  Willan  and  Bateman,  and  more  recently  by  Burgess,  as  con- 
sisting of  oval  or  rounded,  slightly  elevated  patches,  covered  with 
furfur,  and  having  stunted  or  filamentous  hair  projecting  from  the  sur- 
face. It  is  a form  of  skin  eruption  exceedingly  rare  in  Edinburgh.  It 
seems  to  be  represented,  Willan  and  Bateman,  Plate  xxxix. ; Willis 
(Trichosis  scutulata). 

Porrigo  favosa  (favus,  a honeycomb)  is  a disease,  the  true  nature  of 


836 


DISEASES  OF  THE  IXTEGUMENTAET  SYSTEM. 


which  has  been  only  lately  determined.  It  consists  essentially  of  an 
exudation  on  the  skin,  in  which  fungi  or  phytaceous  plants  grow.  Hound, 
isolated,  bright  yellow  crusts  are  formed,  which,  when  compressed  toge- 
ther, assume  an  hexagonal  shape — hence  the  term  favosa.  It  is  well 
represented,  Willis  (Trichosis  lupinosa) ; Erasmus  Wilson,  Fasciculus  I., 
Alibert,  Planche  17. 

Porrigo  lupinosa  {lupinum,  the  lupine). — This  is  the  same  disease  as 
the  last.  The  round  or  oval  crusts,  when  isolated  and  at  an  early  stage, 
present  a concavity  and  form  resembling  that  of  the  lupine  seed — hence 
its  name. 

Porrigo  decalvans  {calvus,  bald). — Baldness  is  so  common  among  the 
aged  that  it  can  scarcely  be  called  a disease ; but  when  it  occurs  in 
young  persons,  and  is  circumscribed,  it  constitutes  the  Porrigo  decalvans 
of  Willan.  It  is  said  by  Gruby  to  depend  on  a vegetable  parasite  grow- 
ing in  the  hair.  It  is  well  represented,  Willan  and  Bateman,  Plate  xl. ; 
Willis  (Trichosis  decalvans). 

From  this  analysis  of  the  different  kinds  of  the  so-called  Porrigo,  you 
observe  that  there  is  nothing  peculiar  with  regard  to  them.  With  the 
exception  of  baldness,  none  essentially  belong  to  the  hairy  scalp.  True 
favus  is  far  more  common  on  the  head  than  elsewhere ; but  I have  fre- 
quently seen  it  on  various  parts  of  the  cutaneous  surface,  and  occasion- 
ally on  the  cheeks  or  shoulders,  without  being  on  the  scalp  at  all.  It 
follows  that,  instead  of  the  term  Porrigo,  you  should  designate  the  disease 
as  Eczema,  Impetigo,  Pityriasis,  Psoriasis,  or  Favus  of  the  scalp,  as  the 
case  may  be. 

Notwithstanding  I have  endeavored  to  place  this  subject  before  you 
in  as  simple  and  uncomplicated  a form  as  possible,  I am  conscious  that 
at  first  you  will  still  experience  considerable  difficulty  in  the  diagnosis 
of  skin  affections.  This  can  only  be  removed  by  practical  experience  at 
the  bed-side,  and  by  constantly  exercising  your  powers  of  observation  in 
detecting  the  essential  elements  which  their  varied  forms  present.  At 
the  same  time,  I think  the  modified  classification  and  short  characters  I 
have  given,  will  materially  assist  your  studies  in  this  important  depart- 
ment of  practical  medicine.  It  must  be  remembered,  however,  that  they 
only  refer  to  those  cutaneous  diseases  which  you  are  liable  to  meet  with 
in  this  country.  Should  you  ever  be  called  upon  to  practise  in  the 
tropics,  or  in  other  places  where  peculiar  skin  disorders  prevail,  it  will, 
of  course,  be  your  duty  to  study  them  in  an  especial  manner.  Here,  as 
they  cannot  be  made  the  subject  of  clinical  observation,  they  are  alto- 
gether removed  from  our  consideration. 

THE  TREATMENT  OF  SKIN  DISEASES. 

Since  the  addition  of  a ward  for  skin  diseases  to  the  clinical  depart- 
ment of  the  Royal  Infirmary,  I have  had  ample  opportunities  of  deter- 
mining what  are  the  more  common  forms  of  cutaneous  eruption  met  with 


THE  TREATMENT  OF  SKIN  DISEASES. 


837 


in  Edinburgh,  and  of  trying  various  kinds  of  remedies.  As  the  illus- 
tration of  so  many  forms  of  integumentary  disease  by  reports  of  cases  is 
in  this  work  impossible,  I propose  now  to  give  a condensed  account  of 
the  treatment  I have  found  most  successful. 

Exanthemata. 

Few  cases  laboring  under  erythema,  roseola,  or  urticaria,  enter  the 
Infirmary ; and  in  such  as  occasionally  present  these  eruptions  during 
their  residence  there,  the  mildest  remedies  suffice  for  their  removal.  In 
the  severer  cases,  a saturnine  lotion  to  diminish  local  irritation,  with  a 
saline  purgative,  generally  suffices  for  the  cure. 

Vesiculje. 

Eczema  is  by  far  the  most  common  disease  met  with,  both  in  its 
acute  and  chronic  forms.  The  local  treatment  I have  found  most  effica- 
cious is  that  which  I first  recommended  in  1849. It  consists  in  keep- 
ing the  affected  part  moist,  with  lint  or  linen  saturated  in  a very  weak 
alkaline  solution,  consisting  of  3 ss  of  the  common  carbonate  of  soda 
dissolved  in  a pint  of  water.  For  this  purpose  it  is  necessary  to  cover 
the  moistened  lint  with  oil  silk,  or  gutta-percha  sheeting,  which  should 
well  overlap  the  lint  below,  so  as  to  prevent  evaporation.  The  usual 
effect  is  soon  to  remove  all  local  irritation,  and  especially  the  itching  or 
smarting  so  distressing  to  the  patient.  It  also  keeps  the  surface  clean, 
and  prevents  the  accumulation  of  those  scabs  and  crusts  which  in  them- 
selves often  tend  to  keep  up  the  disease.  After  a time,  even  the  indu- 
rated parts  begin  to  soften,  the  margins  of  the  eruption  lose  their  fiery 
red  color,  and  merge  into  that  of  the  healthy  skin,  and  finally  the  whole 
surface  assumes  its  normal  character. 

In  private  practice,  it  is  often  a matter  of  great  difficulty  to  secure  a 
proper  application  of  the  lotion.  Individuals  are  slow  to  accept  the 
idea  that  constant  moisture  of  the  part  is  absolutely  necessary  for  the 
treatment,  and  hence  vigilant  superintendence  and  frequent  visits  are 
requisite,  in  order  to  watch  the  progress  of  the  case.  Even  in  the  hos- 
pital constant  care  is  necessary,  to  see  that  nurses  properly  cover  the 
eruption  ; and  when,  as  sometimes  happens,  this  task  is  given  to  the  pa- 
tients themselves,  it  almost  always  fails.  Then  there  are  some  portions 
of  the  surface  which  it  is  very  difficult  to  keep  moist  and  well  covered, 
such  as  the  face  and  axillae.  But,  by  carefully  adapting  lint  and  gutta- 
percha sheeting,  attaching  strings  to  the  edges  of  the  latter,  so  as  to 
keep  the  whole  in  its  place,  I have  never  failed  in  ultimately  carrying 
out  my  object.  In  the  Infirmary  I treat  vesicular  eruptions  of  the  face 
in  this  way  by  means  of  a mask,  having  apertures  for  the  eyes,  nostrils, 
and  moutffi  If  the  eruption  be  very  general,  long  soaking  in  slightly 
alkaline  baths  is  useful. 

In  addition  to  stating  what  I have  found  to  be  beneficial,  it  is  im- 
portant to  say  what  I have,  on  careful  trial,  ascertained  to  be  useless 
or  injurious.  Perhaps  no  remedy  is  more  generally  employed  in  this 
and  a variety  of  other  skin  diseases  than  citrine  ointment — an  applica- 
* Monthly  Journal  of  Medical  Science,  August  1849. 


838 


DISEASES  Ob’  THE  INTEGIIMENTAKY  SYSTEM. 


tion  that  I have  always  found  to  irritate  and  make  eczematous  eruptions 
worse.  At  the  same  time,  there  are  some  very  chronic  forms  of  the  dis- 
ease which  I have  been  told  are  cured  by  this  preparation,  but  what 
these  are  I have  never  been  able  to  ascertain.  Indeed,  all  greasy  appli- 
cations whatever,  in  acute  cases,  are  useless,  and  the  patients  themselves 
say,  are  very  “ heating.”  I have  tried  the  freezing  process  recommended 
by  Dr.  Arnott,  but  the  salt  of  the  frigorific  mixture,  and  the  cold  itself, 
has  caused  apparently  so  much  agony,  that  I have  been  deterred  from 
using  it,  especially  when  the  emollient  moist  alkaline  application  is  so 
efficacious. 

In  some  rebellious  chronic  cases  I have  occasionally  found  the  oil  of 
cade  a useful  remedy,  and  in  others  the  oxide  of  zinc  ointment.  They 
are  most  beneficial  after  a prolonged  use  of  the  moist  alkaline  applica- 
tion In  the  same  way,  friction  with  the  hand  or  a soft  flesh-brush  fa- 
vors the  disappearance  of  the  chronic  induration  and  vascularity  of 
chronic  eczema  of  the  inferior  extremities,  which  should  be  kept  as 
much  as  possible  in  the  recumbent  position.  These  stimulating  appli- 
cations, whilst  useful  in  the  very  chronic  and  non-irritativc  forms  of  the 
disease,  or  to  remove  what  an  emollient  treatment  fails  to  accomplish, 
are  most  injur' ous  in  the  acute  forms. 

llerpes. — This  disease  generally  runs  its  course  in  about  fourteen 
days,  and  requires  no  treatmen't  whatever  further  than  an  acetate  of  lead 
lotion  to  allay  the  smarting.  It  is  not  very  common. 

Scabies  occuis  very  frequently,  and  is  cured  by  a host  of  remedies. 
A strong  lather,  made  of  common  soft  soap  and  warm  water,  twice  a 
day,  answers  very  well.  The  question  with  scabies,  is  not  what  remedy 
is  useful,  but  which  will  cure  it  in  the  shortest  period.  The  most  exten- 
sive experience  at  St.  Louis  has  shown,  that  the  sulphur  and  alkaline,  or 
Helmerinch’s  ointment,  cures  itch,  on  an  average,-  in  seven  days.  That 
sulphur,  however,  is  not  the  active  remedy,  I have  satisfled  myself  by 
experiment.  Soft  soap,  as  we  have  seen,  which  contains  alkali,  and  even 
simple  lard,  if  pains  be  taken  to  keep  the  parts  constantly  covered  with 
it,  will  cure  the  disease  as  soon  as  sulphur  ointment.  I have  tried  the 
Stavesacre  ointment,  recommended  by  M.  Bourguignon,  in  only  a few 
cases,  but  found  it  to  answer  very  well.  Its  superiority,  however,  over 
other  applications,  I am  not  yet  prepared  to  admit.  (See  Dermatozoa.) 

P emphigus. — This  is  rather  a rare  disease,  and  when  chronic,  coming 
out  in  successive  crops,  is  very  rebellious.  I have  cured  several  acute, 
and  some  tolerably  chronic  cases,  in  from  one  to  three  weeks,  by  the 
weak  alkaline  wash,  applied  as  in  the  case  of  eczema,  combined  with 
generous  diet. 

Pustule. 

Impetigo. — This  affection  in  all  its  forms  is  very  common,  and  is  best 
treated  by  the  weak  alkaline  wash,  exactly  the  same  as  in  eczema.  In 
the  chronic  forms  which  attack  the  chin  of  men,  constituting  one  of  the 
varieties  of  mentagra,  the  same  treatment  cures  the  most  rebellious 
cases,  if  the  moisture  be  constantly  preserved.  For  this  purpose  the 
hair  must  be  cautiously  cut  short  with  sharp  scissors,  and  the  razor  care- 
fully avoided.  If  the  side  of  the  cheek  covered  by  the  whisker  be 


THE  TREATMENT  OF  SKIN  DISEASES. 


839 


attacked,  removal  of  the  hair  from  thence  also  is  essential  to  the  treat- 
ment. A bag  or  covering  accurately  adapted  to  the  part  affected  must 
be  made  of  gutta-percha  sheeting,  and  tied  on  with  strings.  This  may 
be  covered  with  a piece  of  black  silk,  to  allow  the  individual  to  go 
about  and  carry  on  his  usual  occupations.  In  this  way  I have  fre- 
quently seen  chronic  impetigo  of  the  chin,  of  from  eight  to  ten  years’ 
standing,  which  has  resisted  all  kinds  of  ointments  and  heroic  remedies, 
completely  removed  in  a few  weeks.  But  then  the  surface  must  be  kept 
constantly  moist,  a circumstance  requiring  great  care  and  determination 
on  the  part  of  the  patient.  When  it  becomes  necessary  to  shave,  flour 
and  warm  water,  or  paste,  should  be  used,  and  not  soap.  Alkalies, 
applied  from  time  to  time  only,  as  in  the  form  of  wash  or  soap,  always 
irritate,  although,  when  employed  continuously,  they  are  soothing. 

Ecthyma  is  not  a common  disease,  and  usually  presents  itself  con- 
joined with  Eczema  or  Impetigo,  and  is  treated  successfully  in  the  same 
manner  as  those  diseases.  The  E.  cachecticum  requires,  in  addition  to 
the  alkaline  wash  locally,  a generous  diet. 

Acne  is  a disease  frequently  requiring  constitutional  rather  than 
local  remedies.  Although  not  uncommon  in  private,  it  is  rare  in  hos- 
pital practice.  Careful  regulation  of  the  diet,  abstinence  from  wine  and 
stimulating  articles  of  food,  watering-places,  baths,  etc.  etc.,  constitute 
the  appropriate  treatment. 

Bupia. — This  disease  I have  never  seen  occur  but  in  individuals 
who  have  been  subjected  to  the  influence  of  mercurial  poisoning. 
Hydriodate  of  potassium  and  tonic  remedies,  with  careful  avoidance  of 
mercury  in  all  its  forms,  is  the  general  treatment  I have  found  most 
successful.  If  the  pustules  be  few  in  number,  the  scabs  may  be  removed 
by  poulticing,  and  the  sores  treated  locally  with  water-dressing  or  red 
wash.  But  if  they  are  numerous,  great  caution  should  be  exercised  in 
exposing  so  many  ulcerated  surfaces,  and  it  is  better  to  let  the  crusts 
remain. 


Papula. 

Lichen  and  Prurigo. — In  both  these  affections,  constant  inunction 
with  lard  is  as  beneficial  as  constant  moisture  in  the  eczematous  and 
impetiginous  disorders.  In  the  prurigo  of  aged  persons,  the  Vng.  JIgd. 
Precip.  Alb.  is  a useful  application,  although  the  disease  is  not  unfre- 
quently  so  rebellious  as  only  to  admit  of  palliation.  The  chronic  papu- 
lar diseases  often  constitute  the  despair  of  the  physician. 

Squama. 

Psoriasis^  and  that  modification  of  it  known  as  lepra^  is  a very  com- 
mon disease,  and  has  been  uniformly  treated  by  me  externally  with 
pitch  ointment.  I have  satisfied  myself,  by  caref^ul  trials,  that  it  is  the 
pitch  applied  to  the  part  that  is  the  beneficial  agent,  as  I have  given 
pitch  pills  and  infusion  of  pitch  largely  internally,  without  benefit. 
With  the  hope  of  obtaining  a less  disagreeable  remedy,  I have  frequently 
tried  creasote,  and  naphtha  ointment,  and  washes,  but  also  without 


840 


DISEASES  OF  THE  INTEGFMENTAEY  SYSTEM. 


benefit.  Lastly,  I have  caused  simple  lard  to  be  rubbed  in  for  a length* 
ened  time,  but  without  doing  the  slightest  good.  The  oil  of  cade  is 
occasionally  useful,  especially  in  psoriasis  of  the  scalp.  Internally,  I 
give  five  drops  of  Fowler’s  solution,  and  as  many  of  the  tr.  cantharidis. 
It  is  rare  that  the  internal  treatment  alone  produces  any  effect  on  a case 
of  psoriasis  of  any  standing.  If  a case  resists  this  conjoined  external 
and  internal  treatment,  I have  always  found  it  incurable.  Some  years 
ago  I carefully  treated  a series  of  cases  internally  with  Donovan’s  solu- 
tion, without  producing  the  slightest  benefit. 

True  Fityriam  frequently  disappears  of  itself.  In  chronic  cases  the 
treatment  by  pitch  is  useful,  and  sometimes  the  application  of  the  Ung. 
Zinci  Oxyd.  or  Ung.  Hyd.  Precip.  Alb.  The  form  of  pityriasis  that  is 
dependent  on  a vegetable  fungus  is  identical  with  favus.  (See  Favus.) 

Ichthyosis. — I have  treated  several  chronic  cases  of  ichthyosis.  But 
while  in  some  cases  the  skin  has  become  a little  softer  from  a course  of 
pitch  treatment,  no  permanent  cure  was  effected. 

Tueerculjs. 

Lupus  is  the  only  kind  of  tubercular  skin  disease  I have  seen  in 
the  skin  ward  of  the  Infirmary,  and  that  is  pretty  common.  It  is  a 
constitutional  disorder,  and  must  be  treated  by  cod-liver  oil,  and  all 
those  remedies  useful  for  scrofula,  of  which  it  is  a local  manifestation. 
The  external  treatment  is  surgical,  consisting  of  the  occasional  applica- 
tion of  caustics,  red  lotion,  water-dressing,  ointments,  etc.,  according  to 
the  appearance  of  the  sore.  I agree  with  Hebra  in  thinking  lupus  and 
the  radesyge  of  the  Norwegians  to  be  the  same  disease.  Many  years 
ago  I found  lupus  of  the  legs  and  thighs  to  exist  among  the  fisher- 
women  of  Newhaven,  who  assisted  their  husbands  in  hauling  in  their 
boats,  or  who  were  accustomed  to  wade  for  any  length  of  time  in  salt 
water. 

Macula. 

Lentigo  I have  never  found  to  be  benefited  by  any  kind  of  treatment, 
local  or  general.  It  is  evidently  connected  with  season  and  the  intensity 
of  the  sun’s  rays,  as  it  often  disappears  in  winter  and  returns  in  summer. 

Bphelis  and  Ncevi  are  alike  incurable.  Bronzing  from  exposure  to 
the  sun,  as  in  hot  climates,  frequently  disappears  on  returning  to  a tem- 
perate latitude. 

Purpura  is  a.  constitutional  disorder,  for  the  most  part  allied  to 
scurvy.  It  consists  ot  an  alteration  of  the  blood,  with  tendency  to  dis- 
integration of  the  colored  corpuscles  and  ditfusion  of  haematozine.  Un- 
der such  circumstances,  ecchymoses  occur  in  the  skin,  sometimes  con- 
fined to  round  spots,  varying  in  size,  at  others  existing  in  patches.  It 
is  for  the  most  part  associated  with  weakness,  and  requires  rest  and  time 
to  permit  absorption  of  the  extravasated  blood,  conjoined  with  tonics, 
anti-scorbutics,  and  generous  diet.  In  sea  scurvy,  lemon  juice  and  fresh 
vegetables  are  the  true  remedies.  (See  Scorbutus.) 

Scalp  diseases  must  be  treated  according  as  they  depend  on  eczema, 


THE  TREATMENT  OF  SKIN  DISEASES. 


841 


impetigo,  psoriasis,  or  favus — in  all  cases  first  removing  the  crusts  with 
poultices,  then  keeping  the  head  shaved,  and,  lastly,  applying  alkaline 
washes,  pitch  ointment,  or  oil,  according  to  the  directions  formerly  given. 
Ringworm  is  a disease  I have  never  seen  in  Edinburgh,  and  of  what  it 
consists  I am  ignorant.  Some  writers  apparently  consider  it  to  be  favus, 
and  others  a form  of  herpes.  On  two  or  three  occasions  I have  seen  a 
scaly  disease  of  the  scalp,  in  the  form  of  a ring — that  is  lepra,  which  I 
have  cured  by  pitch  ointment,  or  oil  of  cade.  Dr.  Andrew  Wood  in- 
formed me  some  time  ago,  that  he  banished  it  from  the  Heriot’s  Hos- 
pital school  of  this  city  by  condensing  on  the  eruption  the  fumes  of 
coarse  brown  paper,  and  thus  causing  an  empyrrheumatic  oil,  or  kind  of 
tar,  to  fall  upon  the  part.  This  at  one  time  led  me  to  suppose  that  it 
might  be  a scaly  disease,  and  a form  of  lepra  or  psoriasis.  On  the 
whole,  I am  inclined  to  think  it  a form  of  favus,  which  has  commonly 
been  mistaken  for  a scaly  disease  of  the  scalp.  (See  Favus.) 

So-called  Syphilitic  diseases  of  the  skin  are,  in  my  opinion,  the 
various  disorders  already  alluded  to,  modified  by  occurring  in  individ- 
uals who  have  suffered  for  periods  more  or  less  long  from  the  poisonous 
action  of  mercury.  A longer  time  will  be  required  for  their  cure,  but 
the  same  remedies  locally,  conjoined  with  hydriodate  of  potassium  in 
small  doses,  with  bitter  infusions,  tonics,  and  a regulated  diet,  offer  the 
best  chance  of  success. 

The  great  difiiculty  in  the  treatment  of  skin  diseases  generally  con- 
sists in  their  having  been  mismanaged  in  the  early  stages — a circum- 
stance I attribute  to  the  little  care  with  which,  until  a recent  period, 
clinical  students  have  studied  them.  Many  chronic  cases  of  eczema  are 
continually  coming  under  my  notice,  which,  in  their  acute  forms,  have 
been  treated  by  citrine  ointment,  or  other  irritating  applications,  that 
almost  invariably  exasperate  the  disorder.  I shall  not  easily  forget  the 
case  of  one  gentleman,  covered  all  over  with  acute  eczema,  who  had 
suffered  excessive  torture  from  its  having  been  mistaken  for  psoriasis, 
and  rubbed  for  some  time  with  pitch  ointment.  In  the  same  way  I have 
seen  a simple  herpes,  which  would  have  readily  got  well  if  left  to  itself, 
converted  into  an  ulcerated  sore  by  the  use  of  mercurial  ointment. 
Nothing  is  more  common  than  to  confound  chronic  eczema  of  the  scalp 
with  favus,  although  the  microscope  furnishes  us  with  the  most  exact 
means  of  diagnosis.  I have  seen  one  case  in  which  a chronic  eczema  of 
the  cheek  was  cut  out  by  a surgeon,  under  the  idea  that  the  disease  was 
malignant.  I presume  that  acne  must  frequently  have  been  mistaken  for 
tubercular  disease.  In  no  other  way  can  I account  for  some  very  dis- 
tressing cases,  where  the  patients’  faces  have  been  painted  over  with  but- 
ter of  antimony.  I need  scarcely  say,  that  the  correct  application  of  the 
remedies  I have  spoken  of  can  only  be  secured  by  an  accurate  discrim- 
ination, in  the  first  instance,  of  the  diseases  to  which  they  are  applicable. 

The  general  constitutional  treatment  in  all  these  cases  seldom  de- 
mands aperient  or  lowering  remedies  except  in  young  and  robust  indi- 
viduals with  febrile  symptoms.  In  the  great  majority  of  cases,  cod- 
liver  oil,  good  diet,  and  tonics  are  required.  In  a few  instances 
sedatives,  both  locally  and  internally,  are  necessary  to  overcome  exces- 
sive itching  or  irritation.  These  the  judicious  practitioner  will  readily 


842 


DISEASES  OF  THE  INTEGUMENTAKY  SYSTEM. 


understand  how  to  apply  according  to  circumstances.  Baths  in  all 
their  various  forms  are  useful  in  skin  diseases,  althougli,  since  I have 
applied  a kind  of  constant  local  bath  in  the  form  of  moist  application, 
formerly  alluded  to  (See  Treatment  of  Eczema),  they  are  comparatively 
seldom  used  by  me  in  the  Infirmary.  The  natural  baths  and  mineral 
springs  of  watering-places  in  Great  Britain,  France,  and  Germany,  are 
undoubtedly  beneficial  in  appropriate  chronic  cases. 

DERMATOZOA. 

The  skin  may  be  attacked  by  certain  animal  parasites.  Of  these 
the  pedicula,  or  lice,  are  too  well  known  to  need  description.  But  we 
may  shortly  allude  to  the  Acarus  scabici,  and  the  Entozoon  follicu- 
lorum. 

Acarus  Scabiei. 

This  insect  has  been  proved  by  the  researches  of  M.  Bourguignon* 
to  be  the  undoubted  cause  of  itch.  The  male  is  about  a third  smaller 


than  the  female.  He  has  suckers  on  two  of  his  hind  feet,  and  possesses 
on  the  abdominal  surface  genital  organs,  all  of  which  characters  are 
* Traite  entomologique  et  pathologique  de  la  gale  de  I’homme.  4to.  Paris,  1852. 

Fig.  484.  Dorsal  surface  of  the  female  Acarus  Scabiei. 

Fig.  485.  Ventral  surface  of  the  same. 

Fig.  486.  Ventral  surface  of  the  male  Acarus. — {Bourguignon.)  100  diam. 


DERMATOZOA. 


843 


absent  in  the  female.  She,  on  the  other  hand,  in  addition  to  her  size, 
and  the  negative  marks  alluded  to,  is  characterised  by  the  three  kinds 
of  horny  spines  which  are  scattered  over  the  back.  The  suckers,  or 
ambulacria,  are  organs  of  locomotion  ; the  mandibles  enable  it  to  cut  the 
epidermis,  and  extract  fluid  from  the  tissue,  which  passes  through  a 
delicate  oesophagus,  the  internal  termination  of  which  is  unknown,  the 
body  of  the  animal  being  apparently  filled  with  an  unorganized,  very 
finely  molecular  pulp.  A short  delicate  tube  may  also  sometimes  be 
observed  at  the  anus — a supposed  rectum.  No  respiratory  apparatus  can 
be  discovered,  although  the  creature  may  be  seen  to  swallow  minute 
bubbles  of  air,  which  pass  down  the  oesophagus,  and,  like  the  nutritive 
juices,  ditfuse  themselves  through  the  interior.  At  all  events,  animal 
juice  and  air  are  both  necessary  to  the  life  of  the  Acarus. 

The  disease  called  scabies  has  been  conclusively  shown  by  M. 
Bourguignon  to  be  entirely  owing  to  the  presence  of  the  insect,  and 
to  be  communicated  from  one  person  to  another,  eight  times  out  of  ten, 
by  their  sleeping  together.  The  female  seldom  quits  her  burrow  but 
at  night,  and  if  impregnated,  not  even  then,  unless  disturbed  mechani- 
cally, as  by  scratching.  Once  in  motion,  she  crawls  over  the  surface 
with  great  rapidity,  and  readily  passes  from  one  person  to  another, 
where  the  skins  are  in  contact.  Communication  is  not  readily  occa- 
sioned by  holding  the  hands  of  those  atfected,  or  by  coming  in  contact 
with  them  during  the  day.  The  disease  cannot  be  communicated  by 
inoculating  with  the  serum  of  the  vesicles,  by  the  pus  of  the  pustules,  or 
by  any  principle  contained  in  the  dead  body  of  the  insect  itself.  Neither 
can  the  Acarus  of  one  species  of  animal,  as  of  the  horse  or  sheep,  inhabit 
the  body  of  a difierent  one.  Still  the  disease  is  not  purely  local,  inas- 
much as  papular,  vesicular,  or  pustular  eruptions  often  occur  in  parts 
which  the  Acarus  has  not  infested,  so  that  they  seem  to  originate  from 
some  cause  independent  of  its  mere  presence. 

The  Acarus  has  a predilection  for  youth  and  a tender  skin,  and 
has  a hatred  of  hair  bulbs.  Hence  why  it  frequents  young  persons 
more  commonly  than  old  ones,  and  why  in  children  it  occurs  indis- 
criminately all  over  the  body,  while  in  adults  it  is  most  often  found 
between  the  fingers  and  toes,  inside  of  the  thighs  and  genital  organs. 
Seventy  times  out  of  a hundred,  scabies  is  confined  to  the  hands,  and  in 
the  other  thirty,  occurs  also  on  the  trunk  and  genitals.  The  only  proof 
of  the  existence  of  itch  is  the  presence  of  the  Acarus,  and  this  is  easily 
to  be  detected  by  a microscope  adapted  for  the  purpose  by  M.  Bourguig- 
non. It  consists  of  a body  with  eye-piece  and  lenses  magnifying  seventy 
diameters  linear,  with  a condensing  lens,  the  whole  placed  on  a movable 
arm  with  several  joints,  attached  to  a firm  stand.  With  this  instrument 
the  entire  surface  of  the  body  may  be  explored,  and  the  movements  and 
doings  of  the  insects  observed  with  the  utmost  facility.  The  associated 
papules,  vesicles,  and  pustules  are,  in  the  opinion  of  M.  Bourguignon, 
in  no  way  diagnostic. 

M.  Biett  made  a series  of  experiments  at  the  Hopital  St.  Louis,  to 
determine  what  substance  would  cure  itch  in  the  shortest  space  of  time. 
He  employed  forty-one  difierent  applications  and  modes  of  treatment. 
The  result  was,  that  frictions  with  the  following  ointment  occasioned 


844 


DISEASES  OF  THE  INTEGUMENTARY  SYSTEM. 


recovery  on  the  average  in  the  smallest  number  of  days  : — Take  of  sub- 
limed sulphur,  two  parts ; of  subcarbonate  of  potash,  one  part ; and  of 
lard,  eight  parts. 

M.  Albin  Grass  endeavored  to  ascertain  what  substances  would 
most  quickly  destroy  the  Acarus  just  removed  from  its  burrow.  It 
survived  three  hours  in  water ; two  in  olive  oil ; one  in  a solution  of 
acetate  of  lead ; four-fifths  of  an  hour  in  warm  water  ; twenty  minutes 
in  vinegar  and  an  alkaline  solution ; twelve  minutes  in  a solution  of 
sulphuret  of  potash ; nine  minutes  in  turpentine  ; and  from  four  to  six 
minutes  in  a solution  of  the  hydriodate  of  potash.  It  survived  sixteen 
hours  in  the  vapor  of  sulphur  under  a watch-glass ; and  one  hour  in 
the  flowers  of  sulphur.  According  to  these  researches,  therefore,  hydrio- 
date of  potash  would  be  the  best  remedy.  He  removed  three  living 
insects  from  a patient  who  had  taken  three  sulphur  baths,  whereas,  after 
a single  application  of  Helmerinch’s  ointment,  that  is,  where  sulphur 
and  potash  are  combined,  he  frequently  found  them  dead. 

M.  Bourguignon  with  his  microscope  watched  with  great  care  the 
effect  of  the  frictions  made  at  St.  Louis  with  the  sulphuro-alkaline 
ointment.  After  the  first  day,  in  which  there  had  been  two  frictions 
and  a simple  bath,  the  Acari  were  in  no  way  disturbed.  In  two  days, 
after  four  frictions,  they  were  still  active,  but  burrowed  deep  in  their 
grooves.  In  three  days  they  still  lived,  but  were  unusually  flat ; but 
their  eggs  could  be  hatched  by  artificial  heat,  and  produced  larvae, 
possessing  great  activity.  In  four  days  the  insects  in  the  superficial 
parts  were  shrivelled  up  and  dead  ; the  deeper  ones,  though  living, 
tres  malades.  Many  of  the  eggs  now  aborted.  In  five  days  all  the 
insects  were  dead  ; and  in  six  even  the  eggs  had  lost  their  vitality. 
The  eruptions,  on  the  other  hand,  often  remained  stationary,  and  not 
unfrequently  became  worse  from  the  irritation  of  the  ointment  and 
frictions,  but  after  a time  they  disappear  also.  Hence  it  is  common 
at  St.  Louis,  after  seven  or  eight  days’  friction,  to  send  out  the  patients 
though  still  covered  with  eruption,  and  in  most  cases  they  get  well. 
About  three  in  ten,  however,  return  with  the  disease  again  established, 
a circumstance  that  Mons.  B.  attributes  to  the  fact,  that  the  frictions, 
which  were  only  applied  to  the  superior  and  inferior  extremities,  had 
not  destroyed  the  insects  which  were  present  on  the  trunk. 

M.  Bourguignon,  on  considering  the  structure  of  these  Acari,  and 
the  facility  with  which  a poisoning  fluid  could  penetrate  their  delicate 
integument,  was  led  to  make  a series  of  observations  to  determine  how 
long  they  would  live  after  the  application  of  various  toxic  solutions. 
He  found  those  which  possessed  the  most  energetic  action  on  these 
creatures  were  solutions  of  the  ioduret  of  potassium  and  of  the  ioduret 
of  sulphur,  which  killed  them  in  eight  minutes.  A solution  of  the 
alcoholic  extract  of  staphisagria  was  the  next  in  virulence,  destroying 
the  animals  in  fifteen  minutes.  The  hands  of  an  itch  patient  were 
immersed  in  a solution  of  the  two  former  for  two  hours,  so  as  strongly 
to  impregnate  and  color  the  integuments.  On  examining  the  insects 
immediately  afterwards,  they  were  as  lively  as  ever,  but  on  the  next  day 
they  were  all  dead,  and  the  eggs  destroyed.  The  epidermis  was  greatly 
shrivelled,  and  in  three  days  complete  desquamation  occurred,  carrying 


DERMATOZOA. 


845 


with  it  Acari,  grooves,  and  eggs,  and  leaving  the  cutis  raw  and  tender. 
The  action  on  the  skin  was  evidently  too  strong.  A bath  of  a solution 
of  the  alcoholic  extract  of  staphisagria  was  then  made,  and  immediately 
after  a two  hours’  immersion  of  the  hands,  all  the  insects  were  found 
dead,  and,  with  one  exception,  the  eggs  destroyed.  So  far  from  irritat- 
ing the  integument,  this  application  at  once  caused  the  itching  to  cease, 
and  produced  such  calmative  effects,  that  M.  B.  proposes  it  as  a local] 
remedy  for  inflammation.  The  eruptions  also  appeared  to  be  rapidly 
cured  by  it.  After  various  experiments,  he  adopted  an  ointment  of  the 
staphisagria  as  the  most  generally  useful  preparation,  prepared  as  fol- 
lows : — Recent  grains  of  staphisagria  in  powder,  300  grammes ; boiling 
lard,  500  grammes.  Digest  for  24  hours  at  the  temperature  of  100°  in 
a sand  bath  and  strain.  Four  days  of  friction  with  this  ointment,  in- 
stead of  seven  with  sulphuro-alkaline  ointment,  not  only  destroys  the 
insects  and  their  egg?,  but  completely  cures  and  prevents  the  integu- 
mentary irritation  and  eruptions. 


Entozoon  Folliculorum. 


This  insect  inhabits  the  sebaceous  follicles  of  the  skin,  and  is  very 
common  in  the  face,  more  especially  when  the  seat  of  acne.  In  the 


Fig.  487. 


Pig.  488. 


follicles  of  the  nose  they  are  present  in  the  majority  of  living  persons. 


Fig.  48 Y.  Three  follicles  of  the  skin  of  the  dog  containing  entozoa.  100  diam. 
Fig.  488.  Cul-de-sac  of  a sebaceous  follicle,  containing  three  animalcules  in 
different  positions,  and  two  eggs — (after  Oruhy).  350  diam. 


846 


DISEASES  OF  THE  INTEGUMENTAEY  SYSTEM. 


and,  according  to  Simon,  are  almost  universal  in  dead  bodies.  He 
frequently  found  them  living  six  days  after  the  death  of  the  individual 
in  whom  they  were  found.  The  animal  measures  from  l-135th  to 
l-64th  of  an  inch  in  length,  and  from  l-155th  to  l-555th  of  an  inch 
in  breadth.  It  is  composed  of  a head,  a thorax,  and  abdomen. 

The  head  represents  in  form  a truncated  cone,  flattened  from  above 
downwards,  and  directed  obliquely  downwards  from  the  anterior  part  of 
the  trunk.  The  existence  of  an  eye  has  not 
been  determined.  The  head  is  furnished 
with  two  maxillary  palpi,  which  admit  of 
extensive  motion.  The  thorax  is  the  broadest 
part  of  the  animal,  and  is  composed  of  four 
segments.  In  each  of  these,  on  each  side 
are  two  legs — eight  in  all.  The  abdomen 
varies  in  length,  is  annulated  in  structure, 
and  admits  of  certain  movements.  Inter- 
nally Dr.  Erasmus  Wilson  has  traced  out  an 
alimentary  canal,  and  its  termination  in  an 
anus,  together  with  a brownish  mass  which 
he  considers  to  be  the  liver.  No  sexual 
differences  have  been  discovered  in  them,  and 
they  possess  no  respiratory  organs. 

The  animalcule  is  easily  found  by  com- 
pressing with  two  fingers  the  skin  we  wish 
to  examine,  until  the  sebaceous  matter  is 
squeezed  out,  in  the  form  of  a little  worm. 
This  matter  should  be  placed  in  a drop  of  oil 
previously  heated,  then  separated  with 
needles,  and  examined  with  a microscope 
magnifying  250  diameters.  Their  move- 
ments are  slow,  whilst  the  conformation  of 
their  articulations  only  permits  them  to 
move  forwards  and  backwards,  like  lobsters 
(Gruby).  They  are  nourished  by  the  seba- 
ceous secretion  of  the  follicles. 

They  most  commonly  occupy  the  excre- 
tory duct  of  the  follicles,  which  are  often 
dilated  in  the  places  where  they  are  lodged. 
Their  head  is  always  directed  towards  the 
base  of  the  gland.  When  there  are  many 
together,  they  are  placed  back  to  back,  and 
their  feet  are  applied  against  the  walls  of  the 
duct.  When  very  numerous,  they  are  compressed  closely  together,  and 
are  found  deeper  in  the  ducts.  They  rarely  exist,  however,  at  the  base 
of  the  gland.  In  young  persons  they  generally  vary  in  number  from  two 
to  four ; in  an  aged  individual,  they  may  be  from  ten  to  twenty.  (Gruby). 

Though  this  entozoon  may  occasionally  be  associated  with  acne,  it 
seldom  gives  rise  to  great  inconvenience.  According  to  Erasmus  Wilson, 

Fi".  489.  Hair  and  its  follicle,  in  which  may  be  seen  the  animalcules  descending 
towards  the  root  of  the  hair,  and  cul-de-sac  of  the  follicles. — {Gruby.)  100  diam. 


DEKMATOPHYTA. 


847 


the  difficulty  seems  not  to  be  to  find  these  creatures,  but  to  find  any 
individual,  with  the  exception  of  newly-born  children,  in  whom  they  do 
not  exist'. 


DEKMATOPHYTA. 

The  growth  of  parasitic  fungi  on  the  surface  of  the  skin  has  now 
been  observed  under  a variety  of  circumstances,  and  constitutes  occasion- 
ally in  man  three  forms  of  skin  disease — viz.,  taenia  favosa,  and  certain 
forms  of  pityriasis  and  of  mentagra.  The  latter  is  very  rare  in  this 
country ; and  I have  never  seen  a case  of  it.  All  these  disorders, 
however,  may  be  classified  under  the  head  of  favus,  under  which  I shall 
consider  them. 


Favus. 

Case  CXCIL* — Favus  of  the  Scalp  in  an  Adult — Incurahle. 

History. — Isabella  Fergusson,  set.  22,  a somewhat  stout  servant  girl,  with  fair 
skin,  and  scrofulous  aspect,  was  admitted  into  the  clinical  ward  of  the  Royal  Infir- 
mary, May  6th,  1849.  She  states  that  there  has  been  an  eruption  on  her  head  for  the 
last  twelve  years.  Four  months  ago  the  catamenia  ceased,  since  which  time  she  has 
been  subject  to  occasional  headache,  constipation,  and  slight  dyspepsia. 

Symptoms  on  Admission. — Nearly  the  whole  of  the  scalp  is  covered  with  a thick 
yellow  friable  crust,  of  uneven  surface,  and  irregular  margin,  emitting  a highly  offen- 
sive odor,  like  cat’s  m*ine,  and  causing  great  itching  and  irritation.  Up  to  the 
middle  of  July  she  was  treated  with  various  internal  remedies,  which  subdued  the 
constipation  and  dyspepsia,  and  caused  return  of  the  catamenia.  The  crusts  on  the 
scalp  were  removed  by  poultices,  and  an  ointment  composed  of  ammon.  mur.  § j ; 
and  ung.  sulphuris  § j,  applied  locally.  Dr.  Bennett  first  took  charge  of  the  case  on 
the  14th  of  June.  The  head  was  then  again  covered  with  favus  crusts,  some  isolated, 
others  compressed  together  .and  forming  an  elevated  scab.  A small  portion,  examined 
under  the  microscope,  presented  the  branches  and  sporules  of  the  cryptogamic  plant 
so  characteristic  of  the  disease.  The  crusts  were  again  removed  hg  poultices  of  linseed 
meal^  the  head  shaved,  ana  cod-liver  oil  ordered  to  be  applied  to  the  scalp  morning  and 
evening — the  whole  to  he  covered  with  an  oil-silk  cap.  This  treatment  was  continued 
for  six  weeks,  but  on  suspending  it  the  favus  crusts  returned.  During  the  months  of 
August  and  September,  iodine  and  pitch  ointments  were  applied : portions  of  the 
scalp  were  even  blistered,  but  without  effect. 

Progress  of  the  Case. — At  the  commencement  of  October,  the  scalp  being  at  the 
time  perfectly  clean  and  closely  shaved,  all  local  treatment  was  suspended,  and  the 
reappearance  of  the  disease  carefully  watched.  In  three  days  the  entire  surface  pre- 
sented a scaly  eruption,  the  epidermis  being  raised,  cracked,  and  broken  up  over  the 
whole  scalp,  which  was  exceedingly  dry  and  harsh.  The  furfuraceous  condition  of 
the  scalp  continued,  becoming  more  and  more  dense,  until  the  fourteenth  day,  when 
there  were  first  perceived  minute  bright  sulphur-colored  spots  in  it.  These,  on  being 
examined  microscopically,  were  seen  to  be  composed  of  fine  molecular  matter,  mingled 
with  epidermic  scales,  from  which  delicate  branched  tubes  were  apparently  growing.  The 
crusts  were  now  once  more  removed  by  repeated  poulticing,  and  cod-liver  oil  applied 
as  formerly  The  scalp  continued  free  from  eruption  until  the  20th  of  November,  when 
she  was  seized  with  febrile  symptoms,  which  ushered  in  a very  severe  attack  of  typhus, 
that  ran  its  usual  course.  She  was  not  considered  fully  convalescent  until  the  8^/i  of 
December.  During  this  period,  no  local  application  was  made  to  the  scalp,  with  the 
exception  of  the  cold  douche  to  alleviate  the  head  symptoms,  delirium  and  coma  hav- 
ing been  severe.  The  surface  latterly  once  more  became  covered  with  furfuraceous 
scales  ; and  on  the  Wth  December  the  bright  yellow  minute  spots  again  made  their 
appearance.  As  her  strength  improved,  the  favus  crusts  increased  in  size  and  num- 
ber, and  the  progress  of  this  very  singular  disease  was  again  very  carefully  watched. 
Each  individual  crust,  at  first  the  size  of  a small  pin’s  head,  gradually  flattened  out, 


* Reported  by  Mr.  William  Johnston,  Clinical  Clerk. 


848 


DISEASES  OP  THE  INTEGUMENTARY  SYSTEM. 


and  became  circular.  Its  centre  was  cupped  and  umbilicated,  and  many,  which  were 
more  isolated  than  the  rest,  grew  until  they  measured  a quarter  of  an  inch  in  diame- 
ter. More  generally,  however,  they  came  in  contact  with  others,  and  groups  of  twos 
or  threes,  and  sometimes  a dozen,  became  compressed  together  and  presented  the 
hexagonal  foi’m  of  the  honey-comb.  Gradually  the  concavity  disappeared.  Each 
crust  presented  an  external  dark  ring,  and  an  internal  lighter  centre,  which  became 
considerably  elevated.  Tlie  various  groups  became  aggregated  together,  and  she 
complained  of  great  itching  and  irritation,  and  it  was  evident  that,  if  allowed  to 
proceed  further,  the  condition  she  presented  on  admission  would  be  soon  produced. 
The  crusts  were,  therefore,  again  removed  by  poultices,  cod-liver  oil  once  more  applied, 
and  the  scalp  remained  clean  and  free  from  irritation  until  \1th  January ^ when  the 
cure  appearing  to  be  hopeless  she  was  dismissed.  She  was  enjoined  to  continue  the 
use  of  the  oil,  which,  whilst  applied,  and  covered  with  the  oil-silk  cap,  had  the  power 
of  preventing  the  formation  of  fresh  crasts  on  the  scalp. 

Case  CXCIII.^ — Fatus  of  the  Scalp  of  three  years'  standing — Cured. 

History. — Margaret  Bryer,  set.  12,  of  scrofulous  and  cachectic  appearance,  was  ad- 
mitted June  19th,  1849,  with  favus  crust  on  the  scalp.  The  crusts  are  most  numer- 
ous and  dense  on  the  crown  of  the  head  ; but  others,  isolated  or  in  small  groups,  are 
scattered  over  the  temples,  forehead,  and  occiput.  The  scalp  is  bald  here  and  there 
in  patches,  varying  in  diameter  from  half  an  inch  to  an  inch.  On  examining  the  crusts 
microscopically,  they  are  seen  to  contain  the  cryptcgamic  branches  and  sporules 
pathognomonic  of  favus.  The  disease  is  of  three  years’  standing,  and  is  attributed  to 
the  use  of  a comb,  belonging  to  another  girl  who  had  a sore  head.  The  crusts  have 
been  several  times  removed  by  means  of  pitch  plasters  and  a variety  of  ointments,  but 
have  always  returned. 

Progress  of  the  Case. — At  first,  the  crusts  were  removed  and  the  scalp  kept  moist 
by  means  of  an  alkaline  lotion,  which  succeeded  in  removing  the  irritation.  Early  in 
July  she  was  ordered  § ss  of  cod-liver  oil  three  times  a day.  The  oil  was  also  directed  to 
be  applied  to  the  shaved  scalp  twice  daily.,  which  was  to  he  Tcept  constantly  covered  with 
an  oil-silk  cap.  This  treatment  was  persevered  in  until  Augxist  lO^A,  when  she  w'as 
dismissed  cured.  This  girl  was  re-admitted  September  hth.,  and  remained  in  the  In- 
firmary five  days,  under  observation.  Up  to  this  time  the  disease  had  not  re-appeared, 
so  that,  when  dismissed  on  the  lO^A,  a permanent  cure  was  undoubtedly  produced. 

Case  C'K.CIY  Favus  caught  in  the  Ward  from  Case  Cured. 

History. — Margaret  Cameron,  aet.  6,  an  ill-nourished,  cachectic-looking  child — 
admitted  July  23d,  1849,  on  account  of  an  eruption  on  the  scalp.  In  some  places 
the  hair  was  matted  together  by  a recent  pustular  eruption  ; groups  of  impetiginous 
pustules  and  eczematous  vesicles  being  scattered  here  and  there.  In  others,  where 
the  disease  was  chronic,  hard,  nodulated,  elevated  masses,  and  friable  crusts 
existed.  The  disease  was  eczema  impetiginodes.  No  favus  was  present,  as  was  proved 
by  careful  examination,  and  microscopic  demonstrations  of  the  scabs.  Poultices  were 
ordered  to  the  scalp.,  to  remove  the  crusts  ; and  afterwards  an  alkaline  wash.,  with  cod- 
liver  oil  internally. 

Progress  op  the  Case. — My  colleagues  taking  charge  of  the  ward  during  the 
months  of  August  and  September,  I lost  sight  of  this  patient ; but,  on  resuming 
duty  in  the  beginning  of  October,  I was  surprised  to  find  the  child’s  head  covered 
with  favus  crusts,  with  the  branches  and  sporules  fully  developed,  as  proved  by  the 
microscope.  It  appeared  that  the  girl  was  a great  favorite  with  Isabella  Fergusson 
(Case  CXCII.),  and  frequently  slept  in  her  bed,  and  there  can  be  little  doubt  she 
had  caught  favus  from  her.  The  child’s  general  health,  however,  had  greatly  im- 
proved ; and  the  crusts  were  ordered  to  be  removed  by  poultices,  the  head  shaved,  and 
cod-liver  oil  applied  locally  twice  daily,  and  an  oil-silk  cap  to  be  worn  constantly. 
This  treatment  was  continued  for  seven  weeks.  At  the  end  of  that  time  all  treat- 
ment was  suspended,  and  the  scalp  watched  daily.  In  fifteen  days  the  head  was 
covered  with  a slight  furfuraceous  desquamation  ; but  the  hair  was  abundant. 
Another  w^eek  elapsed  without  any  return  of  favus ; and,  her  health  being  now  good, 
she  was  discharged,  December  Uh. 


* Reported  by  Dr.  J.  Smith,  Clinical  Clerk. 

\ Reported  by  Mr.  Alexander  Struthers,  Clinical  Clerk. 


FAVUS. 


849 


Case  CXC  V.* — Favus  of  the  Scalp  of  four  years'^  standing^  cured  hy  a 
Sulphurous  Acid  Lotion. 

History. — Helen  Goodall,  aet.  15 — admitted  November  3d,  1853.  She  has  been 
affected  with  favus  of  the  scalp  for  four  years,  and  frequently  been  in  the  Infirmary, 
and  subjected  to  various  kinds  of  treatment,  under  different  physicians,  without  any 
permanent  benefit.  On  admission,  a great  part  of  the  scalp  was  bald,  from  destruc- 
tion of  the  hair  bulbs,  but  the  other  portions  were  covered  with  a prominent  yellow 
friable  crust,  of  mousey  odor,  crowded  with  pediculi.  On  the  ^th  of  November  a 
lotion,  composed  of  one  part  of  sulphurous  acid  and  three  parts  of  water,  was  con- 
stantly applied  by  means  of  lint  saturated  in  it,  and  covered  with  an  oil-skin  cap.  It 
was  suspended  December  23c?,  leaving  the  scalp  partly  bald,  but  quite  clean.  On  the 
\UK  of  January  1854,  the  disease  had  not  returned.  The  scalp  was  then  rubbed 
over  with  the  oil  of  cade,  twice  daily,  to  remove  the  squamous  eruption,  and  she  was 
dismissed  apparently  quite  cured,  February  bth. 

Case  CXCVI.f — Limited  Favus  of  the  Cheehy  cured  hy  Cauterization 
with  Nitrate  of  Silver. 

History. — James  Scott,  set.  15,  a painter,  applied  for  advice,  January  2Yth,  1850. 
He  states  that,  a week  ago,  without  any  known  cause,  he  observed  a small  spot, 
about  the  size  of  a pin’s  head,  over  the  external  angle  of  the  left  malar  bone.  On 
examination,  a circular  reddened  spot  about  the  size  of  a shilling  is  seen  over  the  ex- 
ternal angle  of  the  left  malar  bone,  in  the  centre  of  which  were  several  favus  crusts, 
aggregated  together.  These,  examined  under  the  microscope,  presented  the  branches 
and  sporules  pathognomonic  of  the  disease.  The  whole  was  then  well  cauterized  with 
nitrate  of  silver^  and  was  cured  at  once. 

Commentary. — Of  the  five  cases  of  favus  now  given,  the  first  was 
that  of  an  adult,  and  was  of  twelve  years’  standing.  By  means  of 
poultices  and  excluding  the  air,  with  oily  applications,  the  scalp  could 
easily  be  freed  from  the  eruption  and  kept  so ; but  as  soon  as  these 
means  were  discontinued,  the  disease  returned.  The  second  and  third 
cases  were  permanently  cured  by  the  constant  application  of  oil  to  the 
scalp  for  six  or  seven  weeks.  They  were  children  of  the  ages  of  twelve 
and  five  years  respectively.  In  the  former  the  disease  was  of  three 

years’  standing ; in  the  latter,  it  was  altogether  recent,  and  caught  from 
another  case  in  the  ward.  The  fourth  case  was  cured  by  using  a sulphu- 
rous acid  lotion  instead  of  oil — a practice  recommended  by  Br.  Jenner, 
in  consequence  of  the  powerful  effect  possessed  by  this  acid  in  destroy- 
ing vegetable  growths.  In  the  fifth  case,  the  disease  was  limited,  and 
was  at  once  destroyed  by  means  of  caustic.  It  is  rare  that  favus  can  be 
watched  through  its  entire  progress  in  the  wards  of  a hospital — first, 
because  the  disease  commonly  lasts  months,  often  years,  and  charitable 
institutions  cannot  support  individuals  so  long;  and,  secondly,  because  it 
always  happens,  that  when  urgent  cases  demand  admission,  and  beds  are 
required,  these  are  just  the  parties  who  are  discharged  to  make  room  for 
them.  At  the  same  time,  the  disease  is  so  common  in  Edinburgh,  that 
the  wards  are  seldom  free  of  one  or  more  examples  of  it  in  various  stages. 
Besides,  by  poulticing  off  the  crusts,  and  allowing  the  eruption  to  come 
back,  its  commencement  and  progress  may  be  studied  in  any  individual 
case. 


54 


* Reported  by  Mr.  P.  W.  Wallace,  Clinical  Clerk, 
f Reported  by  Mr.  Hugh  Balfour,  Clinical  Clerk. 


850 


DISEASES  OF  THE  INTEGTJMENTAEY  SYSTEM. 


History  of  Favus  as  a Vegetable  Parasite — (Achorion  Schonleinii  of 

Link) 

The  demonstration  by  Bassi*  of  the  vegetable  nature  of  the  disease 
named  muscardine  in  silk  worms,  which  causes  so  great  a mortality 
amongst  those  animals,  opened  up  to  pathologists  a new  field  for  observa- 
tion, and  led  to  the  discovery  that  certain  disorders  in  the  higher 
animals,  and  even  in  man  himself,  were  connected  with  the  growth  of 
parasitic  plants  of  a low  type.  Schdnlein,t  of  Berlin,  was  the  first  to 
detect  them  in  favus  crusts — an  observation  confirmed  by  Bemak,J 
Fuchs,  and  Langenbeck.^  Grruby||  gave  a very  perfect  description  of 
these  vegetations  in  1841,  and  made  numerous  researches  as  to  their 
seat,  origin,  and  mode  of  propagation.  These  were  repeated  by  myself, 
and  further  extended  in  1842. H In  1845  I succeeded  in  inoculating 
the  disease  in  the  human  subject.  Since  then  they  have  been  made  the 
subject  of  further  investigation  by  Lebert,^*  Remak,tt  Robin, and 
numerous  other  inquirers,  to  whose  observations  I shall  have  occasion  to 
allude  subsequently. 

Mode  of  Development  and  Symptoms  of  Favus. 

By  most  writers,  amongst  whom  may  be  cited  Willan,  Bateman, 
Biett,  and  Rayer,  favus  is  described  as  commencing  in  a pustule,  which 
breaks  and  forms  the  peculiar  scab.  Others,  such  as  Baudelocque, 
Alibert,  and  Gibert,  deny  its  pustular  nature,  and  state  that  it  commences 
in  a crust.  But  numerous  observations  have  satisfied  me  that  the  for- 
mation of  pustules  is  not  essential  to  the  disease,  although  they  are  often 
present.  Hence  the  mistake  of  those  pathologists  who  classified  favus 
amongst  the  pustulas.  M.  Gruby  says  that  they  are  never  present,  which 
is  equally  erroneous,  although  they  appear  to  be  a secondary  result, 
attributable  to  the  irritation  the  disease  produces  in  some  individuals.^i^ 
On  the  other  hand,  I have  never  seen  this  affection  produced  without 
having  been  preceded  by  desquamation  of  the  cuticle,  an  observation 
which  appears  to  me  of  some  importance  in  explaining  the  origin  of  the 
disease,  as  we  shall  subsequently  see.  Occasionally,  also,  the  scales  form 
a thick  mass,  and  the  favus  matter  is  more  disseminated,  and  does  not 
form  the  distinct  umbilicated  crusts.  This  constitutes  the  parasitic  pity- 
riasis of  some  writers. 

After  removing  the  favus  crusts  by  poulticing,  and  then  watching 

* Del.  Mai.  del  Segno  Calcinaccio  o Muscardino.  Milano,  1837. 

f Muller’s  Archives.  1836.  f Medicinishe  Zeitung.  1840. 

§ Comptes  Rendus  de  la  Polyclinique  de  Gottingen. 

II  Comptes  Rendus,  tom.  xiii.  pp.  72  and  309.  1841. 

^ On  Parasitic  Vegetable  Structures  found  Growing  in  Living  Animals.  Edin- 
burgh Philosophical  Transactions,  vol.  xv.  p.  277.  1842.  Monthly  Journal,  June 

1842. 

**  Physiologie  Pathologique,  tom.  ii.  1845. 

+f  Diagnostiche  und  Pathogenische  Untersuchungen.  1845. 

iff  Des  Vegetaux  qui  croissent  sur  THomme,  etc.  1847. 

§§  This  explanation  of  the  origin  of  pustules  and  purulent  matter,  when  present, 
has  been  adopted  by  Lebert,  Rcmak,  and  Simon. 


FAVUS. 


851 


from  day 'to  day  how  the  disease  returns,  it  will  he  seen  that  the  first 
morbid  change  is  increased  vascularity  of  the  skin,  accompanied  with  a 
desquamation  of  the  cuticle;  and  that  in  a period  varying  from  twelve 
to  fourteen  days,  small  spots  of  a bright  yellow  color,  like  that  of 
sulphur,  may  be  detected.  These  gradually  augment  in  size,  but  even 
at  the  earliest  period  may  be  observed,  with  a lens,  to  have  a central 
depression,  through  which  a hair  may  generally  be  observed  to  pass.  The 
crust  or  capsule  niay  enlarge  to  about  the  size  of  a shilling,  and  if  it  be 
isolated,  still  retain  its  rounded  form.  Usually,  however,  its  edges 
come  in  contact  with  other  capsules,  and  then  it  loses  its  rounded  shape, 
and  assumes  the  hexagonal  and  honey-combed  appearances  described  by 
authors.  I consider,  then,  that  the  so-called  Porrigo  lupinosa,  and 
Porrigo  favosa,  constituting  distinct  forms  or  varieties  of  some  writers, 
are  merely  different  stages  of  the  same  disease,  and  dependent  upon  the 
greater  or  less  aggregation  of  the  crusts.  On  the  first  appearance  of  the 
a he 


Fig.  490. 

capsule,  its  edges  are  somewhat  depressed  below  the  surface  of  the  cuticle ; 
but  as  it  increases  in  size,  the  margins  become  more  and  more  elevated 
and  prominent,  whilst  a series  of  concentric  rings  or  grooves  may  be  ob- 
served in  them.  At  first,  also,  the  whole  capsule  appears  of  a homo- 
geneous bright  yellow,  but  when  further  developed,  its  centre  assumes  a 
whiter  color.  This  arises  from  the  aggregation  of  the  sporules  of  the 
plant,  which  are  more  abundant  in  this  situation.  As  the  development 

Fig.  490.  a,  Isolated  crusts  of  Favus,  presenting  the  lupine  seed  like  depression  in 
different  stages  of  growth  (so-called  Porrigo  lupinosa) ; some  are  arranged  in  groups 
of  twos  and  threes.  6,  A larger  group  of  these  crusts,  somewhat  compressed  at  the 
sides,  like  a honeycomb  {Porrigo  favosa),  c.  Another  group,  which  occurred  on  the 
shoulder  of  a young  girl.  No  hairs  passed  through  the  centre  of  these  crusts,  c?, 
Large  isolated  crusts  in  an  advanced  state  of  growth,  the  external  ring  is  cracked,  and 
the  friable  centre  is  enlarged  and  elevated,  e,  Numerous  crusts  aggregated  together, 
so  as  to  form  an  irregular  elevated  mass.  Traces  of  the  original  form  may  be  observed 
in  the  cracked  rings  round  the  margin.  {Natural  size.) 


852 


DISEASES  OF  THE  INTEGUMENTARY  SYSTEM. 


proceeds,  this  central  whitish  yellow  mass  assumes  a mealy,  powdery  con- 
sistence, and  encroaches  upon  the  edges  of  the  capsule,  which  gradually 
disappear,  whilst  its  upper  concave  form  becomes  convex,  as  Gruby 
pointed  out.  In  general,  an  inflammatory  ring  is  seen  round  the  crust, 
which,  as  the  capsule  becomes  elevated  above  the  skin,  enlarges,  and 
assumes  a deeper  color,  indicative  of  the  increased  local  irritation.  At 
length  the  whole  cracks  or  splits  up;  all  regular  form  is  lost;  a dense 
thick  crust  covers  the  scalp  ; an  odor,  like  the  urine  of  cats  or  mice,  is 
evolved ; and,  in  chronic  cases,  vermin  deposit  their  eggs  in  the  inter- 
stices, and  crawl  in  large  numbers  over  the  surface. 

I have  satisfied  myself  that  occasionally  the  disease,  instead  of  pre- 
senting distinct  capsules  round  hair  bulbs,  becomes  diffused  under  the 
epidermis,  which  then  assumes  the  appearance  of  pityriasis,  and  not  un- 
frequently  of  chronic  eczema.  A microscopic  examination,  however,  will 
in  such  cases  always  detect  groups  of  sporules  and  thalli  more  or  less 
developed.  In  one  instance  I found  the  sporules  smaller  than  usual, 
and  perfectly  globular  instead  of  oval.  In  others  I have  seen  the 
sporules  three  or  four  times  larger  than  those  of  ordinary  favus,  with  in- 
cluded nuclei,  multiplying  fissiparously.  Hence  the  so-called  parasitic 
pityriasis  of  the  scalp  I believe  to  be  a modification  of  favus,  and  con- 
sider it  a good  rule,  in  all  chronic  eruptions  on  the  head,  to  examine  the 
crusts  microscopically. 

The  other  local  symptoms  are  merely  those  which  result  from  the 
greater  or  less  degree  of  irritation  produced  in  different  persons  by  the 
changes  above  referred  to.  At  first,  scarcely  any  uneasiness  is  felt ; 
perhaps  occasional  slight  itching  of  the  part.  As  the  disease  pro- 
gresses, however,  the  itching  becomes  more  intolerable,  and  induces  the 
patient  to  rub  and  scratch  the  scalp.  By  these  means,  several  of  the 
crusts  are  forcibly  torn  from  their  attachments,  and  considerable  effusion 
of  serous  fluid  and  blood  is  produced.  Sometimes  inflammation  is  thus 
occasioned.  Impetiginous  pustules  are  frequently  formed,  or  suppura- 
tion produced,  terminating  in  ulceration,  and  the  discharge  of  an 
ichorous  fluid  from  beneath  the  crusts.  At  an  advanced  stage  of  the 
disease,  the  peculiarly  offensive  odor  exhaled  is  insupportable  to  those 
who  surround  the  individual,  and  the  ichorous  discharge,  vermin,  and 
crusts,  which  cover  the  affected  parts,  present  a most  disgusting  appear- 
ance. 

Although  the  disease  most  commonly  attacks  the  hairy  scalp,  it  may 
occur  on  the  forehead,  temples,  cheeks,  nose,  chin,  ears,  shoulders,  arms, 
abdomen,  lumbar  region,  sacrum,  knees,  and  legs.  Alibert  gives  a plate 
in  which  it  is  figured  in  all  these  situations.  I have  myself  seen  it  on 
the  cheek,  shoulders,  back,  arms,  and  inferior  extremities,  and  in  some 
of  these  situations  I could  detect  no  hairs  perforating  the  capsules.  (Fig. 
490,  c.) 

The  constitutional  symptoms  are  of  the  utmost  importance,  but, 
generally  speaking,  receive  little  attention  from  practitioners.  In  most 
of  the  individuals  affected,  who  have  come  undhr  my  notice,  the 
general  health  has  been  greatly  deranged,  and  a scrofulous  or  cachectic 
constitution  more  or  less  evident.  In  some  the  facies  scrofulosa  of 
authors  has-  been  well  marked ; in  others  there  were  engorgements  of 


FAVUS. 


853 


the  lymphatic  glands  of  the  neck ; and  in  the  only  fatal  case  which  has 
come  under  my  observation,  there  were  found  tubercular  depositions  in 
the  lungs,  mesenteric  glands,  and  other  textures.  Indeed,  the  gener- 
ality of  individuals  who  die  laboring  under  favus,  perish  from  phthisis, 
or  other  forms  of  tubercular  disease.  The  beautiful  plates  published  by 
Alibert  are  in  this  respect  far  from  being  true  to  nature  ; for  whilst  the 
capsules  and  crusts  are  accurately  drawn,  the  individuals  affected  seem 
to  be  ideal  personages,  enjoying  the  most  robust  health,  and  possessing 
even  the  utmost  beauty  of  form  and  feature.  In  the  generality  of  cases, 
on  the  contrary,  the  patient  is  thin,  the  countenance  is  of  a dirty  yellow 
color,  and  the  whole  aspect  betrays  depression  of  the  vital  powers.  The 
appetite  is  often  impaired,  the  alvine  evacuations  irregular,  and  the  func- 
tions of  digestion  and  nutrition  are  impeded.  Numerous  writers  have 
observed  the  physical  and  mental  development  of  the  individual  to  be 
retarded;  and  Alibert  gives  instances  where  the  epoch  of  puberty  was 
considerably  delayed. 

By  those  not  well  accustomed  to  the  diagnosis  of  skin  diseases, 
favus  has  often  been  confounded  with  other  eruptions  of  the  scalp,  more 
especially  eczema  and  impetigo,  or  the  combination  of  these  diseases 
known  as  the  eczema  impetiginodes.  In  none  of  these  eruptions,  how- 
ever, do  the  yellow  crusts  or  scales  present  traces  of  vegetations  when 
examined  microscopically.  This,  therefore,  furnishes  the  real  diagnostic 
and  pathognomonic  character  of  the  disease.*  Occasionally,  as  has  been 
stated,  favus  presents  a scaly  character.  It  has  then  been  called  Pity- 
riasis. On  examination  of  the  scurf,  however,  the  epidermic  scales  will 
be  found  associated  with  the  Achorion  Schonleinii,  in  various  stages  of 
development. 


Causes. 

Alibert  considered  the  disease  hereditary,  and  gives  cases  confirma- 
tory of  this  view.  As  regards  age,  it  is  by  far  most  common  in 
children  between  the  ages  of  three  and  twelve  years.  In  infancy,  and 
after  puberty,  it  is  more  rare,  although  sometimes  present ; and  in  a few 
instances  it  has  been  observed  in  persons  advanced  in  years.  In  almost 
all  the  cases  which  have  come  under  my  notice,  the  individuals  have 
been  exposed  to  causes  which  depress  the  vital  powers,  and  are  well- 
known  excitants  of  tuberculous  disease.  Close  questioning  will  usually 
elicit  that  they  are  of  a scrofulous  family ; have  been  exposed  for  some 
time  to  infected  or  corrupted  air  ; inhabited  small  rooms,  or  confined 
streets,  or  dwellings  situated  in  unhealthy  situations ; that  the  aliment 
has  not  been  very  nutritive,  etc.  etc.  Hence,  why  the  disease  is  com- 
mon in  workhouses  and  jails,  and  most  prevalent  amongst  the  poorer 
classes  of  the  population,  and  individuals  who  obtain  a precarious 
existence. 

* In  1842  I discovered  Favus  on  the  face  of  a common  house  mouse,  in  which 
animal  the  same  cryptogamic  vegetations  were  to  be  detected  as  in  man.  Dr.  Carter 
confirmed  this  observation  in  a communication  he  brought  before  the  Royal  Medical 
Society  of  this  city,  during  the  session  1856-57.  Prof  Gluge  of  Brussels  also  described 
and  figured  the  same  fact  (Bulletins  de  1’ Academic  royale  de  Belgique.  2me  serie. 
Tom.  iii.,  No.  12). 


854 


DISEASES  OF  THE  INTEGUMENTARY  SYSTEM. 


Almost  every  writer  on  the  disease  considers  it  to  be  contagious. 
Bateman,  Gruersent,  and  others,  speak  of  its  spreading  amongst  school- 
boys, from  the  employment  of  the  same  towels,  combs,  caps,  etc. 
Gibert  has  seen  it  propagated  in  the  wards  of  St.  Louis  from  the  same 
cause.  It  has  been  observed,  he  says,  two  or  three  times  to  be  com- 
municated by  young  people  kissing  each  other,  when  it  has  appeared  in 
the  chin  or  neighborhood  of  the  mouth.  Mahon  even  pretends  to  have 
contracted  favus  incrustations  on  his  fingers,  from  having  neglected  to 
wash  them  after  dressing  the  heads  of  those  affected.  Alibert,  in  his 
early  writings,  also  thought  it  to  be  contagious.  In  his  later  works,  how- 
ever, he  evidently  doubts  it,  says  that  much  exaggeration  has  been  made 
use  of  on  this  subject,  and  states  that  the  amour-propre  of  parents  usually 
induces  them  to  ascribe  the  origin  of  so  disgusting  a disease  to  external 
communication.  He  further  observes,  “ Mes  fdeves  ont  souvent  tente 
d’inoculer  en  notre  presence,  le  produit  de  I’incrustation  faveuse,  sous 
plusieurs  formes,  et  en  variant  les  precedes.  Le  plus  souvent  il  n’est 
rien  resulte,  dans  d’autres  cas  est  survenue  une  inflammation  passagere, 
qui  s’est  bientot  evanouie — parfois  une  suppuration  semblable  qui  pour- 
rait  s’etablir  par  tout  irritant  mechanique,  ou  par  I’insertion  d’une  sub- 
stance etrangere  dans  le  tegument.”^  Gruby  also,  on  discovering  its 
vegetable  nature,  inoculated  thirty  phanerogamous  plants,  twenty-four 
silk-worms,  six  reptiles,  four  birds,  and  eight  mainmifera,  but  only  pro- 
duced the  disease  once,  and  then  in  a plant.  The  human  arm  was 
inoculated  five  times,  but,  independent  of  a slight  inflammation  and  sup- 
puration, no  efi’ect  was  produced. 

Twenty-two  years  ago  I inoculated  myself  and  others  many  times 
with  a view  of  determining  whether  favus  was  or  was  not  contagious. 
But  in  none  of  these  experiments,  performed  in  various  ways,  and  fre- 
quently repeated  so  as  to  avoid  fallacy,  could  I succeed  in  causing  the 
plant  to  germinate  on  parts  different  from  those  on  which  it  was  originally 
produced  ; in  other  words,  I could  not  communicate  the  disease  to  other 
individuals,  or  from  one  part  of  the  same  individual  to  another. 

At  the  time  I did  not  consider  these  experiments  (performed  in 
1841-42)  as  decisive  of  the  question,  although  they  show  that  it  is  with 
great  difficulty  inoculation  succeeds.  Shortly  after.  Dr.  Remak  of 
Berlin  communicated  the  disease  to  his  own  arm  in  the  following  way  : 
— He  fastened  portions  of  the  crust  upon  the  unbroken  skin,  by  means 
of  plaster.  In  fourteen  days,  a red  spot,  covered  with  epidermis,  ap- 
peared, and  in  a few  days  more  a dry  yellow  favus  scab  formed  itself 
upon  the  spot,  which,  examined  microscopically,  presented  the  mycoder- 
matous  vegetations  characteristic  of  favus.f  Mentioning  this  fact  to  my 
polyclinical  class,  at  the  Royal  Dispensary,  in  the  summer  of  1845,  one 
of  the  gentlemen  in  attendance  volunteered  to  permit  his  arm  to  be  ino- 
culated. A boy,  called  John  Bangb,  ast.  8,  laboring  under  the  disease, 
was  at  the  time  the  subject  of  lecture,  and  a portion  of  the  crust,  taken 
directly  from  this  boy’s  head,  was  rubbed  upon  Mr.  M.’s  arm,  so  as  to 
produce  erythematous  redness,  and  to  raise  the  epidermis.  Portions  of 
the  crust  were  then  fastened  on  the  part  by  strips  of  adhesive  plaster. 

* Traite  des  Maladies  de  la  Peau,  fol.,  p.  443. 

f Medicinische  Zeitung,  August  3,  1 842. 


FAVUS. 


855 


The  results  were  regularly  examined  at  the  meetings  of  the  class  every 
Tuesday  and  Friday.  The  friction  produced  considerable  soreness,  and, 
in  a few  places,  superficial  suppuration.  Three  weeks,  however,  elapsed, 
and  there  was  no  appearance  of  favus.  At  this  time,  there  still  remained 
on  the  arm  a superficial  open  sore  about  the  size  of  a pea,  and  Mr.  M. 
suggested  that  a portion  of  the  crust  should  be  fastened  directly  on  the 
sore.  This  was  done,  and  the  whole  covered  by  a circular  piece  of  adhe- 
sive plaster  about  the  size  of  a crown-piece.  In  a few  days,  the  skin 
surrounding  the  inoculated  part  appeared  red,  indurated,  and  covered 
with  epidermic  scales.  In  ten  days,  there  were  first  perceived  upon  it 
minute  bright  yellow-colored  spots,  which,  on  examination  with  a lens, 
were  at  once  recognised  to  be  spots  of  favus.  On  examination  with  the 
microscope,  they  were  found  to  be  composed  of  a minute  granular  matter, 
in  which  a few  of  the  cryptogamic  jointed  tubes  could  be  perceived.  In 
three  days  more,  the  yellow  spots  assumed  a distinct  cupped  shape,  per- 
forated by  a hair ; and  in  addition  to  tubes,  numerous  sporules  could  be 
detected.  The  arm  was  shown  to  Dr.  Alison  ; and  all  who  witnessed  the 
experiment  being  satisfied  of  its  success,  I advised  Mr.  M.  to  destroy  each 
favus  spot  with  nitrate  of  silver.  With  a view  of  making  some  further 
observations,  however,  he  retained  them  for  some  time.  The  capsules 
were  then  squeezed  out,  and  have  not  since  returned.  Mr.  M.  had  light 
hair,  blue  eyes,  a white  and  very  delicate  skin.  There  is  every  reason 
to  believe  that  the  strips  of  plaster  employed  in  the  first  attempt  shifted 
their  position,  and  that  the  crust  was  only  properly  retained  by  the  cir- 
cular piece  of  plaster  employed  in  the  second  experiment. 

That  the  disease,  therefore,  is  inoculable,  and  capable  of  being  com- 
municated by  contagion,  there  can  be  no  doubt,  a result  which  accords 
with  the  observations  of  most  practitioners,  and  with  numerous  recorded 
facts.  (Case  CXCIV.)  It  must  also  be  evident  that  it  does  not  readily 
spread  to  healthy  persons,  and  that  there  must  be  either  a predisposition 
to  its  existence,  or  that  the  peculiar  matter  of  favus  must  be  kept  a long 
time  in  contact  with  the  skin  previously  in  a morbid  condition. 

Pathology. 

We  have  seen,  when  describing  the  symptoms  and  mode  of  develop- 
ment of  the  disease,  that  it  is  not  essentially  pustular,  and  that  the 
pustules  occasionally  present  are  accidental.  On  the  other  hand,  it 
has  been  shown  that  the  peculiar  favus-crust  is  composed  of  a capsule  of 
epidermic  scales,  lined  by  a finely  granular  mass ; that  from  this  mass 
millions  of  cryptogamic  plants  spring  up  and  fructify ; and  that  the  pre- 
sence of  these  vegetables  constitutes  the  pathognomonic  character  of  the 
disease. 

In  order  to  examine  the  natural  position  of  these  vegetables  micro- 
scopically, it  is  necessary  to  make  a thin  section  of  the  capsule  com- 
pletely through,  embracing  the  outer  layer  of  epidermis,  amorphous 
mass,  and  light  friable  matter  found  in  the  centre.  It  will  then  be  found, 
on  pressing  this  slightly  between  glasses,  and  examining  it  with  a magni- 
fying  power  of  300  diameters,  that  the  cylindrical  tubes  (thalli)  spring 
from  the  sides  of  the  capsule,  proceed  inwards,  give  off  branches  dicho- 


856 


DISEASES  OF  THE  INTEGUMENTARY  SYSTEM. 


tomously,  which,  when  fully  developed,  contain,  at  their  terminations 
{\nycelia)^  a greater  or  smaller  number  of  round  or  oval  globules  {spori- 
dia).  These  tubes  are  from  the  joo  ^ millimetre  in  thickness, 

jointed  at  regular  intervals,  and  often  contain  molecules,  varying  from 
Toooo  ToVo  **  millimetre  in  diameter.  The  longitudinal  diameter 
of  the  sporules  is  generally  from  To  o>  transverse  from 

3 0 0 I'O  of  a millimetre  in  diameter  (Gruby).  I have  seen  some  of 
these,  oval  and  round,  twice  the  size  of  the  others.  The  long  diameter 
of  the  former  measured  yU  of  a millimetre.  The  mycelia  and  sporules 


merous  near  the  external  layer.  There  may  frequently  be  seen  swellings 
on  the  sides  of  the  jointed  tubes,  which  are  apparently  commencing  rami- 
fications. 

On  examining  the  hairs  which  pass  through  the  favus  crusts,  it  will 


Fig.  493. 

often  be  found  that  they  present  their  healthy  structure.  At  other 
times,  however,  they  evidently  contain  long  jointed  branches,  similar 

Fig.  491,  Branches  of  the  Achorion  Schmnleinii  in  an  early  stage  of  development 
growing  from  a molecular  matter,  and  mingled  with  epidermic  scales,  from  a very 
minute  favus-crust. 

Fig.  492.  Fragments  of  the  branches  more  highly  developed,  with  numerous  spo- 
rules and  molecular  matter,  from  the  centre  of  an  advanced  favus-crust.  300  diam. 

Fig.  493.  a,  A light  hair  containing  branches  of  the  Achorion  Schoenleinii  (magni- 
fied 300  diameters  linear).  The  wood-cutter  has  made  the  branches  too  beaded.  6, 
A darker  colored  hair,  containing  branches  of  the  plant.  800  diam. 


FAVUS. 


857 


to  those  in  the  crust,  running  in  the  long  axis  of  the  hair,  which  is 
exceedingly  brittle.  I have  generally  found  these  abundant  in  very 
chronic  cases ; and  on  adding  water,  the  fluid  may  be  seen  running  into 
these  tubes  by  imbibition,  leaving  here  and  there  bubbles  of  air,  more  or 
less  long.  There  can  be  very  little  doubt  that  the  tubes  and  sporules, 
after  a time,  completely  fill  up  the  hair  follicle,  and  from  thence  enter 
the  hair,  causing  atrophy  of  its  bulb,  and  the  baldness  which  follows  the 
disease.  The  various  steps  of  this  process,  however,  I have  been  unable 
to  follow,  never  having  had  an  opportunity  of  observing  favus  in  the  dead 
scalp,  and  of  making  proper  sections  of  the  skin. 

Several  writers  on  favus  have  treated  its  vegetable  nature  as  a mere 
hypothesis.  At  first  it  was  considered,  as  by  Mr.  Erichsen,* * * §  to  be 
founded  merely  upon  the  outward  appearance,  sufficiently  strong  cer- 
tainly, which  the  cup-shaped  crust  of  favus  offers  to  lichens,  or  vegeta- 
tions of  a similar  description.”  Subsequently  favus  was  supposed  to 
consist  of  a mass  of  cells ; and  it  was  argued  by  Dr.  Carpenterf  that  the 
vesicular  organization  is  common  to  animals  as  well  as  plants ; and 
hence  “ to  speak  of  Porrigo  favosa^  or  any  similar  disease,  as  produced 
by  the  growth  of  a vegetable  within  the  animal  body,  appears  to  the 
author  a very  arbitrary  assumption.”  Mr.  Erasmus  Wilson,  in  his  work 
on  “ Diseases  of  the  Skin  ” (p.  430),  as  well  as  in  a special  “ Treatise  on 
Ringworm,”  is  also  opposed  to  the  idea  of  favus  owing  its  essential 
characters  to  a vegetable  growth.  He  considers  that  the  peculiar  branches 
and  oval  bodies  previously  described  are  mere  modifications  of  epidermic 
cells,  which  in  some  cases  he  is  of  opinion  may  be  transformed  into  pus 
cells — in  others,  into  those  observed  in  favus.  The  branches  of  the 
plant  he  calls  “ cellated  stems,”  and  the  sporules,  secondary  cells ; and 
argues,  that  mere  resemblance  to  a vegetable  formation  is  not  sufficient 
to  constitute  a plant.  He  says,  “ The  statement  of  the  origin  of  the 
vegetable  formations  by  roots  implanted  in  the  cortex  of  the  crust  is  un- 
founded ; the  secondary  cells  bear  no  analogy  to  sporules  or  seeds ; and 
it  is  somewhat  unreasonable  to  assign  to  an  organism  so  simple  as  a cell 
the  production  of  seeds,  and  reproduction  thereby,  when  each  cell  is  en- 
dowed with  a separate  life,  and  separate  power  of  reproduction. Lastly, 
M.  Cazenave,^  although  he  acknowledges  himself  to  be  no  histologist, 
says  he  has  sought  for  the  sporules  many  times,  and  believes  himself 
authorised  to  conclude  that  their  detection  is  not  always  so  easy  as  is 
supposed  (p.  225).  Finally,  he  denies  that  favus  is  a vegetable  parasite, 
and  maintains  it  to  be  a peculiar  secretion,  originating  in  the  sebaceous 
glands,  (p.  236). 

With  the  exception  of  Mr.  Wilson,  who  appears  carefully  to  have 
examined  the  favus  crust,  the  opposition  to  the  vegetable  nature  of  this 
production  seems  to  have  originated  in  very  imperfect  notions  as  to  its 
intimate  structure  on  the  one  hand,  and  that  of  certain  cryptogamic  plants 
on  the  other.  For  if  long  hollow  filaments,  with  partitions  at  inter- 
vals, containing  molecules  witbin  their  cells,  springing  from  an  unorga- 

* Medical  Gazette,  December  1841,  p.  415. 

f Principles  of  Physiology,  p.  453. 

X On  Ringworm,  1847,  p.  23. 

§ Traite  des  Maladies  Cuir  Chevelu,  1850. 


858 


DISEASES  OF  THE  INTEGUMENTARY  SYSTEM. 


nized  granular  mass,  and  giving  off  toward  their  extremities  round  oval 
bodies,  or  sporules,  arranged  in  bead-like  rows,  be  not  vegetable,  what 
are  they  ? The  animal  tissues  present  nothing  similar,  while  numerous 
plants,  long  known  to  botanists,  present  the  same  identical  structure. 
But  not  only  must  they  be  referred  to  the  vegetable  kingdom,  but  to  a 
considerably  elevated  position  among  the  cryptogamic  plants.  The 
protococcus  nivalis  and  torula  cerevisice^  universally  considered  as  plants, 
together  with  the  sarcina  ventriculi^  described  by  Goodsir,  are  immeasur- 
ably beneath  them  in  complexity  of  structure ; and  many  of  the  mucores 
or  moulds  growing  in  damp  places  are,  as  I have  satisfied  myself  by  re- 
peated examination,  much  more  simple  in  their  organism.  Any  one  who 
looks  over  the  cryptogamia  of  Greville  will  at  once  detect  the  strong 
analogy  between  the  structures  found  in  favus  and  the  'penicilvum,  glaucum 
of  Link,  the  aspergillus  penicillatus.,  acrosporium  monilioides^  sporotormm 
minutum^  nostoc  cccruleum^  and  other  plants  therein  figured.  Indeed,  it 
seems  to  me  surprising  how  the  vegetable  nature  of  these  structures  can 
for  a moment  be  doubted  by  any  one  who  has  personally  examined  them, 
especially  under  powers  of  from  six  to  eight  hundred  diameters  linear. 

In  considering  whether  the  structure  described,  and  now  by  every  one 
acknowledged  to  exist  in  the  favus  crusts,  really  belong  to  the  vegetable 
kingdom,  we  should  remember  that  they  are  not  the  only  formations 
of  this  kind  which  have  been  found  to  grow  parasitically  in  living  ani- 
mals. In  my  original  paper,"*  I described  others  growing  in  phthisical 
cavities,  in  the  sordes  on  the  gums  and  teeth  of  typhus  patients ; and 
pointed  out  that  they  had  been  observed  in  the  living  tissues  of  mol- 
lusca,  insects,  reptiles,  fishes,  birds,  and  mammiferous  animals.  These 
observations  have  subsequently  been  confirmed  by  numerous  pathologists 
and  naturalists.  Lastly,  we  cannot  overlook  the  opinion  of  botanists 
themselves  concerning  this  question.  The  most  eminent  mycologists,  so 
far  as  I am  aware,  have  no  doubt  of  the  vegetable  nature  of  favus.  l)r. 
Greville,  to  whom  I exhibited  them,  was  quite  satisfied  of  the  fact. 
Brogniart,  according  to  Gruby,  and  Messrs.  Link  and  Klotzsch,  to  whom 
they  were  shown  by  Bemak,  expressed  a similar  opinion.  Brogniart 
considers  them  to  belong  to  the  genus  Mycoderma  of  Persoon.  J.  Muller 
places  them  among  the  genus  Oidium ; but  both  Link  and  Klotzsch 
consider  that  they  ought  to  constitute  a distinct  genus.  The  former,  in 
consequence,  has  given  it  the  generic  name  of  Achorion  (from  achor, 
the  old  term  for  favus),  and  added  to  it  the  designation  of  the  discoverer 
Schonlein.  The  following  is  his  description  of  the  plant : — 

“ Achorion  Schcenleini  nohis  orhiculare.,  Jlavum^  coriaceum,  cuti  humanae 
praesertim  capitis  insidens  ; rhizopodion  molle,  pellucidum,  jioccosum  Jloccis 
tenuissimis.,  vix  articnlatis.,  ramosissimis.,  anastomoticis  (?) ; t mg celmm  Jloccis 
crassioribus,  subramosis.,  distincte  articulatis,  articulis  inaeqnalibus  irregulan- 
bus  in  sporidia  aheuntibus  ; sporidia  rotunda^  ovalia  vel  irregularia.,  in  uno 
vel  pluribus  later  (bus  germinantia.'^ 

The  mode  of  development  from  sporules  has  now  been  determined 
with  considerable  exactitude.  Bemak  made  small  grooves  on  the  cut 
surface  of  a fresh  apple ; placed  portions  of  the  favus  crust  in  them ; 

* Edin.  Philosophical  Trans.  1842. 

f I have  never  seen  any  anastomosis. 


FAVUS. 


859 


tlien  laid  the  apple,  with  the  cut  surface  turned  upwards,  in  moist  sand ; 
and  covered  the  whole  with  a glass  bell.  Under  these  circumstances,  he 
found  that  the  sporules  developed  themselves,  and  he  examined  them 
frequently  up  to  the  sixth  day,  when  the  surface  of  the  apple  became  of 
a brown  color,  and  was  covered  with  a rapid  growth  of  Penicilium 
glaucum,  or  other  kind  of  mould,  among  which  the  structure  peculiar,  to 
favus  could  no  longer  be  traced.  These  observations,  however,  showed 


Fig.  494. 


that  the  sporules  of  the  Achorion  undergo  development  in  the  same  man- 
ner as  those  in  other  crypt ogamic  plants.  That  is,  the  membrane  which 
surrounds  them  throws  out  one  or  more  prolongations,  which  are  con- 
verted into  tubes ; and  these,  in  turn,  present,  generally  towards  their 
extremities,  a number  of  sporules,  which  at  length  are  pushed  out,  or  are 
disintegrated,  and  so  become  free.  Figs.  494  and  495  represent  the 
changes  observed  in  the  sporules  germinating  on  the  surface  of  the  ap- 
ple; and  Fig.  496  shows  the  thalli,  mycelia,  and  sporules  seen  in  the 
crusts,  produced  by  inoculation,  on  E-emak’s  arm. 

The  method  of  reproduction  and  formation  of  sporules  may  be  ob- 
served with  great  facility  in  any  well-developed  favus  crust,  especially 
under  powers  varying  from  500  to  800  diameters  linear.  Thalli,  with 
variable-sized  cells,  may  be  observed  branching  at  the  extremities,  with 
sporules  forming  within  them.  These  are  conjoined  with  separated  my- 
celia, containing  well-developed  sporules,  many  of  which  are  also  free,  as 
in  Fig.  497. 

It  follows,  therefore,  that  all  the  circumstances  connected  with  the 
development  and  mode  of  reproduction  of  the  Achorion  Schoenleini  have 
been  fully  ascertained. 

The  seat  of  favus  has  been  much  disputed  by  authors.  By  some  it 
has  been  located  in  the  piliferous  bulbs  or  follicles  (Duncan,  Baudelocque, 
Bayer),  by  others  in  the  sebaceous  glands  (Sauvages,  Underwood,  Mur- 
ray, Mahon,  and  lately  by  Cazenave),  and  a third  party  in  the  reticular 
tissue  of  the  skin  (Bateman,  Gallot,  Thomson).  According  to  Gruby  the 
plants  grow  in  the  cells  of  the  epidermis,  the  true  skin  is  compressed, 


Fig.  494.  Sporules  developing  on  the  surface  of  an  apple,  after  three  days. 

Fig.  495.  The  same  after  four  days. 

Fig.  496.  The  same  more  fully  developed  on  the  human  arm,  after  inoculation,  a, 
Thalli,  with  pale  walls  ; 6,  containing  sporules  (mycelia) ; c,  mycelium  separated  from 
the  thallus  : f sporules  separated  from  the  mycelium — {after  Remak). 


300  diam. 


860 


DISEASES  OF  THE  IXTEGUMENTAEY  SYSTEM. 


not  destroyed,  and  the  bulbs  and  roots  of  the  hairs  and  sebaceous  fob 
licles  are  only  secondarily  affected. 

I have  made  observations  to  determine  the  correctness  of  this  state- 
ment, and  have  found  that  the  whole  inferior  surface  of  the  capsule  is 
formed  of  epidermic  scales,  thickly  matted  together.  These  are  lined  by 
finely  molecular  matter,  from  which  the  plants  appear  to  spring,  and 
which  unites  the  branches  and  sporules  together  in  a mass.  Superiorly, 


however,  the  epidermic  scales  are  not  so  dense;  and  I have  always  found 
them  more  or  less  broken  up,  and  not  continuous.  This  observation  is 
valuable,  as  indicating  the  probable  mode  in  which  these  plants,  or  the 
sporules  producing  them,  are  deposited  on  the  scalp.  It  will  be  seen 
that  the  appearance  of  the  peculiar  porrigo  capsule  was  invariably  pre- 
ceded by  a desquamation  of  the  cuticle,  that  is,  a separation  or  splitting 
up  of  the  numerous  external  epidermic  scales  which  constitute  its  outer- 
most layer.  Hence  it  is  more  probable  that  the  sporules,  or  matters  from 
which  the  vegetations  are  developed,  insinuate  themselves  between  the 
crevices,  and  under  the  portion  of  epidermis  thus  partially  separated,  than 
that  they  spring  up  originally  below,  or  in  the  thickness  of  the  cuticle. 

The  chemical  constitution  of  the  matter  originally  exuded  is  supposed 
by  M.  Cazenave  to  be  allied  to  fat,  but  it  appears  to  me  to  be  more  pro- 
bably albuminous,  and  allied  to  the  molecular  character  of  all  broken 
down  or  disintegrated  organic  material  in  which  fungi  grow.  We  have 
seen  that,  previous  to  the  return  of  the  favus  crusts,  the  head  is  al- 
ways covered  with  brokeu-up  epidermis,  more  or  less  disintegrated.  Ex- 
periments have  shown  that  the  plants  will  not  grow  on  the  healthy  skin, 
and  that  inoculation  suc('.eeds  only  in  places  where  pustules  have  pre- 
viously been  formed.  It  is  also  exceedingly  probable  that,  when  favus 
is  communicated  from  one  person  to  another,  the  part  affected  (generally 

Fig.  497.  Thalli,  mycelia,  and  sporidia  of  the  Achorion  Schoenlemii  showing  the 
mode  of  reproduction.  800  dia7n. 


FAVUS. 


861 


the  scalp)  has  been  the  seat  of  some  other  eruption  (Case  CXCIV.)  or  is 
not  particularly  clean. 

Mr.  Erichsen  considers,  “ That  the  matter  of  favus  is  a modification 
of  tubercle — that  it  is  a tubercular  disease  of  the  skin.  By  tubercular  I 
do  not  mean  a disease  like  lupus,  characterised  by  small  firm  tumors, 
but  a disease,  the  nature  of  which  consists  in  the  deposition  of  that 
her etolog oils  formation  called  tubercle.”  This  view  of  the  nature  of  favus 
I have  long  held ; and  it  was  distinctly  stated  by  me,  when  treating  of 
the  pathology  of  scrofula,  in  a work  published  in  1841.^  The  favus 
crust,  however,  is  not  constituted  wholly  of  the  tubercular  matter.  The 
peculiar  exudation  only  constitutes  the  soil  from  which  the  mycodermatous 
vegetations  spring,  as  I shall  now  endeavor  to  show. 

Gruby  describes  the  mycodermata  of  favus  as  springing  from  an 
amorphous  mass,  of  which  the  periphery  of  the  capsule  is  composed. 
This  mass  undoubtedly  exists,  and,  according  to  my  observations,  is  com- 
posed of  a finely  molecular  matter,  identical  in  structure  with  certain 
forms  of  tubercle,  or  recently  coagulated  exudation.  The  cheesy  matter, 
for  instance,  so  frequently  found  on  the  secreting  surface  of  serous  mem- 
branes, and  in  tubercular  cavities  and  other  structures  in  chronic  cases 
of  tuberculosis,  or  general  tendency  to  tubercular  deposition,  presents 
this  character.  Every  pathologist  who  has  minutely  examined  tubercle 
recognises  a granular  form  in  which  there  is  no  trace  of  nucleus  or  cell, 
and  which,  therefore,  we  are  warranted  in  considering  as  unorganised.  I 
have  myself  repeatedly  examined  this  tubercular  matter,  and  been  unable 
to  detect  any  difference  between  it  and  the  mass  in  which  the  vegetations 
of  favus  appear  to  grow.  Chemical  analysis  of  this  form  of  tubercle 
demonstrates  it  to  be  composed  principally  of  albumen,  with  a minute 
proportion  of  earthy  salts ; sometimes  there  is  combined  with  it  a small 
quantity  of  fibrin  or  gelatine.  If  this  general  result  be  compared  with 
the  analysis,  by  Thenard,  of  favus  matter,  the  identity  between  it  and 
tubercle  must  appear  highly  probable.  He  found  in  100  parts,  coagu- 
lated albumen,  70  ; gelatine,  17  ; phosphate  of  lime,  5 ; water  and  loss, 
8 parts.  Thus  the  evidence  furnished  by  morphology  and  chemistry 
agrees  in  determining  the  molecular  matter  found  in  the  crusts  of  favus 
and  in  tubercle  to  be  analogous, 

Remak  found  that,  although  the  sporules  underwent  developmental 
changes  on  the  cut  surface  of  an  apple,  as  well  as  in  animal  fluids  to 
which  sugar  had  been  added,  no  such  changes  took  place  in  spring  or 
distilled  water,  in  the  serum  of  blood,  solution  of  albumen,  pus,  muscle, 
substance  of  brain,  cut  pieces  of  skin,  or  animal  fat.  In  these  cases  the 
animal  tissues,  as  well  as  the  portions  of  favus  crust,  became  gradually 
disintegrated,  and  infusorial  formations  commenced.  Hence  the  Achorion 
grows  under  the  same  circumstances  only  as  all  other  moulds.  Putrefac- 
tion of  animal  or  vegetable  substances  is  unfavorable  to  its  production; 
but  that  peculiar  acid  change  which  occurs  in  milk  or  paste  exposed  to 
the  air  for  some  days,  and  in  which  growths  of  mould  and  confervse 
readily  occur,  is  beneflcial  to  the  development  of  favus.  Hence  why 
inoculation  in  healthy  tissues  fails,  and  why  certain  exudations  in 
peculiar  states  of  the  constitution,  or  disintegrated  matters  which  have 
* Treatise  on  the  Oleum  Jecoris  Asselli,  p.  94. 


862 


DISEASES  OF  THE  INTEGUMENTAEY  SYSTEM. 


undergone  particular  chemical  clianges,  probably  from  acid  secretions  of 
the  skin,  are  necessary  to  the  production  of  the  disease. 

I believe,  therefore,  that  the  pathology  of  favus  is  best  understood 
by  considering  it  essentially  to  be  a form  of  abnormal  nutrition,  with 
exudation  of  a matter  analogous  to,  if  not  identical  with,  that  of  tubercle, 
which  constitutes  a soil  for  the  germination  of  cryptogamic  plants, 
the  presence  of  which  is  pathognomonic  of  the  disease.  Hence  is 
explained  the  frequency  of  its  occurrence  in  scrofulous  persons,  and 
among  cachectic  or  ill-fed  children;  the  impossibility  of  inoculating 
the  disease  in  healthy  tissues,  or  the  necessity  for  there  being  scaly, 
pustular,  or  vesicular  eruptions  on  the  integuments,  previous  to  com 
tagion.  But  as  experiments  have  proved  the  possibility  of  inoculation 
in  healthy  persons,  it  follows  that  the  material  in  which  the  vegetations 
grow,  may  at  the  commencement,  in  a molecular  exudation,  be  formed 
primarily  or  secondarily.  That  is,  there  may  be  want  of  vital  power 
from  the  first,  as  occurs  in  scrofulous  cases,  or  there  may  have  been 
production  of  cell  forms,  such  as  those  of  pus  or  epidermis,  which,  when 
disintegrated  and  reduced  to  a like  molecular  and  granular  material 
secondarily,  constitute  the  necessary  ground  from  which  the  parasite 
derives  its  nourishment,  and  in  which  it  grows. 

Treatment, 

Almost  every  species  of  treatment  has  been  had  recourse  to,  in  order 
to  remove  this  disagreeable  and  intractable  disease ; and  there  can  be 
no  doubt  that  cases  have  recovered  under  the  use  of  all  and  each  of  the 
methods  recommended.  In  some  instances,  favus  wears  itself  out,  or 
rather,  as  the  development  of  the  frame  proceeds,  and  the  constitutional 
strength  improves,  the  conditions  necessary  for  its  production  and 
maintenance  are  removed,  and  it  consequently  disappears.  In  every  case, 
howeves-  it  must  be  our  object  to  get  rid  of  the  disease  permanently  as 
soon  as  possible,  and  this  is  only  to  be  done  by  removing  the  pathological 
conditions  on  which  it  depends. 

The  notion  that  it  originates  in  the  bulbs  of  the  hair  caused  an 
attempt  to  remove  the  disease  by  eradicating  the  structures  with  which 
it  was  supposed  to  be  connected.  Hence  the  barbarous  and  cruel  treat- 
ment by  means  of  the  Calotte.  This  consisted  in  spreading  a very 
adhesive  plaster  inside  a cap,  which  closely  fitted  the  shaven  scalp.  The 
hair  was  then  allowed  to  grow  and  insinuate  itself  amongst  the  substance 
of  the  plaster — when  the  whole  was  forcibly  torn  ofif.  In  this  way 
portions  of  the  scalp  were  sometimes  separated — at  others,  pieces  of  the 
plaster  remained  firmly  attached,  and  gave  great  trouble.  A modification 
of  this  plan  consisted  in  covering  the  head  with  the  plaster  in  strips, 
which  were  removed  separately  from  before  backwards,  and  from  behind 
forwards,  so  as  to  tear  out  the  hairs.  Even  this  plan  failed.  The 
practice  I saw  adopted  in  Berlin,  in  1841,  consisted  in  plucking  out  the 
hairs  individually  with  a pair  of  pincers ; but  this  tedious  and  painful 
method,  also,  was  found  to  be  of  little  service.  It  has  been  revived  of 
late  years  by  Bazin  and  Hardy  in  Paris,  and  has  also  been  practised  in 
Glasgow  by  Drs.  Anderson  and  Buchanan,  at  the  skin  Dispensary  there. 
According  to  the  former,  so  called  paracitides  require  to  be  used  after 


FAVUS. 


863 


depillation,  to  destroy  the  fungus,  removal  of  the  hair  bulbs  being  a 
means  for  enabling  the  medicine  to  reach  the  germs.  The  success  of  this 
practice  has  yet  to  be  established. 

^ In  Paris  the  old  treatment  by  the  calotte  was  put  aside  for  the 
milder  empiric  treatment  of  the  frcres  Mahon.  Between  the  years 
1807  and  1813,  439  girls  and  469  boys,  affected  with  favus,  were 
cured  by  them  at  the  Bureau  Central  des  Hopitaux,  and  the  mean 
duration  of  the  treatment  was  56  applications.  These  applications  are 
generally  made  every  other  day,  so  that  the  average  length  of  treatment 
by  this  much  boasted  and  successful  method  is  three  mouths  and  a half. 

T have  endeavored  to  show,  however,  that  in  many  cases  it  is  a 
constitutional  disease,  and  dependent  upon  the  causes  which  induce 
scrofulous  diseases  in  general.  The  treatment,  therefore,  in  such  ought 
to  be  constitutional,  and  directed  to  removing  the  tendency  to  tubercular 
exudation,  on  which  the  malady  depends.  No  doubt,  however,  a local 
treatment  in  this,  as  in  all  disorders  which  are  at  the  same  time  general 
and  local,  is  of  the  utmost  service. 

I consider,  then,  that  the  chief  indications  of  treatment  are — 1st, 
To  remove  the  constitutional  derangement ; and,  2dly,  To  employ  such 
topical  applications  as  tend  to  prevent  the  development  of  vegetable 
life.  This  line  of  practice  may  be  thought  similar  to  that  recommended 
long  ago  by  Lorry,  who  advises,  1st,  A modification  of  the  fluids  and 
solids  of  the  economy  by  a general  treatment ; 2dly,  A vigorous  attack 
upon  the  local  disease  by  topical  applications,  capable  of  removing  the 
crusts,  causing  the  skin  to  suppurate  deeply,  and  substituting  a solid 
cicatrix  for  the  morbid  ulceration  of  the  hairy  scalp.  For  the  most 
part,  however,  the  general  treatment  of  physicians  has  been  confined  to 
diluent  drinks,  blood-letting,  purging,  and  remedies  which  depress  the 
vital  powers,  whereas  it  must  be  evident,  that  if  the  views  of  its  patho- 
logy [ have  brought  forward  be  correct,  and  it  is  in  its  nature  allied  to 
tubercular  affections,  a treatment  exactly  opposite  ought  to  be  pursued. 
The  development  of  vegetable  life  may  also  be  prevented  by  the  applica- 
tion of  much  milder  remedies  than  the  escharotics  or  irritating  ointments 
usually  employed. 

We  have  previously  seen  that  tuberculosis  is  caused  and  kept  up 
by  some  fault  in  the  digestive  process ; that  the  blood  is  secondarily 
affected,  and  its  albuminous  constituents  proportionally  increased ; that 
the  albumen  at  length  becomes  effused  into  the  different  structures  of  the 
economy,  causing  the  various  forms  of  tubercular  disease;  and  lastly, 
as  the  albumen  in  the  blood  becomes  excessive,  and  its  effusion  into  the 
textures  increases,  the  fatty  constituents  of  the  frame  diminish.  It  has 
been  shown,  by  numerous  facts,  that  under  such  circumstances  the 
internal  and  external  exhibition  of  cod-liver  oil  has  been  attended  with 
the  most  marked  advantage,  and  often  been  made  the  means  of  cure  when 
all  other  remedies  have  failed.  The  action  of  the  oil  appears  to  be  the 
same  in  favus  as  in  other  forms  of  scrofulous  disease,  and  its  use  should 
be  combined  with  appropriate  diet  and  exercise,  and  with  reference  to  the 
same  indications  and  contra-indications. 

The  local  treatment  I have  employed  for  several  years,  is  directed 
in  conformity  with  the  pathological  views  previously  detailed,  to  the 
exclusion  of  atmospheric  air,  so  as  to  prevent  vegetable  growth.  For 


864  DISEASES  OF  THE  INTEGUMENTARY  SYSTEM. 

this  purpose,  I direct,  in  the  first  instance,  that  the  afiected  scalp 
should  be  poulticed  for  several  days,  until  the  favus  crusts  are 
thoroughly  softened,  and  fall  off.  Then  the  head  is  to  be  carefully 
shaved,  after  which  it  will  be  found  to  present  a shining  clear  surface. 
Lastly,  cod-liver  oil  should  be  applied  with  a soft  brush,  or  dossil  of 
lint,  over  the  affected  surface  morning  and  night,  and  the  head  covered 
with  an  oil-silk  cap  to  prevent  evaporation,  and  further  exclude  the 
atmospheric  air.  Every  now  and  then,  as  the  oil  accumulates  and 
becomes  inspissated,  it  should  be  removed  by  gently  washing  it  with  soft 
soap  and  water.  Common  lard,  or  any  other  oil,  does  very  well,  but  it  is 
not  so  penetrating  as  cod-liver  oil.  In  one  case  I found  a sulphurous 
acid  lotion  succeed,  and  in  another  a solution  of  carbolic  acid  seemed  to 
answer.  But  further  trials  of  these  remedies,  as  well  as  of  a saturated 
solution  of  sulphuretted  hydrogen,  failed.  I believe,  therefore,  that  cod- 
liver  oil,  both  internally  and  externally,  constitutes  the  best  treatment. 

I have  found  the  average  duration  of  this  treatment  to  be  six  weeks, 
which  contrasts  very  favorably  with  the  results  of  MM.  Mahon’s 
practice  at  the  Hopital  St.  Louis.  Some  cases  seem  to  be  incurable, 
and  these  are  most  frequent  among  adults ; but  even  in  them,  so 
long  as  the  scalp  is  kept  moist  with  oil,  and  the  air  is  excluded,  the 
eruption  will  not  return.  In  young  subjects,  in  whom  general  as  well 
as  local  treatment  is  admissible,  and  in  whom  a scrofulous  disposition 
is  manifest,  the  prognosis  is  more  favorable,  and  the  disease  may  be 
permanently  eradicated  (Cases  CXCIII.  to  CXCV.)  Whenever  favus 
is  recent  and  of  limited  extent,  it  may  at  once  be  destroyed  by  cauteriza- 
tion with  nitrate  of  silver  (Case  CXCVI.) 

Lebert  is  of  opinion  that  poultices  and  oily  applications  soften  the 
favi  and  distribute  the  sporules  over  the  skin.  He  therefore  insists  on 
removing  the  crusts  dry,  by  means  of  a small  spatula,  sewing  needles, 
or  other  instruments.  He  says  that  nothing  is  more  easy  than  to  detach 
them  entire ; for,  although  pushed  into  the  skin,  they  are  not  held 
there  by  any  adhesion.  But  I think  it  will  be  found  that,  however 
dexterous  a person  may  be  in  removing  the  crusts,  the  majority  are 
held  firmly  to  the  scalp,  by  means  of  the  hair  which  perforates  them, 
and  that  tearing  these  out  is  very  painful.  Besides,  the  crusts  are  easily 
broken,  and  the  time  and  trouble  required,  even  when  they  are  thinly 
scattered,  renders  this  plan  impracticable  in  hospitals.  When  densely 
matted  together,  it,  of  course,  cannot  be  done.  I believe,  then,  that 
repeated  poulticing  is  by  far  the  best  and  most  efficient  method  of  freeing 
the  skin  from  the  eruption,  whilst  it  has  the  extra  advantage  of  doing  so 
without  irritation,  and  thereby  diminishing  the  tendency  to  the  formation 
of  impetiginous  pustules. 


Parasitic  Pityriasis. 

Case  CXCYII.* — Parasitic  Pityriasis — Incurable. 

History. — Charlotte  Clerk,  set.  18 — admitted  June  20th,  1867 — a Hindoo  girl  from 
Bombay.  She  has  had  an  eruption  on  her  head  ever  since  she  can  remember.  On 
admission  the  hair  was  found  clipped  short ; the  scalp  was  bald  in  patches,  especially 


* Reported  by  Mr.  TV.  Guy,  Clinical  Clerk. 


PARASITIC  PITYRIASIS. 


865 


over  the  crown  of  the  head.  The  hair  is  filled  with  scales,  easily  detached,  resem- 
bling desquamated  epidermis.  Towards  the  back  of  the  head  these  scales  are  embedded 
in  a diffused  friable  yellowish  matter,  which,  on  examination  under  the  microscope, 
presents  the  thalli  and  sporules  of  favus.  July  i6th. — To  detei’mine  more  certainly 
the  character  of  the  disease,  poultices  have  been  applied  to  the  head,  the  hair  has 
been  shaved,  and  the  disease  allowed  to  return.  To-day,  being  the  seventh  since  the 
head  was  clean,  two  bright  yellow  favus  spots,  each  perforated  by  a hair,  were  observed. 
These  rapidly  increased  and  amalgamated  with  others,  never  forming  distinct  favus 
crusts,  but  causing  a scaly  eruption  over  the  surface,  together  with  a few  pustules  of 
impetigo.  On  removing  the  scales  a friable  yellow  mass  can  be  generally  seen  below, 
presenting  on  examination  the  vegetable  structure  of  the  Achorion  Schbnleinii.  The 
sporules  and  thalli  were  unusually  large  and  well  developed.  This  girl  was  treated  by 
constant  oleaginous  and  other  applications  ; was  dismissed  and  re-entered  the  house ; 
but  when  I last  saw  her,  in  December  IBS'/,  the  disease  still  existed  as  bad  as  ever. 

Commentary. — This  eruption  presented  to  the  naked  eye  all  the 
appearance  of  pityriasis  of  the 
scalp.  The  only  suspicious  cir- 
cumstance was  the  baldness.  I 


microscopically,  in  order  to  arrive 
at  an  exact  diagnosis.  In  this  case  the  fungus  was  essentially  the  same 
as  that  of  favus,  although  it  presented  modifications  as  to  the  size  of  the 
sporules  and  thalli.  As  in  Case  CXCII. , all  the  remedies  tried  were  of 
no  avail. 

Case  CXCVIII.* — Pityriasis  Versicolor — with  the  Mierosporon  Furfur 
of  Fichstddt — Cured  hy  Pitch  Ointment. 

History. — Margaret  Nicol,  aet.  29,  unmarried — admitted  24th  October,  1864. 

The  patient  was  always  well  till 
three  weeks  ago,  when,  on  expo- 
sure to  cold  two  days  after  men- 
struation she  was  seized  with  pain 
of  a sharp  cutting  character,  situ- 
ated deep  in  the  hypogastric  region, 
accompanied  with  a bloody  dis- 
charge, which  ceased  after  four 
days. 

Symptoms  on  Admission. — The 
pain  continues,  and  is  aggravated 
by  deep  pressure  over  the  pubes. 
Pain  on  micturition.  No  uterine 
discharge.  Uterus  considerably 
enlarged,  and  cervix  tender  on 
pressure.  On  the  lower  two-thirds 
of  the  chest  anteriorly,  and  the 
upper  two-thirds  of  the  abdomen, 
are  irregularly-shaped  patches  of 
a yellowish  brown  color,  covered 
h minute  dry  scales,  which,  when  submitted  to  microscopic  examination,  are  found 

* Reported  by  Mr.  W.  T.  P.  Wolston,  Clinical  Clerk. 

Fig.  498.  Thalli  and  sporules  from  chronic  pityriasis  of  the  scalp.  250  diam. 

Fig.  499.  Mierosporon  Furfur,  in  pityriasis  versicolor  {Anderson).  350  diam. 

55 


had  previously  seen  two  similar 
cases,  and  was  in  no  way  surprised 
to  find  that  the  disease  was  a 
parasitic  one.  All  chronic  scalp 
eruptions,  especially  if  there  be 
Alopecia,  should  be  examined 


866 


DISEASES  OF  THE  INTEGUMENTARY  SYSTEM. 


to  contain  multitudes  of  the  sporules  and  thalli  of  the  microsporon  furfur.  Tongue 
furred  ; bowels  constipated.  Other  functions  normal.  Ordered  poultices  to  be  ap- 
plied continuously  to  the  abdomen. 

Progress  of  the  Case. — November  10th. — Uterine  pain  very  much  diminished. 
Ordered  to  apply  pitch  ointment  to  the  patches  of  pityriasis.  Nov.  10th. — Uterine 
enlargement  and  pain  quite  gone.  Color  of  the  pityriasis  much  faded.  December 
Is^. — Dismissed  cured. 

Commentary. — The  general  form  of  this  vegetable  parasite,  first 
discovered  by  Eichstadt  in  1846,  is  different  from  that  of  favus,  con- 
sisting of  masses  of  globular  sporules  seldom  exceeding  the  eight- 
thousandth  of  an  inch  in  diameter,  mingled  with  short  branching 
thalli,  just  large  enough  to  contain  them  (See  Fig.  499).  Dr.  T.  M. 
Anderson  of  Glasgow  has  published  several  cases  strongly  confirmatory 
of  the  contagiousness  of  the  disease.*  Cleanliness  and  unguents  are 
the  best  remedies.  The  above  case  readily  yielded  to  the  common 
pitch  ointment.  In  a case  which  closely  resembled  chronic  eczema  of  the 
scalp,  I found  masses  of  similar  sporules  on  the  hairs,  with  numerous 


Fig.  500. 

others  infiltrated  among  the  fibres  of  the  bulbs,  rendering  the  whole 
structure  very  brittle. 

^ Parasitic  Affections  of  the  Skin,  p.  94. 

Fig.  500.  Portion  of  the  root  of  a hair  plucked  from  a crust  of  chronic  eczema 
of  the  scalp,  easily  made  to  split  up,  and  presenting  within  its  substance  and  sheath 
numerous  minute  globular  sporules.  250  diam. 


SECTION  X. 


DISEASES  OE  THE  BLOOD. 

The  diseases  of  the  blood  have  strongly  engaged  the  attention  of  modern 
pathologists,  who,  putting  aside  the  vague  speculation  which  the  ancients 
held  regarding  this  important  fluid,  have  sought  to  investigate  the  sub- 
ject by  the  aid  of  facts  derived  from  chemical,  microscopical,  and  clinical 
researches.  The  general  results  of  these  have  been  sketched,  pp.  131  to 
133.  The  alterations  of  the  blood  give  rise  to  many  of  the  most  impor- 
tant disorders  which  affect  the  body,  besides  being  necessarily  associated 
more  or  less  with  every  morbid  change  connected  with  alterations  of 
nutrition.  It  is  the  principal  idiopathic  or  essential  forms  of  blood  dis- 
ease which  will  be  treated  of  in  this  place. 


LEUCOCYTHEMIA. 

On  the  19th  of  March,  1845, 1 examined  the  body  of  a man  who  died 
under  the  care  of  Professor  Christison,  in  the  Koyal  Infirmary,  laboring 
under  hypertrophy  of  the  spleen  and  liver,  and  whose  blood  was  covered 
with  corpuscles  which  exactly  resembled  those  of  pus.  This  case  was 
the  first  of  the  kind  in  which  a careful  histological  examination  of  the 
blood  was  made,  and  in  which  the  remarkable  morbid  condition  then 
discovered  was  separated  from  ordinary  pyaemia,  and  shown  to  be  uncon- 
nected with  any  form  of  inflammation.  It  was  published  in  the  Edin- 
burgh Med.  and  Surg.  Journal,  October  1st,  1845,  vol.  Ixiv.,  p.  413. 
Dr.  Craigie,  who  was  present  at  the  dissection,  recognised  its  similarity 
to  one  he  had  had  under  his  care  four  years  previously,  the  blood  of 
which  had  been  examined  microscopically  by  Dr.  John  Reid,  who  found 
“that  it  contained  globules  of  purulent  matter  and  lymph.”  An  account 
of  it  appeared  in  the  same  number  of  the  Edinburgh  Journal  for  October 
1845.  Six  weeks  after  these  cases  had  been  published,  Professor  Vir- 
chow of  Berlin  gave  the  history  of  another,  in  the  second  number  for 
November  1845,  of  Froriep’s  “Notizen”  (No.  780),  under  the  name  of 
“ Leukhemia,”  or  white  blood.  On  the  31st  of  December  1845,  a man 
was  received  into  St.  George’s  Hospital,  London,  in  whom  Dr.  Fuller 
detected,  both  before  and  after  death,  the  increased  number  of  colorless 
corpuscles  in  the  blood.  This  man,  like  the  other  individuals,  had  great 
hypertrophy  of  the  spleen.  A notice  of  the  case  is  inserted  in  the 
“Lancet”  for  July  1846.  Since  then  several  similar  cases  have  been 
met  with,  in  which  this  morbid  condition  of  the  blood  has  been  deter- 


868 


DISEASES  OF  THE  BLOOD. 


mined  to  exist,  by  an  accurate  examination  with  the  microscope  ; and  a 
reference  to  the  records  of  medicine  has  shown  the  previous  occurrence 
of  like  cases.  In  these  last,  the  blood,  with  two  exceptions,  was  not 
physically  proved  to  contain  an  unusual  number  of  colorless  corpuscles, 
although  now  on  looking  back  upon  the  facts  which  are  mentioned  in 
regard  to  them,  we  can  have  little  doubt  that  such  was  the  case.  The 
exceptional  cases  occurred  to  M.  Barth  in  1839,  and  Dr.  Craigie  in  1841. 
In  the  first,  M.  Donne  found  one-half  the  corpuscles  in  the  blood  to  be 
“mucous  globules,”  and  in  the  second.  Dr.  John  Beid  found  that  the 
blood  “ contained  globules  of  purulent  matter  and  lymph.”* 

^ The  term  “ Leukhemia,”  or  white  blood,  given  to  this  disease  by 
Virchow,  is  faulty,  because,  in  the  first  place,  as  was  correctly  stated  by 
Dr.  Parkes,  the  blood  is  not  white,  but  presents  its  usual  red  tinge  when 
drawn  from  the  arm.  The  colorless  clots  occasionally  observed  after 
death  will  certainly  not  warrant  the  application  of  this  term  to  the  blood 
generally,  as  they  are  frequently  present  without  the  morbid  condition 
under  consideration.  Besides,  the  same  name  (white  blood)  has  been 
given  with  more  propriety  to  the  fatty  blood,  examined  by  Drs.  Traill, 
Christison,  and  others,  which  presents  a milky,  opalescent  appearance. 
At  the  meeting  of  the  Academy  of  Medicine  in  Paris,  on  January  29th, 
1856,  the  members  were  naturally  enough  led  into  great  confusion  in 
consequence  of  not  keeping  this  distinction  in  view.  What  ought  to  be 
expressed  is,  that  the  blood  abounds  in  colorless  corpuscles,  and  this  is 
done  by  the  term  Leucocythemia — from  XevKos,  white ; kvtos,  cell ; and 
aljjia,  blood  : literally,  white  cell  blood — which  expresses  the  simple  fact, 
or  pathological  state,  and  involves  no  theory.  Throughout  England  and 
Prance  this  name  has  been  universally  adopted. 

Case  CXCIX.f — Leucocythemia  discovered  after  death — Hypertrophy 
of  the  Spleen,  Liver,  and  Lymphatic  Glands — Absence  of  Phlebitis 
and  of  Purulent  Collections  in  any  part  of  the  body. 

History. — John  Monteith,  aged  28,  a slater — admitted  into  the  clinical  ward  of  the 
Koyal  Infirmary,  February  27,  1845,  under  the  care  of  Dr.  Christison.  He  is  of  dark 
complexion,  usually  healthy  and  temperate  ; states  that  twenty  months  ago  he  was 
affected  with  great  listlessness  on  exertion,  which  has  continued  to  this  time.  In  June 
last  he  noticed  a tumor  in  the  left  side  of  the  abdomen,  which  gradually  increased  in 
size  till  four  months  since,  when  it  became  stationary.  It  was  never  painful  till  last 
week,  after  the  application  of  three  blisters  to  it ; since  then,  several  other  small  tumors 
have  appeared  in  his  neck,  axillae,  and  groins,  at  first  attended  with  a sharp  pain,  which 
has^now,  however,  disappeared  from  all  of  them.  Before  he  noticed  the  tumor,  he  had 
frequently  vomiting  in  the  morning.  The  bowels  are  usually  constipated,  appetite  good, 
is  not  subject  to  indigestion,  has  had  no  vomiting  since  he  noticed  the  tumor ; he  has 
used  chiefly  purgative  medicines,  especially  croton  oil ; employed  friction  with  a lini- 
ment, and  had  the  tumor  blistered. 

Symptoms  on  Admission. — On  admission,  there  is  a large  tumor,  extending  from  the 
ribs  to  the  groin,  and  from  the  spinal  column  to  the  umbilicus,  lying  on  the  left  side. 
It  is  painful  on  pressure  near  its  upper  part  only.  Percussion  is  dull  over  the  tumor ; 

* Gazette  Hebdomadaire,  March  21,  1856,  and  Edin.  Med.  and  Surg.  Journal, 
October  1845. 

•)•  This  case  occurred  in  the  clinical  ward  of  Professor  Christison,  who  treated  it. 
The  body  after  death  was  most  carefully  inspected  by  me  as  pathologist  .to  the  Royal 
Infirmary,  and  parts  were  removed  for  careful  subsequent  examination,  and  for  pre- 
servation, the  appearances  being  altogether  of  a kind  quite  new  to  me.  The  case,  for 
reasons  which  will  appear  in  the  sequel,  is  here  given  as  it  was  originally  published  in 
the  Edinburgh  Journal  for  1st  October  1845. 


LEUCOCYTHEMIA. 


869 


pulse  90  ; states  that  for  three  months  past  he  has  not  lost  in  strength.  There  is  slight 
oedema  of  the  legs.  To  have  two  pilh  of  iodide  of  iron  morning  and  evening. 

Phogress  of  the  Case. — March  l.< — Urine  of  yesterday  somewhat  turbid  when 
just  passed,  natural  in  color,  acid  to  litmus  ; sp.  gr.  1013.  Sediment  presents  cubic 
crystals  under  the  microscope,  disappears  almost  entirely  on  the  addition  of  aqua 
potassa),  but  is  unaffected  by  nitric  acid.  The  filtered  urine  is  not  affected  by  aqua 
potassae,  and  yields  only  a slight  white  haze  when  boiled.  March  ^th. — (Edema  of 
legs  increased.  They  have  been  bandaged  with  flannel  rollers.  Potassce  (Jarhonath 
3i;  Spiritus  ^theris  Nitrici  3 iv  ; Aquce  Menthce  Aquce  fontis  M,  Surnat 

unciarn  ter  in  die.  March  10(A. — Tormina  and  considerable  diarrhoea;  urine  notin- 
creased.  Habeat  haustum  Olei  Ricini  § ss  statim  ; et  exacts  quatuor  horis,  Opii  gr.  ii. 
March  \2>th. — Attacked  this  morning  with  heat  of  skin;  thirst;  pulse  110,  full,  very 
compressible.  The  diarrhoea,  which  had  been  checked,  returned  yesterday ; none  this 
morning  after  taking  an  opium  pill.  Urine  100  ounces.  Omittantur  medicam.enta. 
Sumat  statim  Pulveris  Ipecacuanhce  et  Opii  gr.  x,  et  repetatur  dosis  singulis  scmihoris 
ad  tertiam  vicem.  March  lUh. — No  sweating  from  the  powders  ; diarrhoea  still  rather 
troublesome,  pulse  100,  softer;  tongue  dry  ai  d brown;  febrile  expression  of  counte- 
nance, resembling  that  of  typhus.  Aqicce  Acetatis  Ammonice  3 vi ; Solutionis 

Morphice  3i;  Aquce  fontis  § iij  ; Syrupi  §J.  Sttmat  unciarn  quarto,  qudque  hord. 
Habeat  decoctum  hordei  pro  potu.  March  \Uh. — Died  suddenly  in  the  morning. 

Sectio  Cadaveris. — March  \S)ih  {^fonr  days  after  death). 

Externally,  the  body  presented  a considerable  prominence  of  the  ensiform  cartilage 
and  false  ribs  on  both  sides.  The  ab- 
domen was  contracted ; considerable 
dulness  on  percussion  on  left  side, 
which  had  previously  been  marked 
out  by  a line  formed  with  nitrate  of 
silver.  No  ascites  or  oedema  of  the 
limbs. 

Blood. — The  blood  throughout 
the  body  was  much  changed.  In 
the  right  cavities  of  the  heart,  pul- 
monary artery,  venae  cavae,  vena 
azygos,  external  and  internal  iliac 
veins,  and  many  of  the  smaller  veins 
leading  into  them,  it  was  firmly 
coagulated,  and  formed  a mould  of 
their  size  and  form  internally.  In 
the  cavities  of  the  heart  and  venae  Fig.  50l. 
cavae,  the  blood,  when  removed,  was 
seen  to  have  separated  into  a red  or  inferior,  and  a 
yellow  or  superior,  portion.  The  red  portion  was  of 
a brick-red  color ; it  did  not  present  the  dark  purple 
smooth  and  glossy  appearance  of  a healthy  coagu- 
lum,  but  was  dull  and  somewhat  granular  on  section, 
and  when  squeezed  readily  broke  down  into  a gru- 
mous  pulp.  The  yellow  portion  was  of  a light  yellow 
color,  opaque  and  dull,  in  no  way  resembling  the 
gelatinous  appearance  of  a healthy  decolorised  clot. 
XVhen  squeezed  out  of  the  veins,  as  was  sometimes 
accidentally  done  where  they  were  divided,  it  resem- 
bled thick  creamy  pus.  In  some  portions  of  the 
Fig.  502.  veins,  the  clot  was  wholly  formed  of  red  coagulum. 

In  others  it  was  divided  into  red  and  yellow.  In  a few  places  the  yellow  formed  only 


Fig.  501.  Portion  of  clot  from  the  vena  cava,  showing  the  divisions  into  red  and 
white  coagula.  Half  the  real  size. 

Fig.  502.  • Posterior  surface  of  the  aorta  and  vena  cava.  An  incision  has  been 
made  in  the  latter,  to  show  that  it  is  not  thickened  or  diseased,  as  well  as  to  expose 
colorless  coagula  even  in  the  most  depending  portions  of  the  clot.  Half  the  real  size. 


870 


DISEASES  OF  THE  BLOOD. 


a streak  or  superficial  layer  upon  the  red,  or  covered  the  latter  with  spots  of  various 
sizes.  Whether  this  coagulum  existed  in  all  the  veins,  could  only  hnve  been  ascer- 
tained by  a complete  dissection  of  the  body.  It  was  seen,  however,  that  the  femoral 
veins,  after  passing  under  Poupart’s  ligament,  were  empty  and  perfectly  healthv  as 
far  down  as  the  Sartorius  muscle.  The  external  and  internal  iliac  veins,  as  well  as 
the  pelvic  veins,  were  full  and  distended.  The  azygos,  both  axillary  and  jugular  veins, 
were  full,  also  the  longitudinal,  the  lateral,  and  other  sinuses  at  the  base  of  the  cra- 
nium, and  veins  ramifying  on  the  surface  of  the  brain.  In  this  last  situation  some  of 
the  veins  appeared  as  if  full  of  pus,  whilst  others  were  gorged  with  a dark  coagulum — 
(see  Fig.  503).  In  the  aorta  and  external  arteries  were  a few  small  clots,  resembling 
those  found  in  the  veins.  These  vessels,  however,  were  comparatively  empty.  Tie 
basilar  artery  at  the  base  of  the  brain  was  distended  with  a yellow  clot. 

Vessels. — The  arteries  and  veins  themselves  were  perfectly  healthy.  Although 
carefully  looked  for,  in  no  place  could  thickening  or  increased  vascularity  be  observed. 
Nowhere  was  the  clot  adherent  to  the  vessels,  but,  on  the  contrary,  it  readily  slipped 
out  when  an  accidental  puncture  was  made  in  them. 

Head. — On  removing  the  dura  mater,  the  veins  which  empty  themselves  into  the 

longitudinal  sinus  were  considerably 
engorged,  especially  posteriorly.  Some 
were  filled  with  the  red,  and  others 
with  the  yellow  clot  previously  de- 
scribed. Others,  again,  were  half  filled 
with  red  and  half  with  yellow  coagu- 
lum, the  passage  of  the  one  into  the 
other  being  clearly  perceived.  Both 
hemispheres,  with  the  longitudinal  si- 
nus and  falx  in  situ^  were  removed  by 
a section  across  the  brain,  as  low"  down 
as  the  division  of  the  cranium  would 
permit.  The  brain  was  then  discovered 
to  be  very  soft  uniformly, — a circum- 
stance accounted  for  by  the  time  w hich 
had  elapsed  since  death.  The  part  re- 
moved w"as  put  aside,  in  order  to  be 
preserved  and  hardened  in  spirit.  The 
lateral  ventricles  were  found  healthy, 
contained  no  serum,  and  the  choroid 
plexus  was  perfectly  normal.  At  the 
base  of  the  brain  the  basilar  artery  w as 
seen  distended  with  the  yellow  coagu- 
lum, as  were  also  a few  of  the  arteries, 
but  to  a very  slight  extent.  The  sub- 
stance of  the  brain  itself  was  through- 
out healthy.  All  the  sinuses  at  the 
base  of  the  cranium  gorged  w"ith  the 
red  coagulum. 

Chest. — A few  chronic  adhesions 
Fig  503.  united  the  pleurae  on  both  sides,  which 

were  easily  tom  through.  Both  lungs  were  slightly  engorged  posteriorly  and  inferi- 
orly.  The  anterior  margin  of  the  left  lung  emphysematous,  but  to  no  great  extent. 
On  section,  the  yellow  coagulum  of  the  blood  was  observed  to  occupy  all  the  ramifica- 
tions of  the  pulmonary  artery.  In  some  places  it  was  so  consistent  as  to  be  drawn  out, 
exhibiting  an  arborescent  form ; in  others,  it  was  more  soft,  and  exuded  from  the  cut 
surface  like  thick  pus.  Heart  somewhat  enlarged  ; weighed,  when  freed  from  coagu- 
lum, eleven  and  a half  ounces.  Its  texture  was  healthy  ; the  valves  normal.  The 
right  auricle  much  distended,  and  gorged  with  a firm  coagulum,  the  upper  third  of 
which  w'as  found  composed  of  the  yellow,  and  the  two  inferior  thirds  of  the  red  clot 
formerly  described.  The  right  ventricle  and  pulmonary  artery  were  similarly  dis- 


Fig.  503.  Appearance  of  the  upper  surface  of  the  hemispheres  after  removing  the 
dura  mater,  showing  the  remarkably  white  appearance  of  the  coagula  in  the  veins  and 
longitudinal  sinus.  Half  the  real  size. 


LEUCOCYTHEMIA. 


871 


tended ; portions  of  the  clot  closely  embraced  the  columnae  carnese,  but  were  in  no  place 
adherent.  The  coronary  arteries  and  veins  were  normal. 

Abdomen. — On  the  inferior  surface  of  the  diaphragm  there  existed  a firm,  almost 
cartilaginous,  deposit,  about  a line  in  thickness,  of  a white  color,  oval  form,  two  inches 
long  by  one  and  a half  broad,  with  irregular  margins,  which  were  composed  of  several 
rounded  tubercular  bodies,  the  size  of  a small  pea,  and  of  a fibrous  structure.  The 
liver  enormously  enlarged  from  simple  hypertrophy.  Its  structure  throughout  healthy. 
Gall-bladder  enlarged,  and  distended  with  a clear  pale  yellow  bile.  The  whole  weighed 
ten  pounds  twelve  ounces.  The  spleen  also  enormously  enlarged  from  simple  hyper- 
trophy. It  was  of  a spindle  shape,  largest  in  the  centre,  tapering  towards  the  extremi- 
ties. It  weighed  seven  pounds  twelve  ounces.  It  measured  in  length  fourteen  inches ; 
in  breadth,  at  its  widest  part,  seven  inches ; and  in  thickness,  four  and  a half  inches. 
Towards  its  anterior  surface  was  a yellow  firm  exudation,  about  an  inch  deep,  and  three 
inches  long.  The  peritoneum,  also  covering  a portion  of  its  anterior  surface,  was  thick- 
ened, opaque,  and  dense  over  a space  about  the  size  of  the  hand.  Both  kidneys  healthy. 
The  stomach  and  intestines  healthy  throughout.  About  four  inches  from  the  anus  the 
superior  haemorrhoidal  veins  were  distended  on  both  sides  external  to  the  rectum. 
They  formed  two  chains  of  tumors,  about  three  inches  long,  consisting,  on  the  one  side, 
of  three  swellings  as  large  as  a walnut ; on  the  other,  of  one  swelling  somewhat  larger. 
They  were  filled  with  a red  coagulum,  broken  down  into  a grumous  mass.  The  lymph- 
atic glands  were  everywhere  much  enlarged.  In  the  groin  they  formed  a large  cluster, 
some  being  nearly  the  size  of  a small  hen’s  egg,  and  several  being  that  of  a walnut. 
The  axillary  glands  were  similarly  affected.  The  bronchial  glands  were  not  only  en- 
larged, but  of  a dark  purple  color,  and  in  some  places  black  from  pigmentary  deposit. 
The  mesenteric  glands  were  of  a whitish  color,  some  as  large  as  an  almond  nut.  A 
cluster  of  these  surrounded  and  pressed  upon  the  ductus  communis  choledochus.  The 
lumbar  glands  were  of  a greenish-yellow  color,  also  enlarged,  forming  a chain  on  each 
side  and  in  front  of  the  abdominal  aorta,  more  especially  at  its  bifhrcation  into  the 
iliacs. 

No  collection  of  pus  could  be  found  in  any  of  the  tissues. 

Microscopic  Examination. — The  yellow  coagulum  of  the  blood  was  composed  of 
Fig.  504. 


coagulated  fibrin  in  filaments,  intermixed  with  numerous  colorless  corpuscles,  which 

Fig.  504.  Colorless  corpuscles,  mingled  with  a few  colored  ones,  from  the  white 
clot  of  the  blood  in  Case  CXCIX. 

Fig.  505.  The  same  bodies,  mingled  with  a larger  number  of  yellow  blood  cor- 
puscles in  the  red  clot. 

Fig.  506,  Change  produced  on  the  colorless  corpuscles  on  the  addition  of  acetic 
acid,  the  yellow  corpuscles  being  dissolved. 

Fig.  507.  Cells  in  the  fluid  squeezed  from  the  lymphatic  glands,  after  the  addition 
of  acetic  acid. 

Fig.  508.  Blood-vessels  giving  off  a capillary  from  the  pia  mater ; the  latter  is 
seen  filled  with  colorless  corpuscles ; the  former  partly  with  colorless,  mingled  with 
colored  corpuscles.  250  diam. 


872 


DISEASES  OF  THE  BLOOD. 


could  be  readily  squeezed  out  from  it  when  pressed  between  glasses.  Where  the  yel- 
low coagulum  was  unusually  soft,  the  corpuscles  were  more  numerous,  and  the  fibrin 
was  broken  down  into  a diffluent  mass,  partly  molecular  and  granular,  partly  composed 
of  the  debris  of  the  filaments  broken  into  pieces  of  various  lengths.  The  corpuscles 
varied  in  size  from  the  80th  to  the  120th  of  a millimetre  in  diameter  ; they  were  round 
their  cell-wall  granular,  and  presented  all  the  appearance  of  pus  corpuscles  (Fig.  604)! 
W ater  caused  them  to  swell  and  lose  their  granular  appearance,  and  acetic  acid  dis- 
solved the  cell-wall  and  caused  a distinct  nucleus  to  appear.  This  nucleus  was  com- 
posed sometimes  of  one  large  granule  about  the  200th  of  a millimetre  in  diameter  at 
others  of  two  or  three  smaller  granules,  as  is  seen  in  corpuscles  of  laudable  purulent 
matter  (Fig.  506).  The  red  portion  of  the  coagulum  contained  a smaller  number  of 
these  colorless  corpuscles  mixed  with  a multitude  of  normal  yellow  corpuscles  (Fig. 
505).  The  colorless  corpuscles  now  described  were  found  in  the  blood  throughout  the 
system.  They  were  seen  in  the  veins  and  arteries  ramifying  on  the  brain,  in  the  coro- 
nary veins,  hemorrhoidal  tumors,  and  wherever  the  blood  was  examined.  On  stripping 
off  a portion  of  the  pia  mater,  and  examining  the  capillary  vessels  of  that  membrane, 
all  that  were  not  too  minute  to  contain  them  were  found  crowded  with  the  same  cor- 
puscles (Fig.  508).  This  fact  was  confirmed  by  Dr.  Allen  Thomson,  to  whom  I sent  a 
portion  of  the  brain  for  that  purpose. 

The  cartilaginous  deposit  on  the  inferior  surface  of  the  diaphragm  was  composed  of 
dense  fibrous  tissue,  in  which  numerous  granules  and  molecules  were  observed.  The 
exudation  in  the  spleen  was  composed  of  amorphous  fibrin  mixed  with  numerous 
molecules,  gi-anular  and  imperfect  cells.  These  were  intermingled  with  bundles  of 
filamentous  tissue.  The  enlarged  lumbar  glands,  on  being  pressed,  exuded  a fluid 
that  was  crowded  with  corpuscles  ; some  resembling  the  colorless  corpuscles  already 
alluded  to ; others  oval  and  round,  containing  a distinct  nucleus  (Fig.  60'7). 

The  ultimate  textures  of  the  muscles,  brain,  nerves,  etc.,  were  carefully  examined, 
and  found  normal. 

Commentary . — I have  reprinted  this  case  from  the  original  paper  pub- 
lished by  me  in  the  Edinburgh  Medical  and  Surgical  Journal  for  October 
1st,  1845,  in  order  to  show  that  it  contains  a careful  and  minute  descrip- 
tion of  the  facts  which  I discovered  on  examining  the  body,  March  19th. 
Figs.  501  to  503  are  copied  from  some  of  the  preparations  still  in  my 
possession,  taken  from  the  body.  A cast  of  the  spleen  is  in  the  Univer- 
sity museum.  Numerous  drawings  were  also  made  from  microscopic 
demonstrations;  some  of  which  are  represented  Figs.  504  to  508. 

In  the  remarks  originally  appended  I observed : — “ The  points  con- 
nected with  this  case  that  require  discussion  are — 1st,  The  connection  be- 
tween the  symptoms  and  morbid  appearances;  2d,  Were  the  corpuscles 
contained  in  the  blood  really  those  of  pus  ? and  3d,  If  so,  how  were  they 
produced  ?”  The  discussion  of  these  theoretical  points,  it  appears  to  me, 
has  nothing  whatever  to  do  with  the  correctness  or  incorrectness  of  the 
facts  above  detailed,  which,  it  will  be  observed,  are  studiously  separated 
from  everything  of  a hypothetical  character.  But  in  connection  with 
the  first  point  I observed,  It  is  important  to  remember  that  there  was 
no  phlebitis,  abscess,  or  purulent  collection  to  which  the  appearances 
within  the  vessels  could  be  ascribed.  In  all  cases  of  phlebitis  there  are 
changes  in  the  vessels  themselves,  and  the  clot  is  more  or  less  adherent 
to  the  vascular  walls.  Nothing  of  the  kind  could  be  detected,  although 
particular  attention  was  paid  to  this  point.  How  far  the  hypertrophy  of 
the  liver  and  spleen  may  be  connected  with  the  coagulation  of  the  blood 
and  the  formation  of  pus,  it  is  difficult  to  say.  Whether  the  hypertro- 
phy of  these  organs  exercises  a peculiar  influence  on  the  blood,  or  whether 
the  change  in  that  fluid  be  caused  in  connection  with  chronic  diseases  in 
general,  as  has  lately  been  pointed  out  by  M.  Bouchut,  further  observa- 
tions alone  can  determine.” 


LEUCOCYTHEMIA. 


8'3‘3 

Concerning  the  second  point,  I said,  The  only  bodies  with  which 
they  can  be  confounded  are  the  colorless  corpuscles  of  the  blood  itself, 
the  corpuscles  described  by  Gulliver  as  existing  in  softened  fibrin  and 
those  found  in  lymph.  With  regard  to  the  colorless  corpuscles  of  the 
blood,  we  know  of  no  instance  where  they  existed  in  the  amount,  or  ever 
presented  the  appearance  described.”  I then,  after  considering  the 
structure  of  softened  fibrin,  came  to  the  conclusion  that  the  physical 
characters  of  the  corpuscles  found  in  the  case  of  Menteith  would  leave 
little  doubt  that  they  were  identical  with  those  of  pus. 

In  reference  to  the  third  question,  I pointed  out  that  the  corpuscles 
must  originate  in  the  blood  system  itself,  in  the  same  manner  as  they 
had  been  shown  by  M.  Bouchut  to  occur  in  various  forms  of  cachexia 
and  chronic  diseases.  I distinctly  separated  it  from  what  was  then  un- 
derstood by  pyaemia,  or  purulent  absorption,  saying,  “ Pus  has  long  been 
considered  as  one,  if  not  the  most  characteristic  proof  of  preceding  acute 
inflammation.  But,  in  the  case  before  us,  what  part  was  recently  in- 
flamed ? There  was  none.  Piorry  and  others  have  spoken  of  an  inflam- 
mation of  the  blood,  a true  hematitis ; and  certainly  if  we  can  imagine 
such  a lesion,  the  present  must  be  an  instance  of  it.  But  it  would  re- 
quire no  labored  argument  to  show  that  such  a view  is  entirely  opposed 
to  all  we  know  of  the  phenomena  of  inflammation.  Without  entering 
into  this  discussion,  however,  I shall  assume  it  to  have  been  satisfactori- 
ly demonstrated  that  we  can  form  no  idea  of  this  process  without  the 
occurrence  of  exudation  from  the  blood-vessels,  and  that,  consequently, 
the  expression  inflammation  of  the  blood  is  an  error  in  terms.  A mo- 
ment’s reflection  will  make  it  evident  that  all  our  ideas  of,  and  facts  con- 
nected with,  inflammation  are  associated  with  some  local  change  in  the 
economy.  The  constitutional  disturbances  connected  with  it  are  invari- 
ably ascribed  to  phlegmasia  or  fever,  which  pathologists  hitherto  have 
always  separated  from  inflammation.  Unless,  therefore,  it  could  be 
shown  that  inflammation  and  fever  were  like  processes,  we  must  conclude 
that  the  alteration  of  the  blood  in  this  case  was  independent  of  inflam- 
mation properly  so  called.” 

These  observations  appended  to  the  facts  of  the  case  must  at  least 
be  allowed  to  be  sufficiently  suggestive,  so  that  when  six  weeks  after- 
wards Professor  Virchow  published  a similar  case,  and  said  they  were 
the  colorless  corpuscles  of  the  blood,  he  merely  adopted  another  opinion 
regarding  them  from  what  I had  done.  But  I submit,  this  does  not  en- 
title him  to  claim  for  himself  the  discovery  of  this  morbid  condition,^'  or 
to  represent,  notwithstanding  my  distinct  separation  of  the  lesion  from 
all  known  pre-existing  conditions  of  the  blood,  that  in  my  opinion  it  was 
an  ordinary  case  of  pyaemia.  He  was  fortunate  enough,  however,  to 
meet  with  two  other  cases,  before  I was  enabled  to  resume  the  inquiry 
by  meeting  with  the  following  one  : — 

Case  CG.f — Leucocythemia  detected  during  Life — Hypertrophy  of  the 

Spleen — Ascites, 

History. — Barney  Tinlay,  set.  17,  farm-servant — admitted  into  the  clinical  ward 
of  the  Royal  Infirmary,  January  25,  1850.  With  the  exception  of  an  attack  of  scar- 
let fever,  which  he  experienced  about  three  years  ago,  he  enjoyed  perfect  health 


* See  note  on  the  discovery  of  Leucocythemia  at  the  end  of  this  article, 
f Reported  by  Mr.  Hugh  M.  Balfour,  Clinical  Clerk. 


874 


DISEASES  OF  THE  BLOOD. 


until  twelve  months  since,  when  he  first  noticed  a tumor  in  the  abdomen,  accom- 
panied by  some  pain.  The  tumor  since  this  period  has  gradually  increased  in  size, 
and  latterly  he  has  been  unable  to  walk  fast  on  account  of  dyspnoea.  For  the  last  two 
or  three  years  ho  has  been  employed  in  farm-service,  and  during  three  months  last 
summer  he  resided  in  the  fenny  district  of  Lincolnshire,  but  never  had  intermittent 
fever. 

Symptoms  on  Admission. — On  admission,  his  complexion  is  pale,  the  conjunctivie 
are  unusually  blanched,  and  his  whole  appearance  is  very  cachectic.  On  examining 
the  abdomen,  a hard  tumor  can  be  felt  occupying  the  whole  left  side.  Superiorly,  it 
can  be  felt  emerging  from  the  false  ribs  about  two  inches  to  the  left  of  the  ensiform 
cartilage.  It  then  passes  dowmwards  an  inch  and  a half  to  the  right  of  the  umbilicus, 
and  curves  round  inferiorly  to  a point  about  an  inch  and  a half  above  the  symphysis 
pubis,  from  which  it  may  be  traced  directly  backwards  to  within  three  inches  of  the 
spinous  processes  of  the  lumbar  vertebrae.  Its  anterior  margin  presents  a semi-circu- 
lar convexity,  whieh  is  smooth,  with  a distinct  notch  in  its  upper  third,  and  is  appa- 
rently about  half  an  inch  thick,  as  with  the  fingers  a fold  of  integument  may  be 
pressed  somewhat  below  it.  The  tumor  is  completely  dull  on  percussion  throughout, 
and  is  in  several  parts  painful  on  pressure.  It  measures  about  ten  inches  in  the  long 
diameter,  and  thirteen  and  a half  transversely.  The  rest  of  the  abdomen  has  the 
usual  tympanitic  percussion,  and  there  is  no  fluctuation.  Liver,  on  percussion, 
found  to  be  of  the  natural  size.  Tongue  clean ; appetite  good.  There  is  profuse 
diarrhoea,  the  bowels  being  open  eight  or  ten  times  a day ; this  symptom  has  existed 
for  the  last  three  or  four  weeks.  Pulse  80,  weak.  Complains  of  giddiness  on  assum- 
ing the  erect  posture.  Heart  sounds  natural.  He  has  occasional  epistaxis 

and  hemorrhage  from  the  gums. 
Respiratory  and  urinary  systems 
healthy.  The  appearance  of  the 
blood  drawn  from  the  extremity 
of  the  huger,  when  magnified  250 
diameters  linear,  is  represented 
509.  The  colored  corpuscles 
^for  the  most  part  have  collected 
together  in  rolls,  the  numerous 
colorless  corpuscles  filling  up  the 
intervening  space.  Acetic  acid  dis- 
solved the  colored  bodies,  and  ren- 
dered the  cell-wall  of  the  colorless 
ones  very  transparent — bringing  into  view  the  nucleus,  consisting  of  a single  round  or 
oval  body  in  some,  but  in  the  majority  presenting  two,  three,  or  even  four  granules, 
each  having  a depression  in  their  centre.  Here  and  there  the  nucleus  was  crescentic, 
or  in  the  form  of  a horse-shoe.  (Fig.  510.) 

ProcxRess  op  the  January  27^A.— He  has  had  eight  leeches  applied  to  the 

epigastrium,  and  has  taken  the  lead  and  opium  pills — one  three  times  a day.  The 
diarrhoea  is  much  diminished,  and  there  is  l^s  pain.  R Ferri.  Citratis  3i;  Tinct. 
Card.  Comp.  I i ; Inf  ns.  Calumhce  I vii . M.  Fiat  mistvra  ; sumat  § i ter  in  die. 
R SulpJi.  Quince  gr.  iij  ; Pidv.  Catechu  extr.  gr.  iv ; 01.  Carui  m.  i.  M.  liant  pil. 
ij.  Mitlantur  tales  xij,  et  Sig.  sumat  ij,  mane  et  vespere.  Jan.  ZOth.  Diarrhoea 
now  entirely  ceased.  R Fulv.  Quince  Sulph.  gr.  iij  \ Ferri  Carb.  Sacch.  gr.  vij.  M. 
Fiant  pil.  ij  ; Mittantur  tales  vi ; sumat  unam.,  ter  in  die.  Intermittantur  alia.  Yester- 
day three  ounces  of  blood  were  taken  from  the  arm,  which  Dr.  W . Robertson  was  so 
good  as  to  analyse.  The  results  are  as  follows : — 

Sp.  Grav.  of  the  blood 1041*5 

Sp.  Grav.  of  the  Serum 1026*5 

Composition  of  100  parts — 

Fibrin 6 

Serous  Solids 72 

Globules 67-6 


Fig.  510. 


Total  Solids 145*5 

Water 854*5 


Fig.  509.  Appearance  of  a drop  of  blood  in  this  case. 

Fig.  510.  The  same  after  the  addition  of  acetic  acid.  2^0  diam. 


LEUCOCYTHEMIA. 


875 


10) 
i-  <^J  ^ 

.-—X 

. - .^( 
m - 


15^. 


The  analysis  was  conducted  on  nearly  the  same  plan  as  that  recommended  by  Dr. 
Christison,  and  subsequently  adopted  by  Andral  and  Gavarret ; but  it  is  believed  that 
the  fibrin  is  more  exactly  estimated  than  by  the  process  of  the  latter  authorities.  The 
sp.  grav.  of  the  blood  and  serum  was  very  accurately  taken,  and  the  errors  of  manipu- 
lation cannot  exceed  5 per  1000  in  each  constituent.  The  blood  allowed  to  remain  in 
a vessel  for  twenty-four  hours  presented  a large  and  firm  clot.  Examined  microscopi- 
cally, it  exhibited  the  same  appearance  as  in  Fig.  509,  the  rolls  of  colored  bodies  not 
being  so  large.  On  adding  acetic  acid,  the  same  kind  of  nuclei  were  observed  ; but 
they  were  now  tinted  of  a deep  yellow  color,  having  apparently  imbibed  coloring  mat- 
ter dissolved  in  the  serum.  Some  of  the  crescentic  nuclei  had  become  nearly  straight. 
(Fig.  511.)  February  2d. — Urine  is  observed  to  be  loaded 
with  lithates,  and  diarrhoea  has  returned.  Sumat  pil. 
plumhi  opiat.  unam  ter  in  die.,  et  Syrupi  lodidi  Ferri  guttas 
quindecim  ter  in  die  ex  aqud.  lllinatur  Tinct.  lodinei  parti 
dolenti.  Intermitantur  alia.  March  2Mh. — During  the 
last  few  weeks  the  hemorrhage  from  the  nose  and  gums  has 
continued  to  recur,  and  the  ascites  has  not  abated.  He  was  ,. 
ordered  an  astringent  lotion  for  his  gums.  Since  the  11th, ^ 

Spongio-piline,  with  Tr.  of  Digitalis,  has  been  applied  to  the  " 
abdomen,  which  apparently,  in  consequence,  is  less  tense, 
while  the  pain  has  undoubtedly  diminished.  April  8ih. — 

Diarrhoea  again  violent.  Stools  very  fluid.  He  suffers  also 
from  cough,  and  there  is  harshness  of  respiratory  murmurs,  Uig.  511. 

and  prolonged  expiration  to  be  heard  at  the  apices  of  both  lungs.  No  dulness  on  per- 
cussion. Sumat  pil.  plumhi  opiat.  unam  ter  in  die.  April  12>th. — Pain  in  abdomen, 
and  diarrhoea  nearly  gone.  Sweats  profusely  at  night.  H Quince  Sulph.  gr.  xij ; 
Acidi  Sulph.  dil.  3j;  Syrup.  Aur  ant.  3j;  Aquce  font.  § v.  M.  Ft.  Mistura;  sumat 
3 ss  ter  in  die.  Repetantur  pil.  plumhi  opiat.  April  2S5. — The  diarrhoea  has  ceased 
for  the  last  eight  days,  but  to-day  has  returned  with  considerable  pain.  Tntcrmittatur 
mist.  Quince  Sulph.  ; Applicehtr  emplastrum  Opii  (4  x 4)  ahdomini ; Sumat  pil. 
plumb,  opiat.  ij  ter  in  die  ; Utatur  enem.  amyli  cum  Sol.  Morph,  statim,  et  suppositorio 
opii  quotidie  hard  somni.  May  5th. — Has  complained  a good  deal  lately  of  nausea 
and  vomiting,  for  which  he  has  been  ordered  a draught  every  evening,  with  naphtha. 
He  has  also  taken  the  squill  and  digitalis  pill  three  times  a-day,  and  the  tumor  has 
been  fomented  with  infusion  of  digitalis.  Girth  of  abdomen  at  this  period  was  thirty- 
seven  inches.  1^  Sp.  Mdf.h.  Nitrici  \ iss;  Aquce  Potassce  ; Sol.  Mur.  Morph,  aa  3 ii; 
M.  Sig.  sumat  1 uqua  ter  in  die.  May  *lth. — Distention  of  abdomen  from  accu- 
mulation stil  increases,  and  pain  continues.  The  urine  presents  an  acid  reaction,  and 
is  loaded  with  a copious  sediment  of  lithate  of  ammonia,  with  a few  colorless  rhom- 
boidal  crystals  of  lithic  acid.  Pulv.  Scillce  Dj  ; Pulv.  Digitedis  gr.  x ; Extr. 
Hyoscy.  3 ss  ; Cons.  Rosarum  q.  s.,  ut  fiant  pilulce  xx;  Sig.  sum, at  unam  ter  in  die. 
May  \8th. — Since  last  report  diarrhoea  has  been  very  profuse,  the  bowels  having  been 
acted  upon  sometimes  twenty  times  in  the  course  of  a night.  Stools  very  loose  but 
fseculent.  Spongio-piline  with  digitalis  to  be  discontinued,  on  account  of  its  pressure 
causing  uneasiness.  He  has  taken  the  lead  and  opium  pills  four  times  a day,  as  well 
as  the  starch  injection,  with  Sol.  Mur.  Morph,  at  night.  Omittantur  pil.  plumhi  opiat. 
^ Tannini  gr.  xv  ; Pulv.  Opii  gr.  vj  ; Co7is.  Rosarum  q.  s.  ut  fiant  pil.  vj  ; sumed 
unam  sexto,  qunque  hord.  5 Acidi  Nitrici  dil. ; Syrupi  aa  3ss;  Aquce  |j.  M.  et 
Sig.  sumat  3 j ter  in  die  ex  aqud.  June  — Since  last  report  the  diarrhoea  has  con- 
tinued, but  it  is  now  much  abated.  Fluctuation  in  abdomen  evidently  diminished. 
There  has  been  occasional  slight  epistaxis.  Still  sweats  at  night.  Girth  of  abdomen 
at  broadest  part  diminished  to  thirty-five  and  a half  inches.  Intermitt.  mist.  Quince. 
June  Vlth. — Has  progressed  favorably  to  this  date ; the  tumor  and  ascites  continue  to 
diminish  ; and  the  diarrhoea  and  other  symptoms  having  abated,  the  abdomen  is  now 
flaccid,  and  the  skin  is  cracked,  similar  to  what  is  observed  in  a woman  after  preg- 
nancy. To-day  the  diarrhoea  has  returned  with  some  violence,  with  abdominal  pain. 
Haheat  Pil.  Tannini  ut  antea.  June  2<6ih. — Diarrhoea  still  more  diminished.  There 
is  a good  deal  of  cough,  with  some  expectoration,  and  harsh  respiration  is  heard 
under  clavicle,  with  increased  vocal  resonance.  Has  been  taking  3 ij  of  cod-liver  oil 
three  times  a day.  His  general  strength  is  now  greatly  improved.  He  sits  up  the 
greater  part  of  the  day,  and  even  walks  about  on  the  green.  His  amendment  is  so 

Fifi-.  511.  The  same  after  the  blood  has  stood  for  twenty-four  hours.  250  diam. 


876 


DISEASES  OF  THE  BLOOD. 


great  that  he  is  very  anxious  to  return  to  his  parents,  who  reside  in  Hull.  August 
^th. — Since  last  report  the  diarrhoea  has  returned  at  intervals,  and  still  continues  to  be 
troublesome.  On  the  whole,  however,  his  health  has  improved  ; his  appetite  and 
strength  have  increased,  and  all  ascites  nearly  disappeared.  The  cough  and  expec- 
toration have  ceased.  The  tumor  measures  transversely  thirteen  and  a half  inches, 
and  longitudinally  fifteen  inches.  From  the  lower  border  of  ribs  to  inferior  margin  of 
tumor,  ten  inches.  The  circumference  of  the  abdomen  at  the  widest  part  (a  little 
above  the  umbilicus),  is  thirty-four  inches.  He  was  now  dismissed,  having  for  some 
time  expressed  great  impatience  to  return  to  his  friends  in  Hull,  and  the  further  pro- 
gress of  the  case  has  been  kindly  communicated  to  me  by  Dr.  Sand  with  of  that  town. 
For  some  time  he  was  in  the  Infirmary  there,  when  the  same  symptoms  were  observed, 
more  or  less  severe,  that  had  been  previously  noticed.  Then  he  lived  at  his  parents’ 
hovel,  and  finally  he  went  into  the  Union  Work-House,  where  he  died  at  midnight, 
July  22,  1851.  During  all  this  time  the  abdominal  swelling  from  the  tumor  continued, 
but  he  had  no  ascites  ; the  diarrhoea  was  more  or  less  urgent ; the  emaciation  extreme, 
and  the  weakness  gradually  progressive  up  to  the  moment  of  dissolution. 

Sectio  Cadaveris. — Twelve  hours  after  death. 

This  was  performed  by  Mr.  West,  surgeon  to  the  Union  Work-House.  The  follow- 
ing report  of  the  appearances  observed  was  communicated  to  me  by  Dr.  Sandwith  : — 

Extreme  attenuation  of  the  entire  body. 

Thorax. — The  heart  was  small,  very  small,  with  a few  patchy  points  on  its  sur- 
face. Its  cavities  contained  a whitish  imperfectly-formed  lymph.  The  lungs  had  so  per- 
fectly healthy  an  appearance  that  we  did  not  think  it  necessary  to  cut  into  them.  There 
was  no  more  effusion  into  either  the  pleural  or  peritoneal  cavities  than  is  quite  natural. 
There  was,  however,  an  effusion,  a little  in  excess,  into  the  bag  of  the  pericardium. 

Abdomen. — Nothing  unusual  in  the  appearance  of  structure  of  the  liver,  save  that  the 
larger  hepatic  vessels  were  filled  with  small  patches  of  coagulated  black  blood,  side  by 
side  with  immense  flakes  of  dirty  white  matter,  like  imperfectly  formed  lympli.  The 
gall-bladder  was  filled  with  a glairy  amber-colored  fluid,  not  much  like  bile.  The  liver 
weighed  three  pounds  twelve  ounces.  On  cutting  into  the  organ  there  oozed  out  from 
the  smaller  vessels  a very  thin  watery  blood.  The  spleen  weighed  three  pounds  four- 
teen ounces.  Its  surface  was  of  a sky-blue  color,  and  dappled  with  numerous  specks 
like  cicatrices,  most  of  them  very  small,  but  there 'were  two  much  larger  ones  near  the 
summit.  It  adhered  here  and  there  by  bands  of  lymph  to  the  peritoneal  lining  of  the 
abdomen,  and  also  to  the  peritoneal  covering  of  the  intestines.  On  the  under  surface 
of  the  organ  there  was  a very  small  globular  lobule,  enveloped  in  ( rganised  lymph.  A 
cord,  run  lengthwise  along  both  surfaces  of  the  spleen,  measured  twenty-four  and  a half 
inches.  A cord  similarly  applied  across  the  org.in,  measured  eighteen  inches.  The 
structure  of  the  spleen  was  very  firm — indeed  very  much  like  that  of  liver.  The 
omentum  was  entirely  wasted.  The  mesenteric  glands  were  most  of  them  somewhat 
enlarged,  pale,  and  with  hard  gritty  matter  in  some  of  them.  There  were  several  en- 
larged glands  at  the  caput  caecum  in  a state  of  congestion.  Pale  enlarged  glands  were 
also  seen  all  along  the  sigmoid  flexure  of  the  colon.  The  kidneys  were  unusually 
shrunken  and  small,  and  weighed  together  six  ounces.  There  was  but  little  difference 
in  the  relative  weight  of  each.  Their  structure  Avas  firm. 

Microscopic  Examination. — Next  day  I received  from  Dr.  Sandwith  a portion  of 
the  spleen,  about  four  inches  long,  three  inches  deep,  and  one  inch  thick ; v ith  a no- 
dule, the  size  of  a large  bullet,  at  the  hilus  of  the  organ.  In  structure,  it  ivas  found  to  be 
simply  hypertrophied,  the  fusiform  cells  of  the  trabeculae  presenting  their  noiinal  charac- 
ter and  arrangement,  and  the  cells  of  the  pulp  unusually  abundant.  I also  received  por 
tions  of  the  clot  taken  from  the  heart,  vena  cava  ascendens,  and  vena  portae.  They 
presented  exactly  the  same  appearance  as  the  clot  in  case  CXCIX.,  divided  into  a dead- 
white  purulent-looking  layer,  and  a tolerably  strong  healthy-looking  red  one.  The 
former,  on  microscopic  examination,  was  almost  wholly  composed  of  colorless  corpuscles, 
aggregated  together  by  molecular  fibres  of  fibrin ; and  the  latter,  though  principally 
composed  of  colored  corpuscles,  also  contained  many  colorless  ones.  Two  of  the  en- 
larged mesenteric  glands  which  were  sent,  on  section  yielded  a copious  juice,  that  con- 
tained the  same  cells  as  are  represented  Fig.  50. 

Commentary. — This  boy  was  in  tlie  Infirmary  upwards  of  six  months, 
and  the  symptoms  and  entire  progress  of  the  case  were  watched  with  the 
greatest  care.  Unlike  the  former  case  the  spleen  was  the  only  organ 


LEUCOCYTHEMIA. 


877 


enlarged,  the  liver  presenting  its  normal  dulness  on  percussion.  The 
abdomen,  however,  was  also  the  seat  of  ascitic  distention.  The  smallest 
drop  of  blood  taken  from  the  boy's  finger  exhibited,  during  the  wdiole 
of  his  residence  in  the  Infirmary,  the  excess  of  colorless  corpuscles,  and 
the  number  of  these  underwent  no  perceptible  increase  or  diminution, 
notwithstanding  the  varieties  of  treatment  to  which  he  was  subjected. 
Owing  to  the  theories  which  have  been  from  time  to  time  advanced  re- 
garding the  functions  of  the  two  kinds  of  corpuscles  found  in  the  blood, 
and  of  the  nature  of  its  coloring  matter,  iron  was  the  drug  wnich 
seemed  indicated.  This  boy  had  also  lived  in  the  fenny  districts  of 
Lincolnshire ; and,  although  he  denied  ever  having  been  affected  with 
intermittent  fever,  it  seemed  very  probable  that  the  enlargement  of  the 
spleen  was  owing  to  this  cause.  I commenced  the  treatment,  therefore, 
with  the  exhibition  of  iron  and  quinine.  Other  symptoms,  however, 
became  so  urgent  as  to  demand  special  attention,  and  the  suspension  of 
these  remedies.  I allude  to  the  diarrhoea  and  dyspnoea,  the  former 
of  which  constituted  the  leading  symptom  of  the  disorder  during  the 
entire  period  he  remained  in  the  house.  All  kinds  of  astringents  were 
given,  with  occasional  temporary,  but  never  with  permanent  advantage. 
At  one  period  he  was  so  exhausted  that  for  some  weeks  I daily  expected 
his  death.  He,  however,  again  gained  strength ; and  his  bodily  powers, 
.except  towards  the  termination  of  his  residence  in  the  house,  were  sub- 
ject to  considerable  variations,  evidently  dependent  on  the  amount  of 
diarrhoea. 

In  April,  pulmonary  symptoms  were  added  to  his  other  complaints ; 
and  from  the  character  these  presented,  as  well  as  from  the  physical 
signs,  a strong  suspicion  was  formed  that  he  labored  under  phthisis 
pulmonalis.  Under  a tonic  treatment,  with  cod-liver  oil,  assisted  by  the 
advance  of  summer,  these  symptoms  diminished,  and  his  general  strength 
was  so  improved  that,  as  is  stated  in  the  report,  he  insisted  on  going 
home.  At  the  time  of  his  discharge  he  was  remarkably  ill,  greatly 
emaciated,  cachectic-looking,  with  an  enormous  abdomen, — so  that  it 
was  only  by  comparison  with  what  he  had  been  that  he  could  be  said  to 
enjoy  tolerable  strength.  It  seems,  however,  that  he  reached  Hull,  by 
the  steam-vessel,  in  safety,  and  lived  nearly  a twelvemonth  longer,  so 
that  altogether  he  was  under  medical  observation  nearly  eighteen  months, 
the  morbid  condition  of  the  blood  existing  during  the  whole  of  that 
time.  After  death  the  appearance  and  structure  of  the  coagulated  blood 
exactly  resembled  that  presented  in  the  former  case,  and  there  was  the 
same  hypertrophy  of  the  spleen  and  similar  enlargement  of  the  lymphatic 
glands,  but  not  to  so  great  an  extent.  The  liver,  however,  was  normal, 
and  the  lungs  externally  healthy,  but  not  cut  into. 

Dr.  Eobertson  was  kind  enough  to  analyse  the  blood  for  me  in  this 
case,  and  from  the  results  he  obtained,  it  appears  that  the  fibrin  was  in- 
creased to  about  double  its  amount  in  healthy  blood.  The  albumen  and 
salts  existed  in  their  normal  proportion.  The  globules  were  diminished 
to  about  one-half  their  proper  amount,  which  deficiency  was  counter- 
balanced by  an  increase  in  the  amount  of  water.  This  combination  of 
increase  in  the  anmunt  of  fibrin  and  diminution  in  the  amount  of  cor- 
puscles, indicates  a condition  of  the  blood  which,  so  far  as  I am  aware, 
is  not  peculiar  to  any  other  morbid  condition  of  the  economy. 


878 


DISEASES  OF  THE  BLOOD. 


Case  CCI.^ — Commencing  Leucocythemia  determined  during  Life — 
Enlarged  Spleen  and  Liver — Ascites. 

History. — Thomas  Welsh,  a sailor,  aet.  20 — admitted  into  the  clinical  ward  of  the 
Royal  Infirmary,  September  22d,  1851.  In  June  184Y,  he  first  experienced  a gnawing 
pain  in  the  left  side,  and  a hard  swelling  was  distinctly  felt  in  the  splenic  region. 
Shortly  afterwards  he  was  attacked  with  jaundice,  and  he  became  sensible  of  a swell- 
ing also  on  the  right  side  of  the  abdomen.  He  says  that,  owing  to  medical  treatment, 
this  latter  swelling  disappeared,  and  he  regained  his  health.  Since  then  he  has  occa- 
sionally had  attacks  of  jaundice,  and  the  abdomen  has  slowly  enlarged,  notwithstand- 
ing the  internal  use  of  large  quantities  of  mercury  and  iodine. 

Symptoms  on  Admission. — On  admission,  his  body  generally  is  emaciated ; the 
abdomen  is  considerably  enlarged,  measuring  thirty-two  inches  round  the  most  promi- 
nent part,  which  is  two  inches  above  the  umbilicus ; no  fluid  can  be  detected.  The 
hepatic  duhiess  measures  vertically  at  its  deepest  part  six  inches,  and  its  lower  margin 
can  be  distinctly  felt  below  the  ribs,  the  left  lobe  sweeping  backwards  and  upwards, 
and  apparently  coming  in  contact  with  the  spleen.  The  splenic  dulness  measures  verti- 
cally eight  and  a quarter  inches ; the  anterior  margin  can  be  distinctly  felt,  with  a 
notch  in  its  centre,  terminating  on  a level  with  the  upper  edge  of  the  iliac  bone. 
Bowels  are  generally  loose ; respiration  is  embarrassed  and  thoracic ; no  dulness  on 
percussion  over  the  chest ; no  cough,  but  occasional  sibilation  heard  on  auscultation  ; 
impulse  of  heart  feeble,  otherwise  normal ; pulse  78,  small  and  weak.  He  has  not  in- 
creased in  stature  since  he  was  sixteen,  and  has  the  external  aspect  of  a boy  of  that 
age ; generative  organs  not  developed  ; urine  healthy ; skin  of  a dingy  yellowish  color. 
On  microscopic  examination  of  the  blood,  it  was  ascertained  that  the  colorless  and 
colored  corpuscles  presented  their  normal  relative  number. 

It  is  unnecessary  to  follow  the  pr  ogress  of  this  case  minutely.  It  will  suffice  to 
say  that  the  bowels  every  now  and  then  became  very  loose ; he  occasionally  had 
epistaxis,  and  frequently  more  or  less  tenderness  over  various  parts  of  the  swollen  ab- 
domen. In  October  he  experienced  a severe  attack  of  acute  laryngitis,  from  which  he 
recovered  in  fifteen  days.  During  the  latter  part  of  December  ascites  came  on,  the 
excretion  of  urine  diminished  in  amount,  and  it  was  intensely  loaded  with  lithates. 
The  blood  had  been  examined  from  time  to  time,  and  on  the  third  of  January  a de- 
cided increase  of  the  colorless  corpuscles  was  observed.  A diuretic  treatment,  by  in- 
creasing the  amount  of  urine,  caused  the  ascites  to  diminish.  But  the  number  of 
colorless  corpuscles  gradually  increased,  so  that,  during  the  whole  of  February,  con- 
siderable groups  of  these  bodies  could  be  seen  betw'een  the  rolls  of  colored  discs  in  a 
demonstration  under  the  microscope.  Latterly,  his  general  strength  became  much 
diminished ; but  his  mother  insisted  on  taking  him  home  to  Berwick,  and  he  left 
the  Infirmary,  February  27,  1852.  I learnt  from  Dr.  Johnson  that  he  died  two  days 
after  reaching  Berwick.  There  was  no  post-mortem  examination. 

As  soon  as  it  was  determined  that  the  colorless  corpuscles  of  the  blood  had  de- 
cidedly increased,  I requested  Dr.  W.  Robertson  to  analyse  the  blood,  which  he  did  on 
the  7th  of  January,  with  the  following  results  : — The  blood  coagulated  firmly,  but  little 
serum  exuded  from  the  coagulum,  although  it  stood  undisturbed  for  forty-eight  hours. 


Surface  of  coagulum  flat,  and  thinly  coated  with  fibrin. 

Density  of  blood 1043  * 6 

“ of  serum 1027* 

Composition  of  1000 

Fibrin 3*2 

Serous  soUds,  | [ 80-7 

Globules 82*3 


Total  solids. 166*2 

Water.. 833*8 


1000 

Commentary. — Up  to  the  occurrence  of  the  present  case,  no  example 
of  leucocythemia  had  been  met  with  in  which  the  disease  was  seen  to 


Reported  by  Mr.  Wm.  M.  Calder,  Clinical  Clerk. 


LEUCOCYTHEMIA. 


879 


commence  and  progress.  It  will  be  observed  that  the  spleen  and  liver 
had  attained  a very  large  size  before  the  blood  became  affected. 
Nothing,  indeed,  can  be  more  various  than  the  mere  bulk  of  one  or 
more  of  the  blood  glands,  and  the  leucocythemic  condition  of  the  blood. 
In  several  cases  the  spleen  has  been  greatly  hypertrophied,  without  any 
change  in  the  blood  whatever.  The  true  explanation  of  these  apparent 
discrepancies  has  yet  to  be  discovered.  The  increase  of  colorless  cells 
must  commence  at  some  particular  time,  but  the  exact  period  of  com- 
mencement has  been  observed  subsequently  only  in  one  other  case  by 
Virchow. 

Case  COII.* — Eczema  of  the  Trunk  and  Limbs — Enlarged  Lymphatic 
Glands — Leucocythemna^  which  sensibly  diminished. 

History. — Peter  Smellie,  aet.  62,  workman  at  an  iron  foundry  near  Glasgow — 
admitted  October  4th,  1860.  Sixteen  years  ago  his  legs  and  ankles  first  became 
covered  with  an  eczematous  eruption,  which  disappeared  in  three  or  four  weeks,  but 
generally  returned  every  spring.  Four  years  ago  the  shoulders  were  affected,  and 
from  that  time  it  has  gradually  extended  in  patches  over  the  trunk  and  extremities. 
For  the  last  three  years  the  glands  in  the  groin  and  the  axillm  have  become  enlarged, 
and  three  abscesses  have  been  opened  in  the  right  groin,  the  formation  of  which  were 
preceded  by  febrile  symptoms. 

Symptoms  on  Admission. — The  entire  trunk  is  covered  with  chronic  eczema,  of  a 
dusky  red,  and,  in  some  places,  brown  color.  The  skin,  here  and  there,  is  indurated, 
and  from  the  entire  surface  copious  laminated  scales  are  peeling  off,  accompanied  by 
great  irritation  and  itching.  All  four  extremities  are  similarly  affected ; but  on  the 
legs  the  integument  is  dense  and  hard,  and  the  scales  so  thick  as  somewhat  to 
resemble  ichthyosis.  The  axillary  and  inguinal  glands  are  greatly  enlarged,  consisting 
of  bunches  of  tumors,  soft  to  the  feel,  and  varying  in  size  from  a hazel  nut  to  that  of 
a small  hen’s  egg.  Other  enlarged  glands  may  be  felt  behind  the  sterno-mastoid 
muscles,  and  at  the  flexure  of  the  elbows.  Another  gland,  size  of  a pigeon’s  egg, 
exists  on  the  left  side  of  the  thorax,  inside  the  nipple.  A soft  systolic  murmur  is 
audible  at  the  base  of  the  heart.  Pulse  69,  somewhat  weak.  Dulness  over  liver  and 
spleen  normal.  The  blood  contains  a great  increase  of  colorless  corpuscles,  with 
numerous  naked  nuclei,  exactly  similar  in  size  and  appearance  to  those  represented 
Fig.  622.  The  diseased  skin  over  thighs  and  trunk  was  ordered  to  he  kept  moist  with 
a light  alkaline  lotion  (see  Skin  Diseases,  p.  887),  and  the  legs  to  be  anointed  with  Ung. 
ZincL  Steak  diet. 

Progress  of  the  Case. — December  2%th. — Since  admission  the  eczematous  surface 
has  been  treated  by  the  alkaline  lotion  and  Ung.  Zinci,  and  is  now  everywhere  much 
better,  in  some  places  well,  and  entirely  free  from  itching  and  irritation.  The  glands 
in  the  axilla  and  groin  are  diminished  in  size.  January  \bih. — Dr.  Murray  Thomson 
was  kind  enough  to  analyse  the  blood  for  me,  with  the  following  results  : — 
Composition  of  1000  parts  of  blood. 


Fibrin 

Serous  solids, 
Globules 

j Organic, 

] Inorganic, 

80-54  i 

7*32  f 

87-87 

vo-ss 

Total  Solids 

Water 

828-97 

1000-00 

January  ^Qth. — The  skin  eruption  is  now  gone  from  the  trunk,  but  the  legs  remain 
indurated  and  of  a mahogany  color.  The  glands  are  much  reduced  in  size,  and  the 
colorless  corpuscles  in  the  blood  are  not  so  numerous.  Dismissed. 

Commentary. — This  man,  in  his  occupation  at  an  iron  foundry,  was 

* Reported  by  Messrs.  D.  Murray  and  J.  Saidler,  Clinical  Works. 


880 


DISEASES  OF  THE  BLOOD. 


constantly  exposed  to  the  heat  of  large  fires,  which  at  length  excited 
eczematous  inflammation  of  the  skin.  This  in  its  turn  caused  irritation 
and  enlargement  of  the  lymphatic  glands,  and,  as  a consequence,  leuco- 
cythemia.  The  colorless  corpuscles  in  the  blood  presented  exactly  the 
same  size  and  appearance  as  I previously  noticed  in  a case  of  cancerous 
enlargement  of  the  thyroid  and  lymphatic  glands  (Case  CLXIII.),  and 
could  leave  us  in  no  doubt  as  to  the  source  of  their  origin.  (Figs.  522 
and  523.)  It  was  interesting  to  observe  that,  as  the  skin  eruption  and 
irritation  diminished,  the  glandular  enlargements  and  the  leucocythemia 
diminished  also. 

The  four  previous  cases,  together  with  eight  others  previously  re- 
corded in  this  work  (Cases  LXXIII.,  LXXVIII.,  LXXXV.,  XCIY., 
CXXV.,  CLXIIL,  CLXXXIX.,  and  CXC.),  are  sufficient  for  the  study 
of  this  important  lesion  of  the  blood.  In  my  work  on  Leucocythemia, 
published  in  1852,  I have  given  thirty-seven  cases  more'  or  less  illustra- 
tive of  the  symptoms  and  pathology  of  the  disease.  Since  then  I have 
myself  met  with  a considerable  number  of  others,  and,  many  more  have 
been  published  in  the  British,  American,  French,  and  German  periodi- 
cals. Several  other  analyses  of  the  blood  also  have  been  made.  But 
very  little  advance  seems  to  have  occurred  in  our  knowledge  of  the 
pathology  and  treatment  of  leucocythemia  since  I wrote  in  1852,  whilst 
all  the  facts  which  have  been  published  confirm  the  conclusions  which  I 
then  arrived  at.  A systematic  account  of  the  symptoms  and  progress  of 
the  disease,  divided,  as  is  usual  among  French  writers,  into  three  stages, 
has  been  compiled  by  M.  Vidal,*  chiefly  from  the  facts  contained  in  my 
work.  It  has  been  carefully  done,  although  the  basis  as  regards  num- 
ber of  cases  (only  32)  is  not  sufficiently  large. 

Pathology  and  Treatment  of  Leucocyhtemia. 

If  the  blood  of  living  persons  affected  with  this  disease  be  examined 
microscopically  (which  is  most  readily  accomplished  by  extracting  a drop 
from  the  finger  by  pricking  it  with  a needle  and  placing  it  between 
glasses,  under  a power  of  250  diameters  linear),  the  colored  and  color- 
less corpuscles  will  be  at  first  seen  rolling  confusedly  together,  and  the 
excess  in  number  of  the  latter  at  once  perceived.  This,  however,  be- 
comes more  evident  after  a short  time,  when  the  colored  bodies  are  ag- 
gregated together  in  rolls,  leaving  clear  spaces  between  them,  which  are 
more  or  less  crowded  with  the  colorless  ones.  Means  are  altogether 
wanting  to  enable  us  to  determine  with  exactitude  the  relative  propor- 
tion of  the  two  kinds  of  corpuscles  in  different  cases.  In  some  the 
colorless  corpuscles  are  only  slightly  increased  beyond  their  usual  num- 
ber. In  one  case  they  are  described  as  five  times  as  numerous  as  those 
in  health.  They  are  also  said  in  particular  instances  to  be  “ greatly  in- 
creased,” “ one- third  as  numerous,”  and  “ as  numerous,”  as  the  colored 
corpuscles.  In  all  these  statements  there  is  nothing  exact.  Perhaps 
the  best  method  of  judging  is  to  regard  the  spaces  or  meshes  left  be- 
tween the  rolls  or  aggregations  of  yellow  blood  corpuscles.  When  these 
are  completely  filled  up,  the  colorless  bodies  do  not,  in  fact,  amount  to 
one-third  of  the  colored  ones,  on  account  of  the  large  number  of  the  lat- 


* Gazette  Hebdomadaire,  4 Avril  1856. 


LEUCOCYTHEMIA. 


881 


ter  whicli  may  exist  in  a small  space,  in  the  form  of  rouleaux.  This 
will  appear  upon  counting  them  in  Fig.  f)09,  p.  874. 

The  size  of  the  colorless  corpuscles  in  the  various  cases  given,  differs 
considerably.  Even  when  at  first  sight  they  appear  to  be  of  tolerably 
uniform  size  in  any  one  case,  it  may  be  observed,  when  they  are  magni- 
fied highly  and  carefully  measured,  that  some  are  twice  the  size  of  others, 
with  all  the  intervening  sizes 
between  them.  In  some  cases, 
though  comparatively  few  in 
number,  they  are  described  as 
being  three  or  four  times  larger 
than  the  colored  corpuscles, 
and  in  three  cases  they  were 


in  one  about  the  same  size,  or 
somewhat  smaller,  Fior.  514, 


© 

Fig.  512.  Fig.  518. 

and  in  two  others  of  two  sizes,  one  larger  and  the  other  decidedly  small- 
er, Figs.  522,  523. 

In  the  cases  in  which  the  blood  was  carefully  examined  after  death, 
the  same  variations  with  regard  to  number  and  size  of  the  colorless  cor- 
puscles were  found  to  exist,  as  have  just  been  referred  to  in  blood  drawn 
fresh  from  the  finger.  It  was  always  observable,  however,  that  they 
were  most  numerous  in  the  clot ; and  when  they  existed  in  any  number, 
as  in  case  CXCIX.,  they  communicated  to  the* colorless  coagulum  a 
peculiar  dull,  whitish  look,  and  rendered  it  more  friable  under  pressure. 
When  less  numerous,  portions  of  the  colorless  coagulum  from  the  heart 
and  large  vessels  might  be  seen  to  present  a dull  cream  color,  easily  dis- 
tinguishable from  the  gelatinous  and  fibrous  appearance  of  a healthy  clot, 
and  such  altered  portions  always  contained  a large  number  of  the  color- 
less bodies. 

The  blood  has  been  carefully  examined  chemically  in  several  cases, 
from  which  it  would  appear  that  there  is  generally  an  excess  of  the  fibrin 
and  diminution  of  the  corpuscles.  The  former  ranges  from  3 to  7 parts, 
and  the  latter  from  100  to  49  parts  in  a thousand.  In  a well-recorded 
case  by  Dr.  Wallace  of  Greenock,  the  blood  was  analysed  by  Dr.  W. 
Kobertson,  and  ascertained  to  contain  in  1000  parts  only  1'5  of  fibrin, 
and  79’  of  corpuscles.^ 

The  organs  which  have  been  found  most  uniformly  diseased  are  the 
spleen,  the  liver,  and  lymphatic  glands.  The  spleen^  in  the  great  ma- 
jority of  cases,  has  been  enlarged,  varying  in  weight  from  one  to  above 
nine  pounds.  The  texture  of  the  organ  varied  in  different  cases — in 
some  being  of  unusual  density,  in  others  it  was  natural,  and  in  a third 
class  was  more  or  less  pulpy.  In  a few  cases  it  contained  yellowish 
masses,  apparently  a form  of  deposit,  but  in  reality  degenerated  tissue. 
In  most  cases  the  cell  and  nuclear  elements  of  the  pulp  were  increased 
in  amount,  while  the  fibrous  portion  of  the  organ  was  apparently  normal. 
Merc  enlargement  of  the  spleen,  however,  is  not  necessarily  connected 
with  leucocythemia,  as  I have  met  with  many  cases  where  it  has  been 
greatly  hypertrophied  without  appreciable  alteration  of  the  blood.  It  has 
* Glasgow  Journal,  April  1855. 

Fig.  512.  Colorless  corpuscles  slightly  increased  in  number. 

Fig.  513.  The  same  after  the  addition  of  acetic  acid. 

56 


250  diam. 


882 


DISEASES  OF  THE  BLOOD. 


appeared  to  me  that  in  such  instances  the  enlargement  is- more  owing  to 
congestion  and  fibrous  hypertrophy,  than  to  increase  in  cell  elements. 
!Next  to  the  spleen,  t\\eliver  is  most  commonly  found  diseased  in  leucocy- 
themia.  In  the  majority  of  cases  it  is  simply  hypertrophied,  and  in  a 

few,  cirrhosed  in  various  stages,  or 


G'\ 


Fisr.  515. 


cancerous.  The  lymphatic  glands 
• (C)®*  frequently  enlarged.  In 

most  cases  they  are  soft,  presenting 
on  section  a granular  whitish  ap- 
pearance, and  yielding  a copious 
turbid  juice  on  pressure.  In  a 
few  cases  they  were  indurated, 
loaded  with  calcareous  deposits,  or 
infiltrated  with  cancerous  or  tuber- 
cular exudation.  The  solitary  and 
aggregated  glands  of  Payer  have  also  been  found  hypertrophied  in  a few 
cases.  The  thyroid  body  was  cancerous  in  one  case,  and  evidently  gave 
rise  to  the  leucocythemia  (Case  CXCIII.) ; and  in  certain  cases  of 
bronchocele,  in  which  the  blood  was  examined  by  Drs.  Holland  and 
Neale,  a similar  condition  was  observed.  Hr.  Addison  has  also  shown, 
in  tv/o  of  his  cases  of  disease  of  the  supra-renal  capsules,  that  the  blood 
w’as  leucocythemic.  Other  lesions  which  have  been  occasionally  found 
in  cases  of  leucocythemia  are  evidently  accidental,  and  in  no  way  con- 
nected with  that  morbid  state  of  the  blood  which  we  are  now  con- 
sidering. 

Relation  existing  between  the  Colorless  and  Colored  Corpuscles  of  the 
Blood. — Many  physiologists  have  maintained  that  the  colored  corpuscles 
are  formed  from  the  colorless  ones;  and  among  those  who  hold  this 
opinion,  some  have  supposed  that  the  latter  bodies  are  directly  trans- 
formed into  the  former  (Paget*).  Others,  again,  contend  that,  whilst 
such  may  be  the  case  in  fishes,  reptiles,  and  birds,  in  mammals  the 
colored  disc  is  merely  the  liberated  nucleus  of  the  colorless  cell  (Whar- 
ton Jonesf).  From  the  observations  I have  made  on  the  blood  cor- 
puscles in  cases  of  leucocythemia,  the  latter  appears  to  me  to  be  the 
more  correct  opinion. 

The  mode  of  transformation  of  the  nucleus  of  the  colorless  cell  into 


Fig.  516. 

the  flattened,  biconcave,  colored  disc,  has  not  yet  been  described  ; but, 
from  the  appearances  I have  observed,  it  would  seem  to  take  place  in  the 

* Kirke’s  Physiology,  pp.  68,  69.  •}■  bond.  Phil.  Trans.,  1846. 

Fig.  5M.  Colorless  corpuscles  increased  in  number,  and  of  small  size. 

Fig.  516.  The  same  after  the  addition  of  acetic  acid.  250  diam. 

Fig.  516.  Colorless  blood-cells  observed  in  leucocythemia,  showing  the  different 
appearances  of  the  nuclei,  placed  in  the  presumed  order  of  their  development.  600  di. 


LEUCOCYTHEMIA. 


883 


following  maimer  : — The  colorless  cell  may  frequently  be  seen,  on  the 
addition  of  acetic  acid,  to  have  a single  round  nucleus.  But  more  com- 
monly the  nucleus  is  divided  into  two,  each  half  having  a distinct  depres- 
sion, presenting  a shadowed  spot  in  its  centre.  Occasionally,  before  the 
division  takes  place,  the  nucleus  becomes  oval,  and  sometimes  is  elon- 
gated, more  or  less  bent,  and  even  of  a horse-shoe  form.  Not  unfre- 
quently  the  nucleus  is  divided  into  three  or  four  granules,  each  having 
the  central  shadowed  spot.  All  the  appearances  given.  Fig.  516,  have 
been  frequently  observed,  and  I have  placed  them  in  the  presumed  order 
of  development. 

On  two  occasions  the  colorless  bodies  in  the  blood  were  of  two  dis- 
tinct sizes.  The  smaller  were  evidently  free  nuclei,  such  as  could  be 
observed  within  the  larger.  (See  Figs.  522  and  523.)  On  examining 
these  latter,  after  the  addition  of  acetic  acid,  all  the  appearances  repre- 
sented in  the  accompanying  figure  were  observable,  and  these  I have 

© 

a h Fig.  517. 

again  placed  in  the  presumed  order  of  development.  On  examining  the 
lymphatic  glands  in  the  first  of  these  cases,  they  were  observed  to  con- 
tain the  first  body  figured  («)  in  great  numbers,  associated  with  a few 
of  the  second  one  (h). 

On  several  occasions  the  blood,  when  crowded  with  colorless  cor- 
puscles, was  removed  from  the  arm  by  venesection ; and  it  was  observed, 
that  after  standing  twenty-four  hours  those  variously-shaped  nuclei  had 
become  of  a straw  color,  and  exactly  resembled  the  colored  discs  in  tint. 
It  was  immediately  apparent  that  they  had  imbibed  the  coloring  matter 
of  the  blood,  leaving  the  cell  which  surrounded  them  perfectly  trans- 
parent. (See  Fig.  511,  p.  875.) 

With  a view  of  still  further  determining  the  transitional  changes  in 
the  colorless  cells,  I performed  the  following  experiment : — A rabbit 
was  killed  three  hours  after  having  eaten  a meal.  The  thorax  was 
rapidly  opened,  and  a ligature  placed  round  the  pulmonary  artery,  to 
prevent  the  corpuscles  coming  from  the  thoracic  duct  passing  into  the 
lungs.  The  abdomen  was  then  pressed  gently  for  a few  moments  to 
favor  the  flow  of  chyle,  and  then  a ligature  placed  round  the  large  ves- 
sels, and  the  heart  removed  by  cutting  above  it.  On  examining  the  blood 
in  the  right  ventricle,  it  presented  an  unusually  large  number  of  color- 
less cells,  the  nuclei  of  which,  on  the  addition  of  acetic  acid,  exhibited 
all  the  transition  stages  figured  Fig.  516.  On  examining  the  blood  in 
the  left  ventricle,  the  colorless  cells  were  found  normal  in  amount.  This 
experiment  was  repeated  with  the  same  results. 

I am  therefore  of  opinion,  with  Valentin  and  Wharton  Jones,  that 
the  colored  blood  corpuscles  in  mammals  are  free  nuclei.  But  I do  not 
consider,  with  the  latter  observer,  that  these  nuclei  in  mammals  should 
necessarily  proceed  so  far  in  development  as  to  be  surrounded  with  a 

Fig.  517.  Presumed  development  of  the  nucleus  in  colorless  blood-cells,  in  another 
case  of  leucocythemia.  500  diam. 


884 


DISEASES  OF  THE  BLOOD. 


© © © 


Fish 

(Haddock). 


Reptile 

(Frog). 


Bird 

(Turkey). 


cell-wall, — in  other  words,  the  colored  disc  is  not  always  a further  phase 
in  the  evolution  of  the  colorless  cell.  On  the  contrary,  I believe  that 
the  vast  majority  of  the  colored  blood  discs  simply  reach  the  nuclear 
stage  of  growth  before  they  join  the  circulation.  Many  of  them,  how- 
ever, do  proceed  beyond  this  point  in  development,  and  may  be  seen  to 
have  cell-walls  around  them.  Under  such  circumstances,  the  nuclei  in- 
crease endogenously  by  a process  of  fissiparous  division,  in  the  manner 
formerly  described,  circulate  in  the  blood  within  colorless  cells,  and,  on 
the  solution  of  the  cell-wall,  also  become  colored  blood  discs. 

1 have  further  examined  the  blood  of  birds,  reptiles,  and  fishes,  and 

have  been  enabled  to  observe 
transitional  forms  between  the 
colorless  and  colored  cell, 
with  even  greater  facility  than 
I could  in  man.  Indeed,  the 
attention  once  directed  to  this 
point,scarcely  a demonstration 
of  blood  can  be  made  in  these 
animals  without  seeing  abun- 
dant evidence  that  the  latter 
is  a transformation  from  the 
former.  In  them,  however,  the  colorless  cell,  at  first  round,  enlarges 
gradually,  becoming  oval,  and  color  is  added  to  it.  The  nuclei,  also, 
^ Q Q g o after  the  addition  of  acetic  acid,  may  be  ob- 

^ O served  in  these  animals  to  be  undergoing 

® © © V § O Turkey,  fissiparous  multiplication  within  the  cells. 

Haddock.  Thus  all  the  appearances.  Fig.  519,  may 
readily  be  seen.  Hence  the  same  mode  of 
endogenous  development  may  take  place  in 
the  blood-cells  of  all  the  vertebrated  tribes  of  animals,  the  ditference 
being,  that  whilst  in  birds,  reptiles,  and  fishes,  the  corpuscles  retain  the 
form  of  nucleated  cells,  in  mammals  we  find  the  majority  of  them  to  be 
free  nuclei. 

Origin  of  ilie  Blood  Corpuscles. — Hewson  was  the  first  who  distinctly 
stated  that  the  blood  corpuscles  were  derived  from  the  lymphatic  glands, 
yet  few  have  adopted  his  opinions.  Even  Cruickshank,  who  wrote  on 
the  lymphatic  system  immediately  after  him,  and  was  one  of  his  con- 
temporaries, says  of  the  lymphatic  fluid  in  which  these  corpuscles  swim, 
“ that  we  do  not  know  the  use  of  this  fluid.”^  The  correctness  of  Hew- 
son’s  views  is  not  even  clearly  admitted  by  his  recent  commentator,  Mr. 
Grulliver,t  and  has  been  denied  by  most  physiologists  in  this  country ; 


Fig.  518. 


© © § 


Fig.  519. 


* The  Anatomy  of  the  absorbing  Vessels  of  the  Human  Body.  London,  4to, 
1786.  P.  73. 

f The  W orks  of  William  Hewson,  F.  R.  S.,  edited  by  George  Gulliver,  F.  R.  S.  L. 
Printed  for  the  Sydenham  Society.  Note,  p.  281. 

Fig.  518.  Cells  of  various  sizes,  colorless  and  colored,  observed  in  the  blood  of  a 
haddock,  frog,  and  turkey,  placed  in  the  order  of  their  supposed  development.  The 
three  first  bodies  figured  in  each  line  are  colorless. 

Fig.  519.  The  nuclei  of  the  blood-cells  of  the  haddock,  frog,  and  turkey,  as  seen 
after  the  addition  of  acetic  acid.  450  diam. 


LEUCOCYTHEMIA. 


885 


» •'  .o 


O' 


and  although  Nasse,  Wagner,  Muller,  and  a few  others,  have  contended 
that  the  lymph  corpuscles  in  the  blood  are  the  same  as  those  found  in 
the  lymphatic  vessels,  the  mode  of  their  origin  and  their  functional  im- 
portance is  not  even  alluded  to. 

On  examining  the  chyle  in  the  lacteals  ramifying  below  the  serous 
coat  of  the  intestine,  it  is  found  to  consist  of  a multitude  of  minute  fatty 
molecules,  floating  in  a fluid  (See  Fig.  462,  p.  743).  These  diminish  in 
number  as  the  chyle  progresses  towards  the  thoracic  duct,  in  which  it  is 
found  to  contain  a number  of  free  nuclei,  mingled  with  a few  others  which 
are  surrounded  by  a delicate  cell-wall.  The  free  nuclei  may  frequently 
be  observed  in  mammals  to  present  the  same  size  and  bi-concave  discoid 
form  of  the  colored  blood  corpuscles  (Fig.  462,  a).  Moreover,  on  the 
addition  of  water,  they  in  like  manner  become  globular,  and,  after  the 
fluid  has  been  allowed  to  evaporate  a little,  assume  a puckered  or  crenated 
appearance.  They  only  differ  in  their  want  of  color,  and  in  not  being 
partially  soluble  on  the  addition 

of  acetic  acid  (Figs.  462,  a;  -'0'^  \ •.rr.-j..- 

520,  and  521).  On  cutting  '! 

into  a well-formed  lymphatic 
gland,  and  examining  the  juice  ' 
which  may  be  squeezed  from  * ‘ . 
it,  it  will  be  found  to  contain  '■j/ 

numerous  free  nuclei  and  nude-  ‘ * 

ated  cells.  These  are  evidently  Fig-  520,  Fig.  521. 

the  same  bodies  as  are  found  in  the  lymph  and  chyle,  and  those  found  in 
the  latter  closely  resemble  the  colorless  cells  of  the  blood.  The  nucleus 
of  these  corpuscles  also  may  frequently  be  observed  to  have  undergone 
the  fissiparous  division  formerly  described,  and  to  exhibit  various  stages 
of  this  process  in  chyle  taken  from  the  thoracic  duct.  The  opinion, 
therefore,  held  by  many  physiologists,  that  the  colorless  cells  of  the 
blood  and  those  of  chyle  or  lymph  are  the  same,  and  consequently  that 
in  the  highest  class  of  animals  they  are  not  formed  in  the  blood  itself, 
but  before  they  are  mixed  with  that  fluid,  seems  to  be  well  founded. 

According  to  Henle,  the  molecules  of  the  chyle  unite  together  in 
order  to  form  the  nuclei,  which  are  afterwards  surrounded  by  an  enve- 
lope.* These,  he  thinks,  are  delayed,  and  become  more  fully  developed 
in  the  lymphatic  glands.f  Nasse|  also  states  that  he  has  seen  aggrega- 
tions of  the  chyle  molecules  and  granular  bodies  formed  before  they 
reach  the  lymphatic  glands.  On  the  other  hand,  it  is  certain  that  both 
nuclei  and  cells  are  most  abundant  in  the  glands  themselves,  and  the 
cases  of  leucocythemia  prove  that  excess  of  colorless  cells  in  the  blood 
is  not  dependent  upon  an  increase  in  the  amount  of  chyle  molecules,  but 
is  coincident  with  the  enlargement  of  the  spleen  and  other  glandular 


O' 


* Anatomie  Gencrale,  par  Jourdain.  Tom.  i.  p.  455. 
f Anatomie  Generale,  par  Jourdain.  Tom.  ii.  p.  103. 
Wagner’s  Handworterbuch.  Arts.  Chylus  and  Lymphe. 


Fig.  620.  Fluid  chyle,  mingled  with  water,  taken  from  the  thoracic  duct  of  a cat 
three  hours  after  it  had  been  fed  on  milk. 

Fig.  521.  The  same  after  the  addition  of  acetic  acid.  . 


250  diam. 


886 


DISEASES  OF  THE  BLOOD. 


organs.  It  is  to  these,  therefore,  we  must  attribute  the  principal  influ- 
ence in  the  formation  of  the  colorless  cells,  and  to  them  evidently  we 
must  look  for  the  origin  of  the  blood  corpuscles. 

Hewson  considered  the  lymphatic  glandular  system  to  consist  of  the 
spleen,  thymus,  and  l^unphatic  glands.  He  believed  that  particles  were 
produced  in  these  organs,  which  ultimately  became  the  blood-corpuscles, 
and  that  the  spleen  especially  served  to  secrete  the  coloring  matter 
which  surrounded  them.  This  doctrine,  though  supported  to  a greater 
or  less  extent  by  some  German  authors,  has  been  repudiated  by  all 
British  physiologists  up  to  1852.  Mr.  Simon* * * §  declares  it  to  be  im- 
possible that  the  globules  of  the  thymus  can  enter  the  lymphatic  or 
blood-vessels,  on  account  of  the  limitary  membrane  within  which  they 
are  enclosed.  But  that  they  do  find  their  way  into  those  vessels  was 
shown  by  Hewson  and  Sir  Astley  Cooper,!  who  found  them  there;  and 
that  the  colorless  corpuscles  of  the  spleen  and  lymphatic  glands  enter 
the  blood  in  large  numbers  is  proved  by  what  occurs  in  leucocythemia, 
and  by  the  great  preponderance  of  the&e  bodies  at  all  times  in  splenic 
and  portal  blood. 

But  there  are  other  glands  which  must  be  associated  with  those  just 
mentioned  as  part  of  the  lymphatic  system,  such  as  the  thyroid  body 
and  supra-renal  capsules.  The  pituitary  and  pineal  glands  have  also 
been  referred  to  the  same  class  of  organs  by  Oesterlen  ! Without  en- 
tering into  lengthy  anatomical  details  of  each,  it  may  be  said  that  all 
these  organs  resemble  one  another  in  the  following  particulars : — 

1.  They  consist  of  a fibrous  stroma,  enclosing  spaces  lined  by  a 
structureless  membrane,  which  spaces  are  filled  with  colorless  molecules, 
nuclei,  and  cells,  in  all  stages  of  development. 

2.  The  corpuscles  of  all  these  glands  resemble  one  another, — the 
nuclei  corresponding  in  size  to  the  colored  blood-discs  of  mammals,  and 
the  cells  corresponding  to  the  colorless  corpuscles  of  the  blood.  The 
very  slight  differences  which  do  exist  are  at  once  explained  by  variations 
in  the  degree  of  development. 

3.  They  have  no  excretory  ducts,  so  that  if  the  corpuscles  formed  in 
them  are  to  leave  the  organs  in  which  they  originate,  it  can  only  be  by 
the  lymphatics  or  veins. 

Now,  it  is  certain  that  the  blood  of  the  splenic  and  portal  veins,  even 
in  health,  is  always  richer  in  colorless  corpuscles  than  that  of  the  sys- 
temic circulation.^  It  is  also  well  known  that  in  young  animals  the 
blood  contaius  a larger  number  of  the  bodies  than  it  does  in  their  adult 
condition — that  is,  when  all  these  glands,  including  the  thymus,  thyroid, 
and  supra-renal  capsules,  are  fully  developed  and  in  a state  of  activity. 
In  leucocythemia,  we  observe  that  when  these  glands  are  hypertrophied 
and  their  corpuscular  elements  are  multiplied,  the  colorless  corpuscles 
of  the  blood  are  increased  in  number.  Two  very  carefully  made  obser- 
vations, however,  appear  to  me  sufficient  in  themselves  to  determine  the 

* On  the  Thymus  Gland,  p.  91. 

- f Anatomy  of  the  Thymus  Gland,  pp.  15  and  43. 

X Beitrage  zur  Physiologie  des  gesunden  und  kranken  Organismus.  Jena,  1843. 

§ This  well-known  fact  has  been  confirmed  by  the  careful  observations  of  Funke. — 
Henle's  Zeitschrift,  1851,  p.  172. 


LEUCOCTTHEMIA. 


887 


0 

Q> 

o * * 

. ® © 
'r.  © . 

0 

o 

© 

. " o 

w 

""'o  O 

© o 

Fig.  522. 

Fig.  523. 

connection  of  these  lymphatic  glands  with  the  cells  of  the  blood.  Thus 
in  Case  CXCIIL,  where  the  thyroid  body  was  enlarged,  its  cells  and  their 
included  nuclei  were  considerably  smaller  than  usual,  and  it  was  ascer- 
tained that  the  colorless  bodies 
in  the  blood  and  their  nuclei 
were  smaller  also  (Figs.  463 
and  464,  p.  755,  and  Fig.  514, 
p.  882).  In  two  cases  it  was 
seen  that  the  colorless  cor- 
puscles in  the  blood  were  of  two 
distinct  sizes,  the  smaller  corre- 
sponding with  the  nuclei  of  the 
larger  ones,  and  in  one  of  them 
the  lymphatic  glands  were 
found  to  be  crowded  with  corpuscles,  also  of  two  distinct  sizes,  exactly 
corresponding  to  those  in  the  blood  (Figs.  522  and  523).  From  these 
facts,  we  can  have  little  doubt  that  the  colorless  corpuscles  are  formed 
in  the  lymphatic  glands,  and  from  thence  find  their  way  into  the  blood. 

By  what  channel  they  effect  this,  whether  by  the  lymphatics,  the 
veins,  or  by  both,  it  is  very  difficult  to  determine.  The  limitary  mem- 
brane which  surrounds  the  saccular  glands  is  exceedingly  delicate ; in- 
deed, so  much  so,  that  its  existence  has  been  denied  by  some  observers. 
When  distended,  therefore,  it  may  easily  break,  and  the  contents  be 
poured  into  the  pulp,  surrounding  stroma,  or  blood-vessels.  Dr.  Sanders* 
has  shown  that  the  Malpighian  sacs  of  the  spleen  are  traversed  by  very 
large  vessels,  and  Mr.  Gray  has  attempted  to  demonstrate  an  intimate 
relation  between  the  former  and  the  splenic  veins.f  But  it  Taust  be  ac- 
knowledged, that  notwithstanding  the  certainty  which  exists  as  to  the 
connection  between  the  closed  lymphatic  glands  and  the  blood-vessels, 
and  the  passage  of  corpuscles  from  one  to  the  other,  the  method  by 
which  this  is  accomplished  has  not  yet  been  satisfactorily  shown.  I can- 
not help  thinking,  however,  that  there  must  be  a direct  venous  commu- 
nication. 

Of  late  years  physiologists  have  been  in  the  habit  of  calling  these 
glands  the  blood  glands,  although  nothing  more  definite  has  been  deter- 
mined with  regard  to  them  than  that  they  are  in  some  way  subservient 
to  nutrition,  especially  during  an  early  period  of  life.  But  if  I have 
been  successful  in  establishing  that  the  corpuscular  elements  found  in 
these  organs  are  transformed  into  those  of  the  blood,  it  will  follow  that 
the  lymphatic  glands  secrete  the  blood  corpuscles  in  the  same  manner  as 
the  testes  secrete  the  spermatozoa,  the  mammae  the  globules  of  the  milk, 
or  the  salivary  and  gastric  glands  the  cells  of  the  saliva  and  gastric  juice. 

With  regard  to  the  exact  mode  in  which  the  corpuscles  are  formed 
in  the  glands,  two  theories  exist,  both  of  which  are  dependent  upon  nu- 


* Report  of  Physiological  Society  of  Edinburgh  for  January  31st,  1862.  Monthly 
Journal  for  February  1852. 

jf  On  the  Spleen,  pp.  233-34.  1854. 


Fig.  522.  Numerous  naked  nuclei  with  the  colorless  corpuscles  of  the  blood. 
Fig.  523.  The  same  after  the  addition  of  acetic  acid.  250  diam. 


888 


DISEASES  OF  THE  BLOOD. 


merous  facts  and  observations  closely  connected  with  the  origin  of  all 
vital  structures,  and  indeed  of  organization  itself.  One  is,  that  tliev  are 
thrown  off,  in  the  form  of  epithelium,  from  the  membrane  which"  sur- 
rounds them ; the  other,  that  they  originate  in  an  organic  fluid,  by  the 
production  of  molecules,  the  successive  development  and  aggregation  of 
which  constitute  the  higher  formations.*  I have  long  been  of  opinion 
that  the  latter  theory  is  the  more  consistent  with  known  facts,  and  cer- 
tainly all  that  I have  seen  during  repeated  investigations  into  the  struc- 
ture of  the  various  lymphatic  glands  is  in  harmony  with  it.  Nowhere 
have  I seen  the  nuclei  and  cells  of  these  glands  attached  to,  or  apparently 
given  off  from,  a membrane,  still  less  from  supposed  fixed  germs,  but 
everywhere  pervading  a molecular  fluid  within  the  closed  sacs.  But 
however  produced,  whether  from  molecules  or  fixed  germs,  it  is  here  they 
are  formed,  and  are  subsequently  thrown  into  the  torrent  of  the  circula- 
tion— there,  color  is  added  to  them,  and  they  become  blood  corpuscles. 
Multitudes  of  free  nuclei  in  this  way  join  the  blood,  and  are  at  once  con- 
verted into  colored  blood  discs.f  The  cells,  which  in  health  are  com- 
paratively few  in  number,  circulate  for  a time  as  colorless  corpuscles, 
but  after  a certain  period  their  walls  dissolve,  when  their  included  nuclei 
also  become  colored  discs.  In  leucocythemia  the  colorless  cells  are 
increased,  whilst  the  free  nuclei  are  diminished  in  number.  The  conse- 
quence is,  that  the  former  are  developed  at  the  expense  of  the  latter,  and 
as  they  do  not  become  colored  on  reaching  the  lungs,  the  formation  of 
red  blood  is  more  or  less  checked.  In  the  three  inferior  vertebrate 
tribes,  the  entire  cell  becomes  oval,  and  assumes  color. 

All  that  is  known  of  the  development  of  the  blood  corpuscles,  on  the 
one  hand,  and  of  the  blood  glands  on  the  other,  supports  the  theory  now 
brought  forward.  The  primitive  production  of  blood  in  the  embryo 
occurs  in  the  interior  of  cells  in  the  vascular  layer  of  the  germinal 
membrane,  which  cells  are  afterwards  transformed  into  vessels.  At  this 
period  the  colorless  cells  are  very  abundant,  and  their  nuc’ei  maybe 
seen  to  undergo  the  fissiparous  mode  of  multiplication  formerly  described  ; 
the  cells  themselves  also  in  this  foetal  condition  multiply  by  division,  j 
In  the  invertebrate  tribes,  there  are  no  lymphatic  vessels  or  glands.  In 
fact  there  is  only  one  circulation,  which  has  been  shown  by  IMilne  Ed- 
wards to  consist  of  a series  of  tubes,  analogous  to  arteries  or  veins,  which 
communicate  by  means  of  lacunae  that  surround  viscera.  But  the  cir- 
culating fluid  contains  two  distinct  kinds  of  corpuscles,  which  Mr. 
Wharton  Jones  has  shown  to  be  different  phases  of  each  other,  and  to 
correspond  with  the  colorless  and  colored  corpuscles  of  fishes,  reptiles, 
and  birds.  In  fishes  a lymphatic  system  exists  separately,  and  in  them 

* Report  of  Physiological  Society  of  Edinburgh  for  January  31st,  1852.  Monthly 
Journal  for  April  1852. 

f In  making  this  statement,  I am  aware  of  the  possibility  of  these  nuclei  being 
surrounded  by  a cell-wall  so  fine  as  not  to  be  detected  by  the  best  instruments.  But 
having  confirmed  the  observations  made  originally  with  Oberhaeuser’s  microscope,  by 
means  of  an  excellent  lens  by  Ross,  of  one-eighth  of  an  inch  focus,  with  the  most 
careful  attention  to  the  management  of  the  light,  it  is  my  conviction  that  the  great 
majority  of  these  bodies  possess  no  cell-walls. 

These  changes  are  well  figured  by  Fahrner. — De  Olobuloruni  Sanguinis^  etc., 
Turici,  1845. 


LEUCOCTTHEMTA. 


889 


we  first  observe  a pituitary  body,  supra-renal  capsules,  and  a spleen.  In 
reptiles  there  are  added  the  thymus  and  thyroid  glands,  and  in  both  these 
classes  of  animals  the  communications  between  the  blood-vessels  and  lym- 
phatics are  numerous  and  direct.  In  birds  we  first  observe,  in  addition, 
glands  on  the  lymphatics  of  the  neck,  but  not  on  the  lacteals,  and  there 
are  two  thoracic  ducts.  In  the  mammalia  the  highest  development  of 
the  lymphatic  glandular  system  exists,  including  mesenteric  and  lympha- 
tic glands,  a spleen,  thymus,  thyroid,  pineal  and  pituitary  bodies,  and 
supra-renal  capsules.  Thus,  we  observe  a correspondefice  between  the 
amount  of  corpuscular  elements  in  the  blood,  and  the  extent  and  com- 
plexity of  the  lymphatic  glandular  system.  The  corpuscles  are  compar- 
atively few  and  colorless  in  most  of  the  invertebrata,  and  in  such 
animals,  as  stated  by  Wagner,  should  be  considered  analogous  to  those 
of  lymph.  They  become  more  numerous  and  colored,  with  the  appear- 
ance of  a spleen  and  supra-renal  capsules,  in  fishes.  Both  in  fishes  and 
reptiles,  however,  the  colorless  cells  are  numerous.  In  birds  the  color- 
ed cells  are  smaller,  but  still  nucleated ; and  in  mammals  the  colored 
bodies  are  free  nuclei,  and  are  even  much  more  abundant. 

Again,  it  has  been  supposed  that  the  colored  cannot  be  formed  from 
the  colorless  bodies  of  the  chyle, — 1st,  Because  the  former  can  be  seen 
of  all  sizes  in  the  blood  itself;  2d,  Because,  on  examining  the  blood  of 
foetal  animals,  no  intermediate  stages  of  growth  can  be  seen  between 
them ; and  third,  Because,  on  the  addition  of  acetic  acid,  while  the 
colored  bodies  are  nearly  dissolved,  the  naked  nuclei  of  the  chyle  are 
not,  and  hence,  it  is  said,  they  are  of  different  chemical  composition. 

With  regard  to  the  first  argument,  derived  from  variations  in  the 
size  of  the  colored  particles,  it  may  be  said  that,  granting  the  fact, 
nuclei  may  also  be  observed  both  free  and  within  cells,  of  all  sizes,  so 
that  they  correspond  perfectly  with  the  colored  corpuscles  of  the  blood. 
Besides,  in  different  cases  of  leucocythemia,  although  the  colorless  cells 
have  been  seen  to  be  smaller,  of  the  same  size,  somewhat  larger,  and 
even  twice  as  large  as  the  colored  bodies,  their  nuclei  may  always  be  ob- 
served to  correspond  exactly  with  the  different  phases  of  the  latter. 
With  regard  to  the  second  argument,  advanced  by  those  who  have  not 
succeeded  in  detecting  transition-forms  in  embryonal  blood,  I am  per- 
suaded that  this  arises  from  the  circumstance  that  attention  is  directed 
to  the  colorless  cells,  instead  of  to  their  nuclei.  For  my  own  part,  I 
have  never  failed  to  observe  all  the  changes  previously  described,  not 
only  in  foetal,  but  even  in  adult  blood.  As  to  the  third  objection,  in 
reference  to  dissimilarity  of  chemical  composition,  it  must  be  remem- 
bered that  when  the  chyle  corpuscles  enter  the  circulation  by  the  left 
jugular  or  sub-clavian  vein,  they  pass  immediately  through  the  pulmon- 
ary artery  into  the  lungs,  come  in  contact  with  oxygen,  and  undergo 
chemical  changes  with  which  we  are  as  yet  unacquainted.  Some  phy- 
siologists have  supposed  that  color  is  added  to  them  before  they  join  the 
pulmonary  circulation,  because  yellow  corpuscles  have  been  seen  in  the 
upper  extremity  of  the  thoracic  duct.  In  all  such  observations,  how- 
ever, they  have  been  necessarily  exposed  to  the  atmosphere  ; and  I have 
frequently  confirmed  the  observation  of  Emmert,  viz.,  that  the  coagulum 
of  chyle,  at  first  colorless,  becomes  pinkish-red  in  contact  with  air.  On 


890 


DISEASES  OF  THE  BLOOD. 


this  point  I offer  no  opinion,  believing  that  neither  chemistry  nor 
physiology  has  as  yet  communicated  to  us  any  exact  information  with 
regard  to  the  when  or  how  ha3inatin  is  produced.  But  whatever  the 
changes  may  be  which  occur  in  the  lymph  corpuscles  on  their  passage 
into  the  lungs,  to  those  organs  we  must  attribute  the  alteration  in  their 
chemical  constitution,  as  they  are  colorless  and  insoluble  in  the  lympha- 
tic glands  and  in  chyle,  but  colored  and  partially  soluble  in  the  torrent 
of  the  circulation. 

Moleschott,*  having  found  the  colorless  cells  increase  in  the  blood  of 
the  frog  after  excision  of  the  liver,  supposes  that  it  is  in  the  latter  organ 
color  is  added  to  the  blood.  In  man  we  have  seen  that  the  structural 
diseases  of  the  liver  are  frequently  associated  with  enlargement  of  the 
spleen  in  leucocythemia,  but  in  other  cases  the  liver  has  been  quite  nat- 
ural even  in  very  severe  examples  of  the  blood  disease.  Besides,  it  is 
difficult  to  understand  how  chemically  so  important  a function  should  be 
performed  by  this  organ. 


& 


Fig.  524. 


Ultimate  destination  of  the  blood  corpuscles. — There  may  frequently 
be  observed,  in  the  spleen  of  all  animals,  groups  of  blood  corpuscles 
surrounded  by  an  albuminous  deposit  closely  resembling  a cell-wall. 

This  fact  has  been  differently  interpreted.  Gerlach  is  of 
opinion  that  they  are  new  blood  corpuscles  forming 
within  a mother  cell ; f whilst  Kdlliker^  and  Ecker^ 
maintain  that  they  are  old  ones,  which,  having  fulfilled 
their  functions  in  the  circulation,  go  to  the  spleen,  and 
are  there  dissolved.  These  large  cells,  containing  sev- 
eral colored  nuclei,  I believe  to  be  cells  of  the  lympha- 
tic glands  which,  under  especial  circumstances,  assume 
power  of  increased  development,  with  endogenous  multiplication  of 
nuclei.  They  are  common  not  only  in  the  spleen,  but  in  the  mesenteric 
and  other  lymphatic  glands,  especially  when  hypertrophied  from  neigh- 
boring irritation,  the  result  of  inflammatory  or  cancerous  exudations, 
and  especially  in  typhoid  fever.  A similar  increased  power  of  devel- 
opment may  occasionally  be  observed  in  the  epithelial  cells  of  the  pul- 
monary air  vesicles  in  certain  kinds  of  pneumonia;  in  those  covering 
the  choroid  plexus  in  hydrocephalus ; in  those  of  the  epidermis  in 
epithelial  cancer;  and  in  pus.  On  the  other  hand,  that  extravasated 
blood  corpuscles  may  assemble  together  in  groups,  and  subsequently  be 
surrounded  by  an  albuminous  deposit  closely  resembling  a cell- wall,  is  a 
fact  of  great  pathological  importance.  1|  It  is  true  they  closely  resemble 
the  lymph  cells,  with  multiplying  nuclei,  but  may,  I think,  be  separated 
from  them  by  possessing  more  color.  I have  seen  them  not  only  in 


* Muller’s  Archives.  Hept,  1,  1853. 

f Handbuch  der  Allgemeine  und  SpecieHen  Gewebelehre,  etc.,  s.  63. 

\ Mikroskopisohe  Anatomie,  etc.  2 Band,  s.  282. 

§ Wagner’s  Handworterbuch.  Art.  Blukgefassdriisen. 

I See  Dr.  Sanderson  on  the  Metamorphosis  of  Colored  Blood  Corpuscles,  etc. 
Monthly  Journal  for  September  and  December  1851. 

Fig.  524.  Cells  with  single  and  multiple  nuclei ; many  of  the  latter  in  color  and 
form  exactly  resemble  blood  globules.  From  the  human  spleen.  250  diam. 


LETJCOCYTHEMIA. 


891 


the  spleen,  but  in  other  glands,  and  especially  in  the  brain,  following 
spontaneous  and  artificial  sanguineous  extravasations  (See  Figs.  ol6, 
817,  p.  248),  But  surely  it  will  not  be  maintained  that  the  normal 
function  of  the  organs  in  which  these  accidental  formations  occur  is  to 
dissolve  the  blood  corpuscles.  Besides,  from  the  numerous  facts  which 
have  been  referred  to,  I trust  it  has  been  made  apparent  that  the  spleen 
is  much  more  probably  a blood-forming  than  a blood-destroying  gland. 

The  view  which  seems  to  me  most  consistent  with  facts  is,  that  the 
blood  corpuscles  are  dissolved  in  the  liquor  sanguinis,  and,  with  the 
effete  matter  absorbed  from  the  tissues  by  the  lymphatics,  constitute 
blood  fib  rin. 

From  the  various  facts  which  have  been  stated,  I think  we  may  con- 
clude : 

1.  That  the  blood  corpuscles  of  vertebrate  animals  are  originally 
formed  in  the  lymphatic  glandular  system,  and  that  the  great  majority 
of  them,  on  joining  the  circulation,  become  colored  in  a manner  that  is 
as  yet  unexplained.  Hence  the  blood  corpuscles  may  be  considered  as  a 
secretion  from  the  lymphatic  glands,  although  in  the  higher  animals  that 
secretion  only  becomes  fully  formed  after  it  has  received  color  by  ex- 
posure to  oxygen  in  the  lungs. 

2.  That  in  mammalia  the  lymphatic  glandular  system  is  composed 
of  the  spleen,  thymus,  thyroid,  supra-renal,  pituitary,  pineal,  and  lym- 
phatic glands. 

3.  That  in  fishes,  reptiles,  and  birds,  the  colored  blood  corpuscles 
are  nucleated  cells,  originating  in  these  glands ; but  that  in  mammals 
they  are  free  nuclei,  sometimes  derived  as  such  from  the  glands,  at 
others,  developed  within  colorless  cells. 

4.  That  in  certain  hypertrophies  of  the  lymphatic  glands  in  man 
their  cell  elements  are  multiplied  to  an  unusual  extent,  and  under  such 
circumstances  find  their  way  into  the  blood,  and  constitute  an  increase 
in  the  number  of  its  colorless  cells.  A corresponding  diminution  in 
the  formation  of  free  nuclei,  and  consequently  of  colored  corpuscles, 
must  also  occur.  This  is  leucocythemia. 

Since  the  above  views  were  published  by  me  in  1851  they  have 
been  confirmed  by  observations  of  various  kinds.  Thus  Holland*  and 
Nealef  have  shown  that  in  many  cases  of  bronchocele  the  blood  is 
leucocythemic.  In  the  only  two  cases  of  supra-renal  disease  described 
by  Addison  in  which  the  blood  was  examined,  the  colorless  cells  were 
increased  in  number.  In  a case  of  dysentery,  with  thickening  of  the 
mucous  membrane  of  the  small  intestine,  I found  leucocythemia.  (Case 

Lxxxy.) 

Attempts  have  been  made  to  divide  leucocythemia  into  varieties. 
Thus  Virchow  speaks  of  a splenic  and  a lymphatic  variety.  But  in  this 
manner  we  might  make  further  distinctions  of  a thyroid,  a supra-renal, 
an  intestinal,  and  a mesenteric  variety,  according  as  disease  in  these 
organs  occasioned  the  blood  lesion.  Nay,  more,  we  might  speak  of 
an  hypertrophic,  a tubercular,  a cancerous,  a dysenteric,  and  an  anaemic 
form,  according  as  we  found  the  blood  glands  simply  increased  in  size, 
loaded  with  tubercle  or  cancer,  or  associated  with  dysentery  or  anaemia. 

* Journal  of  Microscopical  Science,  vol.  i.,  p.  176. 
f Medical  Times  and  Gazette,  vol.  viii.,  p.  430. 


892 


DISEASES  OF  THE  BLOOD. 


These  distinctions  I believe  to  be  of  no  advantage,  either  in  a scientific 
or  practical  point  of  view.  The  different  blood  glands  contain  elements 
which,  when  locally  increased  in  number,  find  their  way  into  the  blood 
to  constitute  leucocythemia.  They  form  one  system  of  organs,  and  any 
hind  of  disease  in  them  may  structurally  affect  the  blood.  What  appears 
to  me,  however,  now  a desideratum  in  research  is,  to  determine  why,  in 
some  cases,  the  blood  should,  and  in  others  should  not,  be  leucocy- 
themic,  when  these  glands  are  diseased ; and  why  simple  anaemia,  as  was 
first  shown  by  Remak,  should  increase  the  number  of  colorless  cells  in 
the  blood?  In  one  case  examined  by  me  in  the  autumn  of  1852,  and 
the  characteristic  blood  in  which  I had  the  pleasure  of  showing  to  Dr. 
Hanover  of  Copenhagen  and  to  Dr.  Sharpey  of  London,  I unexpectedly 
ascertained  that  the  microscopic  examination  cleared  up  a doubtful 
diagnosis.  It  was  the  case  of  a woman  concerning  whom  a difference  of 
opinion  existed  between  two  distinguished  obstetricians,  the  one  declar- 
ing a tumor  in  the  left  flank  to  be  splenic,  and  the  other  that  it  was 
ovarian.  I showed  it  to  be  splenic  by  demonstrating  that  the  blood 
was  crowded  with  colorless  cells. 

With  regard  to  treatment,  nothing  that  I have  yet  tried  has  appeared 
to  be  of  the  slightest  service  directly  in  well-marked  cases  of  leucocy- 
themia associated  with  distinct  glandular  enlargement.  Iron,  quinine, 
chloride  of  potassium,  hydriodate  of  potash,  and  a variety  of  medicines 
given  internally,  with  tincture  of  iodine  applied  externally,  have  been 
of  no  avail.  But  I have  now  seen  several  cases  where,  in  the  course  of 
time  and  by  judicious  treatment,  the  enlarged  glands  have  diminished, 
and  the  morbid  condition  of  the  blood  become  less  and  ultimately  dis- 
appear. Of  this,  cases  CXG.  and  CCII.  are  good  examples.  The  chief 
indications  for  treatment  in  advanced  cases,  however,  will  be  found  to  be 
furnished  by  accidental  complications,  the  most  common  of  which  are 
diarrhoea  and  epistaxis,  which  require  astringents,  combined  with  tonics, 
nutrients,  and  stimulants,  to  support  the  vital  powers. 

Discovery  of  Leucocythemia. 

Professor  Kolliker  of  Wurtzburg  (in  Month.  Journ.  of  Med.  Science,  Oct.  1854) 
laid  before  the  English  medical  public  the  history  of  the  discovery  of  Leucocythemia, 
as  it  is  understood  in  Germany.^  from  the  representations  of  Professor  Virchow.  The 
following  is  my  reply : — 

It  is  said  by  Professor  Kolliker  that  the  first  observations  on  this  subject  occur 
in  the  year  1845,  and  take  their  origin  from  a case  of  disease  observed  by  Dr.  Craigie. 
Now,  the  fact  is,  that  Dr.  Craigie’s  case  occurred  in  1841;  audit  is  admitted  by 
Dr.  Craigie  himself  that  it  would  not  have  been  published  even  four  years  afterwards 
but  for  the  occurrence  of  mine.  He  says,  “ I kept  it  unpublished  from  the  period  at 
which  it  took  place  ; and  it  is  published  at  this  time,  chiefly  because  the  occuiTcnee 
of  a case  in  many,  if  not  in  all,  respects  similar,  to  another  physician  in  the  same 
hospital,  led  me  to  anticipate  similar  results,  and  went  far  to  confirm  my  conclusions 
deduced  from  the  first  case.” — Edin,  Med.  and  Surg.  Journal,  vol.  Ixiv.,  p.  402. 

Professor  Kolliker  takes  great  pains  to  show  that  Dr.  Craigie  and  myself  held  the 
same  opinions  as  to  these  cases,  and  that  in  mine,  which  followed  his,  “ nothing 
further  was  elucidated.”  On  the  other  hand,  he  says  Professor  Virchow  was  the 
first  to  point  out  that  “ no  signs  of  inflammation  in  the  veins  were  any  where  dis- 
coverable,” etc.  Now,  exactly  the  contrary  of  this  is  the  fact.  Dr.  Craigie  put  forth 
two  possibilities  as  to  the  cause  of  the  blood  disorder.  Is^,  He  says,  “ It  is  barely 
possible  that  some  inflammatory  action  had  taken  place  in  the  tributary  or  constituent 
veins  of  the  mesenteric  trunks,  and  that  the  purnlc'iit  matter  and  lymph  thus  formed 
had  been  conveyed  into  their  interior  with  the  blood,  and  thence  into  the  vena  cava. 


LETJCOCYTHEMIA. 


893 


heart,  and  vessels  of  the  brain.”  2c?,  He  says,  “ Another  opinion  occurred  to  me, 
however,  as  more  probable,  and  which  various  circumstances  in  the  case  induced  me 
to  regard  as  the  most  correct.  Considering  that  the  spleen  had  been  for  some  time — 
that  is,  for  several  weeks — in  a state  of  chronic  injiammation^  and  taking  into  account 
the  large  vessels  with  which  this  organ  is  connected  to  other  organs,  it  appeared  to 
me  that  this  inflammatory  process^  which  had  been  continuing  so  long  without  abat- 
ing, subsiding,  or  being  subdued,  was  at  length  beginning  to  give  rise  to  the  formation 
of  lymph  and  purulent  matter,  and  that  these  substances,  as  they  were  formed,  were 
immediately  taken  into  the  veins,  and  thus  circulating  with  the  blood,  gave  rise  to 
the  peculiar  assemblage  of  symptoms  which  the  patient  presented  during  the  few  days 
preceding  his  death.”  (P.  409.)  From  these  extracts  it  must  be  clear  that  JJr. 
Craigie  considered  the  blood  disease  as  secondary,  and  dependent  on  the  absorption 
of  pus  from  an  inflammatory  lesion  either  in  the  mesenteric  veins  or  spleen. 

The  view  taken  up  by  myself  was  wholly  different,  viz.,  that  the  blood  disease 
was  primary,  originating  in  that  fluid  itself,  altogether  independent  of  local  inflam- 
mation, and  especially  unconnected  with  inflammation  of  the  veins.  This  will  appear 
from  the  following  extracts  from  my  paper  : — “ In  the  present  state  of  our  knowledge, 
then,  as  regards  this  subject,  the  following  case  seems  to  me  particularly  valuable,  as 
it  will  serve  to  demonstrate  the  existence  of  true  pus  formed  universally  within  the 
vascular  system,  independent  of  any  local  purulent  collection  from  which  it  could  he 
derived.''''  (Pp.  413,  414.)  And  again,  “ Pus  has  long  been  considered  as  one,  if  not 
the  most  characteristic,  proof  of  preceding  acute  inflammation.  But  in  the  case  before 
us,  what  part  was  recently  inflamed  ? There  was  none.  Piorry  and  others  have  spoken 
of  an  inflammation  of  the  blood,  a true  hematitis ; and  certainly  if  we  can  imagine 
such  a lesion,  the  present  must  be  an  instance  of  it.  But  it  would  require  no  labored 
argument  to  show  that  such  a view  is  entirely  opposed  to  all  we  know  of  the  phenomena 
of  inflammation.''''  (P.  421.)  From  these  passages  it  must  be  clear  that  I then  sepa- 
rated the  state  of  the  blood  from  pre-existing  inflammation  in  any  of  the  tissues,  which 
had  not  been  done  by  any  preceding  author.  I especially  distinguished  it  from  pyaemia 
as  it  was  then  generally  understood.  Thereby  I established  a new  blood  disease — one 
of  a primary  nature.  I carefully  described  all  the  facts,  which  Virchow  has  only  sub- 
sequently confirmed.  I spent  three  entire  days  investigating  the  histological  character 
of  all  the  tissues  in  the  body,  and  in  demonstrating  the  important  fact,  that  the  color- 
less corpuscles  in  the  blood,  which  I minutely  described,  were  unconnected  with  inflam- 
mation. Notwithstanding  all  this.  Professor  Virchow  has  pertinaciously  endeavored 
to  persuade  his  countrymen  that  I regarded  the  case  as  one  of  ordinary  pygemia  or 
purulent  absorption;  and  Professor  Kblliker,  in  his  communication,  says  of  these 
laborious  researches  that  “ nothing  further  was  elucidated  ” beyond  what  had  previ- 
ously been  determined  by  Craigie  and  Reid. 

Here  it  should  be  observed  that  Dr.  Craigie  was  no  histologist,  and  had  never  em- 
ployed the  microscope  in  the  investigation  of  disease.  To  argue,  then,  that  the  dis- 
covery of  this  condition  of  the  blood — a discovery  altogether  dependent  on  histolo- 
gical research — was  made  by  him,  seems  absurd  in  the  extreme.  But  it  may  be 
maintained  that  this  part  of  the  inquiry  was  carried  out  by  Dr.  John  Reid,  because 
he  stated  in  the  register  kept  by  him  as  pathologist  of  the  Infirmary  that  the  blood 
“ contained  globules  of  purulent  matter  and  lymph.”  The  few  words  now  quoted 
constitute  literally  the  whole  of  Dr.  Reid’s  observations  on  the  matter.  They  would 
have  been  buried  in  oblivion  if  I myself  had  not  found  them  in  the  register  of  dissec- 
tions, pointed  them  out  to  Dr.  Craigie,  and  indicated  their  importance.  I have  fre- 
quently conversed  with  Dr.  Reid  himself  on  the  subject,  who  had  forgotten  the  cir- 
cumstance of  having  examined  the  blood  microscopically  in  Dr.  Craigie’s  case,  or  of 
having  made  a note  of  it.  Certainly  he  paid  no  more  attention  to  it,  or  in  any  way 
thought  it  more  important  than  a host  of  other  notes  he  made,  which  still  exist  in  the 
pathological  register,  and  in  which  some  future  controversialist  may  doubtless  find 
many  similar  discoveries,  as  yet  unknown.  At  all  events,  it  is  certain  that  neither 
Dr.  Craigie  nor  Dr.  Reid  ever  imagined  to  themselves  that  the  “globules  of  purulent 
matter  and  lymph  ” seen  by  the  latter  originated  independent  of  purulent  absorption, 
or  ever  dreamed  of  claiming  for  then) selves  the  discovery  of  leucocythemia.  Who 
then  did  make  it  ? Certainly  not  Virchow,  who,  with  Kblliker,  in  order  to  depreciate 
the  value  of  my  observations,  claims  it  for  these  gentlemen.  And  if  none  of  the  three 
made  it,  the  inference  undoubtedly  is,  that  the  discovery  belongs  to  me. 

What  then,  it  may  be  asked,  does  Professor  Kblliker  claim  for  his  colleague?  It 


894 


DISEASES  OF  THE  BLOOD. 


cannot  be  the  discovery  of  the  facts,  or  of  the  existence  in  large  numbers  of  colorless 
corpuscles  in  the  blood,  independent  of  indainraation.  All  the  histological  facts — 
the  white  appearance  of  the  blood  (white  blood),  its  independence  of  inflammation, 
and  its  separation  from  all  previously  known  pathological  conditions — were  minutely 
described  by  me  in  the  paper  of  the  1st  of  October  1845,  and  their  accuracy  has  been 
everywhere  confirmed.  (See  Case  CXCIX.)  Surely  this  description  oi  facU  never 
before  published,  and  of  their  connection  with  a new  blood-disease,  constitutes  the 
discovery.  On  the  other  hand,  Virchow’s  short  and  comparatively  imperfect  histo- 
logical description  of  a case  of  white  blood  (the  white  appearance  of  the  blood  being 
the  chief  point  he  dwelt  upon)  was  printed  in  the  second  number  for  the  following 
November,  although,  from  the  admission  of  Professor  Kolliker,  as  to  the  practice  which 
prevails  in  Germany,  the  actual  period  of  its  publication  may  have  been  much  later. 
Hence  all  that  can  be  claimed  for  Virchow  amounts  to  this,  that  he  put  forth  an  opinion 
regarding  these  facts  different  from  mine,  but  the  possibility  of  which  I clearly  indi- 
cated. For,  having  described  the  peculiarities  of  the  blood — the  white  coagulum,  its 
structural  characters,  the  colorless  corpuscles,  the  relation  to  the  red  ones,  and  the 
absence  of  the  inflammatory  appearances  in  every  tissue,  not  excepting  the  veins — the 
questions  remained.  What  are  these  corpuscles  ? How  are  they  produced  ? In  reply, 
I remarked,  that  “ with  regard  to  the  colorless  corpuscles  of  the  blood,  we  know  of  no 
instance  wliere  they  existed  in  the  amount,  or  ever  presented  the  appearance  described.” 
From  this  passage  Professor  Kolliker  draws  the  inference  that  I denied  that  these  bodies 
were  the  colorless  corpuscles  of  the  blood.  But  I need  scarcely  point  out  that  the 
passage  does  not  fairly  bear  that  construction.  On  the  other  hand,  it  clearly  shows 
that  the  possibility  of  their  being  these  colorless  corpuscles  was  fully  entertained.  At 
that  time  the  whole  subject  was  histologically  new ; and  having  shown  that  the  cells 
observed  closely  resembled  those  of  pus  in  their  structural  and  chemical  characters,  I 
said  so,  and  concluded  they  were  pus  corpuscles.  But  having  also  demonstrated  that 
they  could  not  have  been  derived  from  any  inflamed  tissue,  it  only  remained  to  be  con- 
cluded that  these  bodies  were  formed  in  the  blood  system  itself,  constituting  a primary 
suppuration  of  the  blood.  Here,  I contend,  was  the  real  discovery,  which  was  at  that 
time  quite  new,  and  remains  up  to  this  hour,  in  my  belief,  a correct  generalization. 

Whilst  Professor  Kolliker  seems  to  attach  no  importance  whatever  to  my  careful 
histological  examination  of  the  blood  and  of  the  tissues,  and  wholly  disregards  the  fact 
I was  at  so  much  pains  to  establish,  that  the  colorless  corpuscles  I described  were  not 
dependent  on  inflammation,  he  thinks  it  of  the  greatest  importance  that  Virchow  should 
have  stated  that  these  corpuscles  were  not  those  of  pus.  To  me  it  has  always  seemed 
of  little  importance  by  what  name  these  bodies  were  designated,  so  long  as  the  facts 
regarding  them  were  described  with  exactitude.  It  cannot  be  denied  that  I first  dis- 
covered and  described  them,  and  pointed  out  their  origin  in  the  blood  itself.  What 
histological  difference  there  can  be  between  pus  cells  independent  of  inflammation, 
originating  spontaneously  in  the  blood,  and  the  colorless  corpuscles  of  that  fluid,  I am 
at  a loss  to  imagine.  Yet  this  is  the  only  distinction  which  Virchow  made.  But  what 
are  pus  corpuscles  but  cells  presenting  certain  physical  characters  originating  in  an 
exuded  blood-plasma?  and  what  are  the- colorless  corpuscles  of  the  blood  but  similar 
cells  originating  in  a plasma  contained  in  the  blood  glands  ? I have  yet  to  learn  that 
there  is  any  true  histological  difference  between  them ; I believe  still  that  the  only 
distinction  is,  that  the  same  corpuscles  originate  in  blood-plasma,  sometimes  outside, 
and  sometimes  within  the  blood  system.  If  so,  the  controversy  raised  by  Virchow, 
and  maintained  by  Kolliker,  is  wholly  one  of  words.  Here  I may  mention,  that,  act- 
ing on  the  persuasion  that  the  two  kinds  of  corpuscles,  hitherto  separated,  are  really 
identical,  I opposed  the  generalization  of  Mr.  Henry  Lee,  which  set  forth  that  pus 
brought  in  contact  with  living  blood  caused  its  coagulation.  In  conjunction  with  the 
late  Professor  Barlow  of  the  Veterinary  College,  I injected  considerable  quantities  of 
pus  into  the  veins  of  an  ass,  in  order  to  determine  this  point.  I thus  increased  the 
colorless  cells  in  the  blood  of  the  animal  without  producing  any  coagulation  or  inflam- 
mation whatever. — (Monthly  Journal,  January  and  March  1853,  pp.  80  and  2V2,  2'7o.) 
Moreover  it  may  be  questioned,  and  indeed  it  has  been  questioned  in  a communication 
which  I received  from  Professor  Gluge  of  Brussels,  and  in  an  article  by  Dr.  Radcliffe 
(Half-Yearly  Abstract  of  the  Medical  Sciences,  vol.  xvi.,  p.  295),  whether  this  distinc- 
tion can  have  any  real  foundation.  Rokitansky  still  maintains  that  the  colorless  cor- 
puscles of  the  blood  in  leucocythemia  are  truly  those  of  pus,  and  Vidal,  after  a series 
of  observations  directed  to  this  very  point,  has  come  to  the  conclusion  that  the  color- 


LEUCOCYTHEMIA. 


895 


less  corpuscles  of  the  blood,  those  of  pus  and  those  of  mucus,  are  the  same  (Gazette 
Hebdomadaire,  Avril  11th,  1856),  If  so,  the  pretended  discovery  of  Virchow  sinks 
into  nothing,  as  it  is  not  founded  on  fact,  but  simply  on  opinion. 

As  to  the  subsequent  progress  of  this  inquiry,  I have  only  to  express  my  astonish- 
ment at  the  statement  made  by  Professor  Kdlliker,  that  in  1851,  in  the  Monthly 
Journal,  and  that  in  1852,  in  my  separate  work,  I made  no  allusion  to  my  former 
views,  and  did  not  take  the  slightest  notice  of  the  labors  of  Virchow.  It  is  most 
untrue.  My  views  regarding  this  disease  have  always  been  the  same,  but  never  such 
as  Virchow  and  Kolliker  have  represented  them ; and  so  far  from  denying  the  labors 
of  the  former  pathologist,  I have  fully  set  .tliem  forth,  and  quoted  all  his  facts  and 
observations.  I always  have  and  still  continue  to  estimate  highly  the  value  of  the 
facts  he  has  contributed  in  connection  with  this  important  subject.  But  what  he  has 
accomplished  does  not  entitle  him  to  the  original  discovery  of  leucocythemia,  or  to  the 
merit  of  giving  it  a place  in  pathology. 

Careful  investigation  into  this  subject  will,  I am  satisfied,  convince  the  candid 
mquirer  that  the  discovery  of  leucocythemia,  and  the  subsequent  progress  of  ideas 
r<  garding  its  nature,  may  be  divided  into  three  epochs  or  stages  as  follows : — 

1.  Professor  Bennett. — Discovery  of  a new  morbid  condition  of  the  blood,  con- 
Octoher  1,  1845.  sisting  of  multitudes  of  colorless  corpuscles,  resembling 

those  of  pus,  associated  with  hypertrophy  of  the  spleen 
and  liver,  and  presenting  after  death  peculiar  v/hite 
coagula.  Shown  to  be  unconnected  with  inflammation 
in  any  of  the  tissues,  and  especially  unconnected  with 
phlebitis.  Attributed  to  the  development  of  the  corpus- 
cles in  the  blood  itself. 

2.  Professor  Virchow. — Confirmation  of  the  preceding  facts,  but  the  corpuscles 

Series  of  papers  from  the  said  to  be  an  increase  in  the  colorless  cells  of  the  blood. 

2(/  or  Sd  week  of  Novem-  New  cases,  and  especially  one  of  great  value,  in  which  a 

her  1845  to  1847.  similar  condition  of  the  blood  was  associated  vvdth  enlarge- 

ment of  the  lymphatic  glands  without  hypertrophy  of  the 
spleen.  Origin  of  the  colorless  cells  attributed  to  the  lymph 
glands ; proposed  name  of  leukhemia,  or  white  blood. 

3.  Professor  Bennett. — Systematic  view  of  the  whole  subject.  Additional  facts 

Series  of  Papers^  1851,  and  cases,  with  chemical  analyses  of  the  blood.  Doc- 

and  separate  work,  trine  that  the  lymphatic  and  other  ductless  glands  secrete 
1852.  Bl.  8vo,  Edinr.  the  blood ; proposed  name  of  leucocythemia,  or  white- 
cell blood,  and  the  relation  of  this  disease  to  other  patho- 
logical conditions  and  to  practical  medicine  pointed  out. 

From  this  view  of  the  case,  it  will  be  seen  that  although  I claim  the  discovery  of 
leucocythemia,  and  have  given  it  the  correct  scientific  name  it  bears,  I am  far  from 
undervaluing  or  wishing  to  hide  Professor  Virchow’s  contributions  to  its  pathology ; 
whereas  he,  in  order  to  make  it  appear  that  the  origin  as  well  as  development  of  the 
whole  subject  is  due  to  himself,  has  not  hesitated  to  give,  and  circulate  in  Germany, 
the  most  erroneous  and  partial  accounts  of  my  facts  and  views. 

Since  the  above  statement  was  published.  Professor  Virchow  has  continued  not  only 
to  repeat  his  former  errors,  but  to  assert  that  his  case,  published  at  least  six  weeks 
after  mine,  was,  in  fact,  the  first  one.  Thus,  in  his  “ Gezammelte  Abhandlungen,” 
dated  1856,  he  says,  p.  155 — '■‘■About  the  same  time  that  my  case  was  published,  two 
other  cases  were  made  known  in  Edinburgh,”  etc.  He  the:j  goes  on  to  detail  them, 
observing,  “Case  1,  observed  by  me ; Case  2,  by  David  Craigie ; Case  3,  by  John  Hughes 
Bennett.”  Thus  distinctly  claiming  for  himself  priority  in  observation.  In  the  same 
manner,  Vogel,  in  giving  a report  in  Canstatt’s  Jahrbiicher  of  the  progress  of  Medical 
Science  in  1852,  part  3,  on  special  and  local  pathology,  puts  1st,  Virchow’s  paper  from 
the  Archives,  vol.  v. ; 2dly,  my  papers  in  the  Monthly  Journal ; and  3dly,  my  separate 
work.  Yet  what  are  the  dates  of  these  publications?  My  papers  appeared  in  1851, 
with  the  first  chemical  analyses  of  the  blood  made  by  Dr.  W.  Robertson.  My  separate 
work  is  dated  March  1852,  and  Virchow’s  paper,  with  the  chemical  analyses  by  Pro- 
fessor Scherer,  is  dated  August  1852  ! 

The  French  writers  on  this  subject  have  declared  the  term  leukhemia  to  be  faulty, 
and  adopted  that  of  leucocythemia.  Leudet,*  Vidal,f  and  Schnepfij;  have  followed 

* Gazette  Hebdomadaire,  27  Juillet  1855.  \ Idem,  15  Fevrier  1856. 

X Gazette  Medicale  de  Paris,  5 Avril  1856. 


896 


DISEASES  OF  THE  BLOOD. 


the  representations  of  Virchow,  and,  in  a professed  historical  sketch,  have  stated  that 
his  and  my  cases  appeared  about  the  same  time.  As  if  six  weeks  were  not  more  than 
a sufficient  period  for  the  Edin.  Med.  and  Surg.  Journal  to  reach  Berlin,  and  to  be 
placed  on  the  library  table  of  the  Koyal  Library  there,  where  it  might  have  been  seen 
by  such  readei'S  of  English  medical  literature  as  Virchow  undoubtedly  is  long  before 
the  latter  published  his  note,  in  the  2d  number  for  November  of  Froriep’s  Notizen. 
Schnepf  (who  is  evidently  unacquainted  with  my  writings,  and  has  only  seen  the  short 
resume  I presented  to  the  Biological  Society  of  Paris  in  1851,  at  the  request  of  my 
friend  M.  Lebert)  represents  Virchow’s  case  as  occurring  in  March,  and  mine  in  October, 
1845.  That  is,  he  gives  to  Virchow’s  case  the  date  at  which  mine  was  investigated  in 
Edinburgh,  five  months  before  the  latter  occurred  ! The  real  dates  are  as  follows  : — 

Observed.  Published. 

1st  Case. . . .Prof.  Bennett. . . .March  19th,  1845. . . .October  1st,  1845. 

2d  Case. . . .Prof.  Virchow. . . .August  1st,  1845. . . .November,  2d  week,  1845. 

3d  Case.  . . .Dr.  Fuller Decern.  31st,  1845 July,  1846. 

Dr.  Craigie’s  case  must  obviously  be  placed  amongst  those  that  occurred  long  before 
the  discovery  of  leucocythemia  was  made,  although,  on  looking  back  upon  it,  one  can 
have  no  doubt  that  it  was  an  example  of  the  disease  similar  to  a very  excellent  one 
published  by  Duplay,  in  the  Archives  Gen.  de  Medicine,  2d  series,  vol.  xxxvi.,  p.  223, 
1834  ; or  the  one  which  occurred  to  M.  Barth  in  1836,  but  was  only  published  in  1856 
by  Vidal,  when  the  subject  was  fully  known. 


Notwithstanding  the  above  explanations  and  dates,  which  may  be  easily  determined 
to  be  correct,  the  Medical  Times  and  Gazette,  when  under  the  editorship  of  Mr.  Spencer 
Wells,  continued  to  represent  Virchow’s  first  paper  as  having  been  published  two 
months  before  mine  (see  No.  for  February  2,  1861).  In  a long  leading  article,  also 
(see  No.  for  October  5,  1861),  other  misrepresentations  are  published,  which,  as  they 
may  deceive  others,  require  to  be  exposed.  This  is  further  requisite,  in  order  to  defend 
the  reputation  of  Hewson,  whose  scientific  labors,  while  now  recognised  to  be  of  the 
highest  merit,  are  completely  ignored  by  Virchow. 

When  I published  Case  CXCIX.  on  the  1st  of  October  1845,  the  subjects  of 
inflammation  and  pyaemia  were  actively  engaging  the  attention  of  pathologists  and 
practical  men.  By  some  (Addison,  Williams)  it  was  maintained  that  an  increase  of 
the  colorless  cells  in  the  blood  was  the  cause  of  inflammation.  Piorry  talked  of  a 
haematitis  or  inflammation  of  the  blood  itself.  Others  spoke  of  pyaemia  or  purulent 
blood ; and  among  these,  discussions  arose  as  to  whether  pus  entered  the  blood  by 
metastasis,  by  absorption,  or  as  the  result  of  phlebitis.  The  subject  of  inflammation, 
in  its  various  aspects,  had  strongly  engaged  my  attention.  It  was  natural,  therefore, 
when  meeting  with  this  important  case,  that  my  inquiries  regarding  it  should,  in  the 
first.instance,  bear  reference  to  its  connection  with  that  morbid  process.  And  whereas, 
previously,  most  inquirers  had  associated  such  appearances  in  blood  either  with  in- 
flammation or  with  the  softened  clots  so  accurately  described  by  Gulliver  in  1839,  I 
conclusively  demonstrated,  for  the  first  time,  that  in  reference  to  this  case  neither  of 
these  views  was  applicable.  True,  the  cells  described  were  called  pus-corpuscles, 
because  they  were  identical  with  them,  and  I spoke  of  suppuration  of  the  blood ; but 
pus  and  suppuration  were  not  necessarily  with  me  expressions  that  implied  inflamma- 
tion. A pus  cell  was  a structure  having  certain  characters,  and  a suppurative  fluid 
was  one  containing  pus-cells.  But  in  saying  that  these  might  occur  without  inflamma- 
tion, an  entirely  new  opinion  was  advanced,  and  a morbid  state  indicated  never  pre- 
viously suspected.  In  the  then  state  of  science,  the  important  point  to  prove,  as  it 
appeared  to  me,  was  that  there  was  no  inflammation  whatever,  either  primary  or  se- 
condary, no  abscess  anywhere,  no  phlebitis,  no  haematitis,  no  metastasis,  no  absorption 
of  pus.  As  the  corpuscles,  therefore,  were  not  derived  trom  wdthout  or  from  the 
vascular  walls,  it  followed,  and  this  was  distinctly  stated,  that  they  originated  in  the 
blood  itself.  I therefore  called  the  condition  of  the  blood  “ suppuration,  independent 
of  inflammation,”  an  idea  which  has  proved  very  perplexing  to  all  those  who  regard 
suppuration  as  necessarily  dependent  on  inflammation. 

The  truth  is,  the  mere  name  given  to  these  corpuscles  appeared  to  me  (then,  as  it 
does  now)  to  be  of  secondary  importance,  so  long  as  the  meaning  attached  to  them 
is  understood.  Call  them  pus-cells,  colorless  cells,  or  leucocyths,  after  Robin ; 
speak  of  the  fluid  in  which  they  occur  as  a purulent  fluid,  as  leukhaemic  fluid,  or  as 


LEUCOCYTIIEMIA. 


897 


1 leucocytotical  fluid  (see  Virchow’s  Cell.  Pat.,  p.  167),  the  cells  and  the  fluid  are 
the  same.  But  to  show  that,  whatever  term  be  employed,  the  cells  and  fluid 
tf'unainmg  them  were  in  no  way  connected  with  inflammation,  was  an  important 
even  in  pathology.  Still,  it  occurred  to  me  that  the  employment  of  the  terms  pus 
tnd  suppuration  was  apt  to  mislead  persons  not  acquainted  with  histology.  This 
was  why  subsequently  I proposed  the  expression  leucocythemia,  or  white-cell  blood, 
oecause  it  “expresses  the  simple  fact,  or  a pathological  state,  and  involves  no 
taeory.” 

In  Virchow’s  first  paper  (Froriep’s  Notizen,  November  1846),  which  appeared  six 
weeks  after  the  appearance  of  mine,  he  says : — “ In  the  older  authors  observations 
occur  here  and  there  concerning  blood  which  had  so  completely  lost  its  color  that 
it  was  likened  to  milk,  chyle,  mucus,  or  pus.  The  communication  of  the  following 
case  will  confirm  this  apparently  fabulous  statement.” 

Then  follows  the  case,  concerning  which  I need  only  remark,  that  the  fact  pointed 
out  by  Virchow  was  the  color  of  the  bloody  which,  as  he  truly  says,  was  well  known 
to  previous  writers.  Hence  why  he  called  it  “'Leukhsemia,”  or  white  blood,  whiclj 
he  supposed  to  occur  during  life  in  the  last  stage  of  the  disease.  His  words  are 
“ It  must  not  be  overlooked  that  cough,  diarrhoea,  and  oedema  occurred  before  the 
epistaxis,  and  that  the  remarkable  transformation  of  the  red  blood  into  white  ca.i 
only  have  occurred  to  that  degree  in  the  latest  stages^  for  the  blood  of  the  epistaxis  was 
always  redy  Now  the  truth  is,  that  in  this  disease  the  blood  is  never  white  at  aJ 
during  life.  The  coagula  auer  death  are  white  or  colorless,  but  so  they  are  in 
variety  of  affections  where  coagulation  takes  place  slowly.  If,  then,  I committed  an 
error  in  calling  the  state  of  the  blood  “ suppuration  ” without  inflammation,  as  some 
maintain,  I must  leave  you  to  judge  whether  a greater  error  was  not  committed  ia 
calling  it  white  blood,  when  it  certainly  was  not  white.  Moreover,  if  my  term 
suppuration  led  to  confusion  by  assimilating  the  altered  blood  to  inflammatory  pus, 
Professor  Virchow’s  term  led  also  to  confusion  by  causing  it  to  be  confounded  with  a 
state  of  the  blood  which  has  been  recognised  as  white,  fatty,  or  chylous  blood  from 
the  earliest  times. 

Thus,  then,  while  I endeavored  to  prove  that  a new  morbid  condition  was  inde- 
pendent of  inflammation.  Professor  Virchow  sought  to  establish  the  doctrine  of  a 
“ white  blood,”  which  he  himself  says  was  previously  known  to  the  older  writers ; 
but  it  appears  to  me  that  he  might,  with  equal  correctness,  have  easily  framed,  after 
the  notions  of  Hippocrates,  another  doctrine  of  black  blood,  the  truth  being,  that 
neither  the  one  nor  the  other  has  any  foundation  except  on  post  mortem  pheno- 
mena, The  real  white — that  is,  milky  or  chylous  blood — had  been  long  known,  is 
altogether  different  in  itself,  and  is  owing  to  different  causes.  His  views  concerning 
epistaxis  being  the  cause  of  white  blood,  and  that  the  alteration  must  have  been  pro- 
duced shortly  before  death,  because  the  bleeding  from  the  nose  was  red,  while  they 
prove  that  the  color  of  the  blood  was  what  principally  engaged  his  attention,  do  not 
merit  refutation. 

Attention,  however,  being  now  directed  to  the  new  morbid  state,  other  cases  soon 
occurred.  The  magnificent  hospital  of  La  Charite  in  Berlin  furnished  several  before 
I could  meet  with  one  other  in  Edinburgh,  all  of  which  were  immediately  published 
by  Professor  Virchow.  They  tended  to  show  that  the  blood  disease  occurred  either 
from  enlargement  of  the  spleen  or  the  lymphatic  glands.  In  the  Med.  Zeitung, 
another  Berlin  medical  journal,  for  August  and  September  1846,  Nos,  xxxiv.-xxxvi., 
he  adds  three  cases  to  his  own,  which  he  finds  recorded  in  the  British  medical  journals. 
These  he  introduces  to  the  German  scientific  world  in  the  remarkable  manner  for- 
merly referred  to  : — “ About  the  same  time  that  I published  my  case,  other  two  cases 
were  made  known  in  Edinburgh.”  He  then  enumerates  them  as  follows : — Case  1. 
observed  by  me ; Case  2,  by  David  Craigie ; Case  3,  by  John  Hughes  Bennett ; 
Case  4,  by  John  Fuller.  That  some  French  and  German  writers,  therefore,  should 
have  been  mistaken  as  to  the  priority  of  observation,  is  not  surprising.  But  it  was 
reserved  for  the  Medical  Times  and  Gazette,  so  late  as  February  1861 — long  after 
these  errors  had  been  clearly  exposed — boldly  to  tell  its  readers  that  Professor  Virchow’s 
original  case  was  publislied  two  months  before  none,  although,  in  fact,  it  appeared  six 
weeks  afterwards. 

The  object  of  this  second  paper  by  Virchow  was  “ to  vindicate  for  the  colorless  blood- 
corpuscles  a place  in  pathology,”  and  to  maintain  that  “ in  man  there  was  a white  as 
well  as  a red  blood.”  I shall  only  say  that  the  notion  of  the  blood-corpuscles  being 
% cause  of  disease  had  been  previously  entertained  by  many,  especially  by  Addison  and 

57 


898 


DISEASES  OF  THE  BLOOD. 


Williams  in  this  country,  so  that  they  already  had  a place  in  pathology,  and  with 
regard  to  the  white  (that  is  chylous)  blood  of  preceding  writers  being  dependent  on 
these  corpuscles,  the  idea  was  then  and  it  is  now  erroneous.  It  was  in  the  same  journal 
(Med.  Zitung  for  January  184V)  that  the  connection  between  this  supposed  white 
blood  and  the  spleen  was  first  referred  to,  and  it  is  observed  that  the  splenic  bodies 
are  shut  sacs,  and  he  compares  them  to  the  placenta ; so  that,  if  they  furnish  nourish- 
ment to  the  blood-cells,  the  nutritive  matter  must  transude  through  the  membrane  to 
nourish  them.  But  this,  he  says,  “ is  naturally  a pure  speculation,  and  only  consti- 
tutes a basis  for  further  researches.”  So  that  up  to  this  time  nothing  positive  had 
been  made  out  by  Virchow  as  to  the  cause  of  leucocythaemia. 

In  his  Archiv  fiir  Patholog.  Anat.  und  Physiolog.  for  1848,  Professor  Virchow  in- 
serts a short  abstract  of  the  preceding  papers,  with  another  case.  In  the  same  periodi- 
cal for  1849  he  gives  one  more  case ; and  the  theoretical  conclusion  he  now  arrives 
at  as  to  the  changes  in  the  blood  is  the  following  : — “ The  blood  being  a constantly  de- 
veloping, transitory  tissue,  with  a fluid  intercellular  substance,  always  contains  young 
elementary  tissue-cells.  In  health,  the  majority  of  these  transform  themselves  into 
specific  blood-cells ; the  red  blood-corpuscles  carrying  hmmatine.  Under  abnormal 
circumstances  an  interniption  of  development  occurs,  which  prevents  the  formation 
of  specific  tissue  elements,  and  favors  the  development  of  young  cells  as  non-specific 
simple  cells.  These  last  are  the  so-called  colorless  blood-corpuscles  or  lymph-cor- 
puscles. Now,  if  we  take  a general  survey  of  the  circumstances  under  which  a dis- 
tinct increase  of  the  colorless  blood-corpuscles  occurs,  we  can  distinguish  three  ditfer- 
ent  states  of  the  blood — 1.  The  simple  interruption  of  specific  cells  (leukeemia),  with 
chronic  enlargement  of  the  spleen  and  lymphatic  glands ; 2.  The  simultaneous  change 
in  the  development  of  the  specific  tissue  elemente  of  the  blood,  the  hsematin e-cells 
and  fibrine,  in  inflammations,  pregnancy,  and  after  repeated  bleedings  ; 3.  The  in- 
terruption of  the  specific  blood  development  connected  with  atrophy  of  the  blood  in 
typhus,  in  cholera,  and  in  putrid  infection  (the  so-called  pyaemia).” 

I do  not  see  that  any  definite  infoi'mation  is  to  be  obtained  from  these  passages  as 
to  the  origin  of  the  blood-corpuscles  from  the  blood-glands,  nor  any  explanation  of 
the  causes  of  leucocytheraia. 

It  was  in  January  1851  I again  wrote  on  the  subject  (Monthly  Journal,  January  to 
October  1851),  Tiaving  in  the  interval  also  been  making  investigations  and  studying 
the  disease.  In  this  paper  I object  to  the  term  “ white  blood,”  saying  it  properly 
belongs  to  the  milky  or  ch)dous  blood  formerly  known  ; I no  longer  call  the  cells  in  the 
blood  pus-cells,  though  still  maintaining  their  identity  with  those  of  pus  ; and  propose 
the  name  leucocythemia^  or  white  cell-blood,  because,  as  previously  stated,  it  “ expresses 
the  simple  fact,  and  involves  no  theory  ; ” that  is,  it  avoids  equally  the  errors  likely  to 
arise  from  the  use  of  the  term  pus,  suppuration,  and  white  blood.  I then  reproduced 
all  the  facts  known  on  the  subject,  carefully  translating  all  Virchow’s  cases.  The 
subject  is  illustrated  by  numerous  woodcuts  ; and  several  analyses  of  the  blood  are 
given,  made  by  Dr.  Wm.  Robertson  at  my  request.  It  is  pointed  out  that  mere  en- 
largement of  the  spleen  is  not  necessarily  the  cause  of  leucocythemia,  as  shown  by 
hypertrophy  of  that  organ  from  intermittent  fever,  which  does  not  produce  it.  A 
systematic  account  of  the  symptoms,  the  structural  and  chemical  composition  of  the 
blood,  and  the  morbid  anatomy  of  leucocythemia  are  detailed.  Further,  in  a paper 
on  the  Function  of  the  Spleen  and  other  Lymphatic  Glands  as  Secretors  of  the  Blood, 
read  to  the  Roya.  Society  of  Edinburgh,  Feb.  2,  1852,  I fully  develope  these  points, 
carefully  giving  to  each  observer  his  due  credit  in  the  matter.  Perhaps  I do  not  suffi- 
ciently dwell  on  the  great  merits  of  Hewson,  although  it  is  said  “ Hewson  was  the 
first  who  distinctly  stated  that  the  blood-corpuscles  were  derived  from  the  lymphatic 
glands ; yet  few  have  adopted  his  opinions.”  And  again,  “ Hewson  considered  the 
Ijnnphatic  glandular  system  to  consist  of  the  spleen,  thymus,  and  lymphatic  glands. 
He  believed  that  particles  were  produced  in  these  organs  which  ultimately  became 
the  blood-corpuscles,  and  that  the  spleen  especially  served  to  gecrete  the  coloring 
matter  which  surrounded  them.  This  doctrine,  though  supported  to  a greater  or  less 
extent  by  some  German  authors,  has  been  repudiated  by  all  British  physiologists  up 
to  this  time.  Mr,  Simon  declares  it  to  be  impossible  that  the  globules  of  the  thymus 
can  enter  the  lymphatic  or  blood  vessels,  on  account  of  the  limitary  membrane  within 
which  they  are  enclosed.”  (This,  we  have  seen,  was  the  view  of  Virchow.)  “ But 
that  they  do  find  their  way  into  tliese  vessels  was  shown  by  Hewson  and  Sir  Astley 
Cooper,  who  found  them  there ; and  that  the  colorless  corpuscles  of  the  spleen  and 
lymphatic  glands  enter  the  blood  in  large  numbers  is  proved  by  what  occurs  in 


LETJCOCYTHEMIA. 


899 


leucocythsemia,  and  by  the  great  preponderance  of  these  bodies  at  all  times  in  splenic 
and  portal  blood.”  Here  I vindicate  for  Hewson  the  merit  of  having  first  pointed 
out  the  true  origin  of  the  blood-corpuscles  in  the  spleen  and  lymphatic  glands  ; and 
the  idea  that  such  would  ever  be  claimed  for  Virchow  must  appear  to  any  reader  of 
Hewson’s  works,  and  of  Gulliver’s  notes  on  this  point,  to  be  simply  preposterous. 

My  paper  concludes  as  follows  ; — “ From  the  various  facts  which  have  been  stated, 
I think  we  may  conclude — 1.  That  the  blood-corpuscles  of  vertebrate  animals  are 
originally  formed  in  the  lymphatic  glandular  system  ; and  that  the  great  majority  of 
them,  on  joining  the  circulation,  become  colored  in  a manner  that  chemists  have 
not  yet  explained.  Hence  the  blood  may  be  considered  as  a secretion  from  the 
lymphatic  glands,  although  in  the  higher  animals  that  secretion  only  becomes  fully 
formed  after  it  has  -received  color  by  exposure  to  oxygen  in  the  lungs,  2,  That  in 
mammalia  the  lymphatic  glandular  system  is  composed  of  the  spleen,  thymus,  thyroid, 
supra-renal,  pituitary,  pineal,  and  lymphatic  glands,  3,  That  in  fishes,  reptiles,  and 
birds,  the  colored  blood-corpuscles  are  nucleated  cells,  originating  in  these  glands  ; 
but  that  in  mammalia  they  are  free  nuclei,  sometimes  derived  as  such  from  the  glands, 
at  others  developed  within  colorless  cells.  4.  That,  in  certain  hypertrophies  of  the 
lymphatic  glands  their  cell  elements  are  multiplied  to  an  unusual  extent,  and  under- 
such  circumstances  find  their  way  into  the  blood,  and  constitute  an  increase  in  the 
number  of  its  colorless  cells  ; this  is  leucocythemia.  6.  That  the  solution  of  the 
blood-corpuscles,  conjoined  with  the  etfete  matter  derived  from  the  secondary  digestion 
of  the  tissues,  which  is  not  converted  into  albumen,  constitutes  blood-fibrine.” 

Here,  then,  it  seems  to  me,  is  a distinct  theory  of  leucocythemia  brought  forward. 
Further,  in  a separate  work  on  Leucocythemia  (Edinburgh,  March  1852),  besides  a re- 
print of  all  the  previous  facts,  additional  chapters  are  given  on  the  disease  viewed  in 
relation  to  inflammation,  to  purulent  infection,  to  phlebitis,  and  to  other  morbid  condi- 
tions of  the  lymphatic  glandular  system,  in  which  the  subject  was  almost  exhausted. 

It  was  in  the  fifth  volume  of  his  Archiv  for  1863,  and  bearing  the  special  date  of 
Wurzburg,  August  23,  1852  (six  months  after  the  publication  of  my  separate  work,  a 
copy  of  which  had  been  sent  to  him),  that  another  long  paper  appeared  by  Virchow, 
claiming  for  himself  the  discovery  of  the  whole  matter ; and  that  he  still  considers 
himself  to  be  the  discoverer  is  proved  by  the  following  paragraph  from  his  Cellular 
Pathology,  published  in  English  in  1861,  in  which  he  thus  speaks  to  the  countrymen 
of  Hewson  : — “A  good  many  years  elapsed  (after  1845),  during  which  I found  myself 
pretty  nearly  alone  in  my  views.  It  has  only  been  by  degrees,  and  indeed,  as  I am 
sorry  to  be  obliged  to  confess,  in  consequence  rather  of  physiological  than  pathological 
considerations,  that  people  have  come  round  to  those  ideas  of  mine^  and  only  gradually 
have  their  minds  proved  accessible  to  the  notion  that,  in  the  ordinary  course  of  things, 
the  lymphatic  glands  and  the  spleen  are  really  immediately  concerned  in  the  production 
of  the  formed  elements  of  the  bloody — (Cellular  Pathology,  by  Chance,  p.  1'72,  1860.) 

The  fifth  chapter  of  Hewson’s  work,  containing  an  account  of  the  manner  in  which 
the  red  particles  of  the  blood  are  formed  (p.  2V4,  Sydenham  Society’s  edition),  may 
be  referred  to  for  a complete  refutation  of  this  claim  of  Professor  Virchow.  Hewson 
says,  concerning  the  production  of  the  formed  elements  of  the  blood  (sect.  108,  op. 
cit..,  p.  285) : “ But  if  we  allow  the  spleen  to  make  the  red  part  of  the  blood,  we  can 
readily  account  for  the  reason  why  the  spleen  may  be  cut  out  of  an  animal,  and  yet 
the  animal  survive  and  suffer  but  little  inconvenience ; for  though  the  office  of  the 
spleen  is  to  form  the  red  particles  of  the  blood.,  yet  it  is  not  the  only  organ  in  the  body 
capable  of  doing  that  office;  for  we  have  already  proved  (sections  85  and  88)  that  the 
lymphatic  vessels  do  also  form  the  vesicular  portion  ; the  spleen,  therefore,  is  not  the 
only  organ  capable  of  doing  it,”  etc. 

I submit,  therefore,  that  to  Hewson  (whose  name  is  not  mentioned  in  the  Cellular 
Pathology),  and  not  to  Virchow,  are  we  indebted  for  our  knowledge  of  this  matter. 
It  is  further  to  be  observed  that,  though  fully  acquainted  with  my  paper  published 
in  March  1852,  in  which  Hewson’s  views  are  referred  to,  and  the  whole  subject  fully 
elaborated,  he  continues,  in  the  Cellular  Pathology,  to  represent  me  as  continuing  to 
hold  no  other  opinion  than  that  leucocyihaemia  was  pyaemia,  although  from  the  com- 
mencement my  object  was  to  prove  there  never  could  have  been  pyaemia,  by  which 
was  understood  absorption  of  pus  into,  and  poisoning  of,  the  blood.  He  says  : 
“ This  conclusion  of  his,  indeed,  was  not  original,  but  was  based  upon  the  haematitis 
of  Piorry.”  But  in  my  first  paper  (1846)  it  was  said  of  this  very  theory  of  Piorry’s, 
that  such  a view  is  opposed  to  all  we  know  of  the  phenomena  of  inflammation^  and 
was  thus  emphatically  repudiated. 


900 


DISEASES  OF  THE  BLOOD. 


The  whole  arguments  of  the  Medical  Times  and  Gazette  in  1861  consist  in  main» 
taining  that,  as  I called  the  corpuscles  in  the  blood  pus,  while  Virchow  called  them 
colorless  corpuscles,  therefore  the  entire  originality  belongs  to  him.  But  Virchow 
now  tells  us  (Cellular  Pathology,  page  155):  “A  pus-corpuscle  can  be  distinguished 
from  a colorless  blood-cell  by  nothing  else  than  its  mode  of  origin.  If  you  do  not 
know  whence  it  has  come,  you  cannot  say  what  it  is ; you  may  conceive  the  greatest 
doubt  as  to  whether  you  are  to  regard  a body  of  the  kind  as  a pus  or  a colorless 
blood  corpuscle.  In  every  case  of  the  sort  the  points  to  be  considered  are,  where  the 
body  belongs  to  and  where  its  home  is.  If  this  prove  to  be  external  to  the  blood, 
you  may  safely  conclude  that  it  is  pus ; but  if  this  is  not  the  case,  you  have  to  do 
with  blood-cells.”  According  to  this  definition,  a cell  closely  resembling  a pus-cell 
in  the  saliva,  inasmuch  as  it  originates  externally  to  the  blood,  is  a pus  and  not  a 
salivary  cell.  On  the  other  hand,  if  a blood-vessel  be  full  of  a thick,  creamy,  yellow 
fluid,  containing  a multitude  of  cells  undistinguishable  from  pus-cells,  inasmuch  as 
these  are  formed  in  the  blood,  it  is  not  pus.  According  to  Professor  Virchow,  there- 
fore, practical  men  in  future,  in  a case  of  puerperal  phlebitis,  when  they  see  the 
uterine  sinuses  and  neighboring  veins  distended  with  pus,  or  surgeons,  when  they 
see  the  veins  of  the  arm  full  of  purulent  matter  from  the  bend  of  the  elbow  to  the 
axilla,  are  to  conclude  that  it  is  not  pus  ! I maintain,  on  the  contrary,  that  it  is  pus, 
because  it  results  from  inflammation  ; that  is  the  real  question  to  be  considered.  It 
is  only  when  it  occurs  independently  of  inflammation  that  the  lesion  can  be  said  to  be 
one  of  a novel  character,  as  I first  stated.  But  perhaps  some  one  will  say  it  is  not 
pus  but  leucocytosis.  This  new  word  of  Professor  Virchow’s  means  white  cell  forma- 
tion ; so  that  most  embryonic  transformations,  the  secretion  of  saliva,  a gonorrhoea,  or 
an  abscess,  is  a leucocytosis,  inasmuch  as  there  is  a formation  of  colorless  cells  in  all 
of  them.  Such  confusion  of  ideas  and  of  terms  can  never  take  a place  in  pathology. 
White  blood  has  no  real  existence,  unless  chylous  blood  be  so  called,  the  term  being 
copied  by  Professor  Virchow  from  the  older  writers.  Hence,  the  expression  leucocy- 
themia,  or  white  cell-blood,  is  the  only  one  which  properly  distinguishes  the  lesion  in 
question. 

It  follows  from  what  has  been  said,  therefore — 1.  That  Professor  Virchow  cannot 
claim  the  discovery  of  leueocythemia  as  a matter  of  fact  and  observation,  because  the 
first  case  of  it  was  carefully  described  and  published  by  me,  before  he  wrote  on  the 
subject,  and  separated  from  all  known  lesions,  under  the  name  of  “ suppuration  of 
the  blood  independent  of  inflammation  ” — an  idea  previously  unknown.  2.  That  he 
cannot  claim  it  in  consequence  of  calling  it  “ white  blood,”  as  this  was  spoken  of 
by  the  ancients,  and  is  everywhere  known  as  the  milky  or  chylous  blood  of  authors. 
The  confusion  resulting  from  applying  this  term  to  leueocythemia  may  be  Judged  of 
by  reference  to  a discussion  in  the  Academie  de  Medecine,  January  29,  1856,  when 
the  most  distinguished  chemists  declared  they  had  been  familiar  with  it  long  before 
Professors  Bennett  or  Virchow  wrote.  3.  That  he  cannot  claim  it  on  the  ground 
that  he  has  demonstrated  any  difference  between  the  colorless  corpuscles  of  the 
blood  and  pus  cells,  as  he  himself  admits  they  are  identical ; and  4.  That  he  cannot 
claim  it  on  the  ground  that  he  first  pointed  out  the  blood-corpuscles,  colored  or 
colorless,  to  be  derived  from  the  spleen  and  blood-glands,  as  this  was  unquestionably 
made  out  by  Hewson  nearly  a century  ago,  and  was  claimed  for  him  by  myself,  to 
the  exclusion  of  Virchow,  in  March  1852. 

At  the  same  time,  great  merit  is  due  to  Professor  Virchow  for  diligence  in  observa- 
tion and  the  publication  of  many  valuable  cases,  which  his  superior  advantages  as 
pathologist  to  the  great  hospital  of  La  Charite  in  Berlin  enabled  him  to  do.  It  is 
only  to  be  regretted  that,  while  assisting  in  the  development  of  this  subject,  he  should 
have  claimed  for  himself  priority  in  its  discovery,  and  have  concealed  and  misrepre- 
sented the  labors  of  those  who  had  preceded  him  in  the  inquiry. 

CHLOROSIS  AND  ANAEMIA. 

Case  C CIII.^ — Chlorosis  and  Ancemia — Cured. 

History. — Lilias  Ross,  aet.  19,  servant  in  a hotel — admitted  October  13th,  1856. 
She  states  that  menstruation  commenced  in  her  sixteenth  year,  and  continued  to  recur 
regularly  till  about  a year  ago.  It  then  ceased,  and  she  experienced  debility,  palpita- 
tion with  pain  under  the  left  breast,  defective  appetite,  and  discomfort  after  meals. 


* Reported  by  Mr.  John  Glen,  Clinical  Clerk. 


CHLOEOSIS  AND  ANEMIA. 


901 


On  leaving  off  work  for  six  weeks,  her  health  was  restored,  and  the  catamenia  returned. 
She  again  went  into  service,  and  in  four  months  the  symptoms  came  back.  She  dates 
the  present  indisposition  from  the  last  menstrual  period,  four  weeks  ago. 

Symptoms  on  Admission. — She  seems  in  every  respect  well  formed,  not  emaciated, 
but  the  skin  is  blanched,  and  of  a slight  greenish  waxy  tint.  Over  the  chest  and 
mammae  are  a few  patches  of  pityriasis  versicolor,  of  a faint  yellowish  tint.  She 
complains  of  occasional  palpitation.  On  examination,  the  heart’s  impulse  is  in  its 
normal  position,  and  is  at  present  of  natural  force.  There  is  a soft  but  distinct 
blowing  murmur  with  the  first  sound,  loud  at  the  base  of  the  organ,  and  audible  in 
the  course  of  the  aorta  and  large  arteries.  Over  the  carotids  ab^ove  the  clavicle,  a 
loud  double  blowing  is  audible,  which,  on  pressure  with  the  stethoscope,  becomes  a 
continuous  humming-top  sound.  Pulse  100,  soft.  Tongue  pale  and  fiabby,  appetite 
defective,  food  causes  a painful  sense  of  weight  with  distention  in  the  stomach,  no 
vomiting  or  flatulence,  occasional  sense  of  constriction  in  the  throat,  bowels  costive, 
having  for  some  weeks  been  opened  only  by  laxatives.  She  has  frequent  giddiness, 
rarely  headache,  often  darkness  before  the  eyes,  no  spinal  irritation,  but  great  weak- 
ness over  the  loins,  and  such  a sense  of  fatigue,  with  heaviness  in  the  limbs,  that  she 
has  great  difficulty  in  walking.  The  catamenia  have  not  appeared  at  the  usual 
period  on  this  last  occasion.  They  have  never  been  profuse  or  accompanied  by  pain. 
Urine  healthy.  Respiratory  system  normal.  R Pil.  Rhei  Comp.  xij.  Two  to  be 
taken  every  third  night.  R Ferri  Citratis^  3 j ; Syrupi  Aurantii  et  Tr.  Aurantii 
aa  I j ; Inf  us.  Calumh.  § iv.  M.  One  table-spoonful  to  he  taken  three  times  a day. 

Progrkss  op  the  Case. — October  2Mh. — Is  improved  in  strength,  and  can  walk 
about  the  ward.  The  heart’s  palpitations  are  easily  excited.  Sometimes  the  murmur 
over  the  carotids  in  the  neck  is  of  a hoarse  double  character,  at  others  continuous  and 
very  loud.  To  encourage  a return  of  the  catamenia,  four  leeches  ordered  to  be  applied 
to  the  vulva.,  followed  by  a warm  hip-bath.  November  \0th. — Is  gaining  strength  slowly 
on  the  whole,  but  experiences  alternations  in  this  respect — palpitations  and  pain  under 
left  mamma  being  sometimes  severe,  at  others  absent.  The  soft  blowing  murmur  at 
base  of  heart  has  disappeared,  but  the  humming-top  sound  over  cervical  vessels  con- 
tinues. November  2Uh. — Blowing  murmur  at  base  of  heart  occasionally  returns  only 
after  exertion.  Sounds  in  neck  less  intense.  No  catamenia,  although  pediluvia,  mus- 
tard poultices  to  the  feet,  and  other  means  have  been  employed  at  the  supposed 
menstrual  period.  December  \Qth. — Has  continued  to  take  the  chalybeate  mixture 
all  this  time,  and  is  now  strong  and  vigorous.  A faint  sound  only  is  audible  over  the 
vessels  in  the  neck,  after  exertion.  Appearance  healthy,  appetite  good,  bowels  regular, 
no  headache  nor  nervous  pain.  With  the  exception  of  amenorrhcea,  may  be  said  to 
be  quite  well.  Advised  to  go  to  the  country  for  a little.  Dismissed. 

Commentary. — This  was  a well-marked  case  of  anaemia  and  chlo- 
rosis, cured  by  iron,  tonics,  and  rest.  Such  cases,  in  young  women, 
are  exceedingly  common  in  the  female  wards  of  the  Infirmary,  espe- 
cially among  the  class  of  servants.  Great  discussion  has  occurred  as 
to  the  cause  of  the  murmurs  in  the  heart  and  large  blood-vessels — 
some  maintaining  their  seat  to  be  the  arteries,  others  the  veins.  The 
arguments  of  Dr.  Ogier  Ward,  who  first  maintained  the  seat  of  the 
anaemic  murmur  to  be  in  the  jugular  vein,  are  generally  considered  to 
be  well  founded.  They  are — 1st,  The  continuous  murmur  is  often  co- 
existent with  distinct  carotid  impulse,  which  alternates  with  repose ; 
2d,  It  may  be  interrupted  by  pressing  the  vein  above  the  stethoscope ; 
3d,  The  two  murmurs  may  be  occasionally  heard  by  employing  a small- 
ended  stethoscope,  and  shifting  it  slightly  to  the  right  or  left ; 4th,  It 
is  increased  by  any  cause  which  accelerates  the  flow  of  blood  through 
the  jugular  vein,  as  during  the  act  of  inspiration,  and  when  in  the 
upright  posture — it  is  diminished  when  there  is  an  impediment  to  the 
venous  circulation,  as  during  expiration,  the  recumbent  posture,  and 
when  the  veins  are  swollen  or  turgid.  Andral  endeavored  to  show 
that  the  constancy  of  the  murmur  is  proportionate  to  the  diminution  of 
corpuscles,  and  that  it  became  continuous  if  the  blood  globules  fell 


902 


DISEASES  OF  THE  BLOOD. 


below  80  parts  in  1000.  But  Dr.  Davies  has  pointed  out  that  the 
murmur  is  not  peculiar  to  anaemic  persons,  but  often  exists  in  indivi- 
duals of  robust  health.  He  attributes  it  to  friction  on  the  inner  surface 
of  the  veins,  which  is  more  or  less  audible  according  to  the  readiness 
with  which  their  parietes  take  up  vibrations,  and  the  facility  with  which 
the  latter  are  conducted  to  the  outer  surface  of  the  body.  Hence  their 
frequency  in  children  and  young  persons,  and  in  the  quick  ventricular 
contraction,  with  thin  blood,  of  the  chlorotic  girl,  and,  on  the  other  hand, 
their  absence  during  the  slower  circulation,  and  thickened  condition  of 
the  tissues  in  adult  and  aged  persons.  At  the  same  time  there  can  be 
little  doubt  that  the  interrupted  blowing  at  the  base  of  the  heart,  over 
the  aorta  and  carotids,  which  is  synchronous  with  the  impulse,  is  often 
arterial  and  not  venous.  Indeed,  the  separation  of  anaemic  arterial  and 
venous  murmurs  is  frequently  a matter  of  excessive  difficulty.  Some- 
times also,  as  has  been  well  pointed  out  by  Stokes,  they  are  associated 
with  organic  disease,  which  adds  to  the  complexity,  and  occasions  still 
greater  difficulty  in  forming  a correct  diagnosis. 

The  colored  corpuscles  of  the  blood  may  be  increased  or  dimi- 
nished in  quantity,  constituting  and  Oligocythcemia  (Vogel). 

These  changes  may  be  absolute  or  relative.  In  the  former  case,  the  cor- 
puscles are  uniformly  increased  or  diminished  throughout  the  body  gene- 
rally; in  the  latter,  this  depends  upon  the  amount  of  water,  which,  by 
being  less  or  more,  alters  the  proportion  of  the  corpuscles  to  the  other 
constituents  of  the  blood.  Becquerel  drew  a distinction  between 
anaemia  and  chlorosis,  which,  on  the  whole,  is  well  founded.  Thus, 
anaemia  is  caused  by  a variety  of  circumstances  which  impoverish  the 
blood,  such  as  long  continued  hemorrhage,  exhaustive  discharges,  star- 
vation, chronic  diseases,  certain  poisons,  etc. ; chlorosis  is  induced  by 
obscure  causes  connected  with  the  nervous  system,  generally  originating 
in  disturbed  uterine  functions.  In  anaemia,  the  alteration  of  the  blood 
is  constant  and  pathognomonic;  in  chlorosis,  it  is  only  one  of  the  pheno- 
mena, and  not  always  present.  In  both  diseases  the  physical  signs  may 
be  alike,  but  in  anaemia  the  functional  sound  is  more  often  in  the  arteries, 
in  chlorosis  in  the  veins.  In  anaemia  there  is  constant  relation  between 
intensity  of  symptoms  and  poverty  of  the  blood.  This  is  not  the  case  in 
chlorosis.  The  duration  and  progress  of  anaemia  is  dependent  on  the 
causes  which  produce  it,  but  chlorosis  is  very  variable,  and  no  such 
evident  connection  is  visible.  The  treatment  of  anaemia  has  two  indi- 
cations— 1st,  To  suppress  the  exhausting  causes  which  occasion  it;  and, 
2dly,  By  means  of  wine,  proper  nutrients,  and  regulated  exercise,  to  im- 
prove the  quality  of  the  blood.  In  chlorosis,  iron  is  the  chief  remedy, 
which  should  be  conjoined  with  efforts  to  regulate  the  menstrual  function. 

ICHORHiEMIA  or  (so-called)  PYEMIA. 

Case  CCIV.'^ — Acuie  Articular  Bheumatism — Mulii'ple  Abscesses  in 
the  Joints^  in  the  Muscles,  within  the  Cranium,  etc. 

History. — James  Lockie,  set.  17,  a rope-spinner — admitted  December  1,  1854. 
Ten  days  ago,  when  spinning  ropes  m the  open  air,  he  was  exposed  to  more  than 
usual  cold  and  wet.  Next  day  rigors  and  other  febrile  symptoms  appeared,  followed 
by  pain,  redness  and  swelling  of  the  right  elbow-joint.  During  the  four  following 


* Reported  by  Mr.  A.  W.  Moore,  Clinical  Clerk. 


ICHORH^MIA  OR  PYEMIA. 


9C3 


days  the  right  wrist  and  ankle  joints  were  also  affected,  together  with  both  knee- 
ioints.  Four  days  before  admission  the  heart’s  action  became  very  violent,  and 
leeches  were  applied  to  the  precordial  region.  The  pain  and  swelling  of  the  joints 
have  continued  since. 

Symptoms  on  Admission. — On  admission  he  complained  of  great  pain  in  the 
right  wrist,  ankle,  and  left  shoulder  joints,  which  were  swollen,  immovable,  doughy 
to  the  feel,  tender  to  the  touch,  with  the  integuments  over  them  erythematous. 
From  the  left  shoulder-joint  the  swelling  extended  into  the  axilla  and  down  the 
inside  of  the  arm.  Pulse  130,  full  and  strong ; heart’s  impulse  violent,  but  no 
blowing  murmur.  The  tongue  coated  with  brown  in  the  centre  and  white  at  the  edges ; 
no  appetite ; great  thirst ; skin  hot  and  dry ; urine  turbid  from  excess  of  lithales ; 
bowels  open ; no  headache,  and  the  other  functions  normal.  Fiat  venesectio  ad  | xiv. 

Fotassce  NUratis  5 ss,  Aqum  § vj.  Solve.  § ss  to  he  taken  in  half  a tumblerful  of 
water  every  four  hours — warm  saturnine  lotions  to  the  inflamed  joints. 

Progress  op  the  Case. — December  2d. — Little  change,  pulse  120,  more  soft,  blood 
not  buffed,  but  it  was  drawn  from  a small  orifice.  Dec.  Adh. — Pain  in  all  the  joints 
greatly  diminished ; the  swelling,  however,  continues.  A blister  has  formed  over  the 
external  malleolus  of  right  ankle — complains  of  soreness  in  the  heels.  Pulse  100,  of 
good  strength.  No  blowing  murmur  with  the  heart’s  sounds.  Took  ^ j of  castor-oil 
last  night  (the  bowels  having  been  constipated),  which  has  acted  copiously.  Tongue 
dry,  and  covered  with  a brown  fur.  Febrile  symptoms  continue,  with  profuse  dia- 
phoresis. On  the  ^th  December  the  blister  over  the  malleolus  of  right  ankle  burst, 
and  gave  issue  to  a quantity  of  pus.  Distinct  fluctuation  existed  over  the  right  wrist 
and  dorsum  of  the  hand,  which  was  opened  by  an  incision,  and  also  gave  exit  to  a 
considerable  quantity  of  pus.  To  omit  the  nitrate  of  potash.  On  the  %th,  complained 
of  pain  in  the  back  of  the  neck,  and  a bed  sore  was  seen  to  be  forming  over  the 
sacrum.  To  he  placed  on  the  water  bed.  From  this  time  the  pulse,  which  ranged  from 
110  to  140,  lost  its  fulness,  and  became  much  more  weak;  the  skin  assumed  a dirty 
yellowish  or  tawny  hue,  the  typhoid  febrile  symptoms  continued,  with  dry  tongue  and 
sordes,  and  numerous  abscesses  formed  in  the  joints  and  various  parts  of  the  body, 
several  of  which,  as  soon  as  they  became  soft,  were  opened.  A very  large  abscess 
formed  over  the  occiput,  which  was  opened  on  the  18^A,  and  another  over  the  manu- 
brium of  the  sternum,  extending  up  the  left  side  of  the  neck,  which  was  opened  on  the 
24^/i.  The  skin  over  the  heels,  trochanter  of  the  right  hip,  and  the  sacrum,  sloughed, 
notwithstanding  every  care  taken  to  prevent  it.  On  the  26<A,  the  whole  of  the  right 
lower  extremity  was  swollen,  cedematous,  and  white,  resembling  in  aspect  phlegmasia 
dolens ; there  were  laborious  breathing  and  great  prostration.  Low  muttering  delirium, 
and  involuntary  evacuations  supervened,  and  he  sank  on  the  morning  of  the  2*lth. 
The  treatment  had  latterly  been  directed,  by  generous  diet  and  stimuli,  to  support  his 
strength,  relieve  pressure  on  depending  parts,  and  to  dressing  his  sores. 

Sectio  Cadaveris. — Seventy-two  hours  after  death. 

Body  greatly  emaciated ; a fistulous  opening,  the  size  of  a shilling,  existed  imme- 
diately in  front  of  the  left  sterno-clavicular  articulation.  Other  sores,  varying  in  size 
from  half  an  inch  to  three  inches  in  diameter,  and  laying  bare  the  bones,  existed  over 
the  right  elbow,  ankle,  both  hip-joints,  right  knee,  and  sacrum. 

Head. — The  integument  covering  the  occiput  was  separated  from  the  skull,  infil- 
trated with  putrid  pus,  a great  quantity  of  which  had  been  evacuated  by  openings  pre- 
viously made.  On  removing  the  calvarium,  an  abscess,  containing  thick  yellow  pus, 
existed  between  the  bone  and  dura  mater,  about  the  centre  of  the  occipital  bone.  The 
bone  externally  was  somewhat  carious,  but  internally  it  was  healthy.  No  communica- 
tion could  be  traced  between  the  external  and  internal  abscesses.  Drain  healthy. 

Chest. — On  removing  the  heart  and  aorta,  a fluctuating  oval  swelling,  about  f 
inch  in  its  long  diameter,  was  situated  outside  the  aorta,  about  an  inch  from  the  aortic 
valves,  which  was  distended  with  yellow  purulent  matter.  The  posterior  portions  of 
both  inferior  lobes  of  the  lungs  were  condensed.  On  section  they  presented  a reddish- 
purple  color,  the  air  vesicles  filled  with  a soft  sanguineous  exudation  and  readily  sink- 
ing in  water.  Heart  healthy. 

Abdomen. — Kidneys  slightly  enlarged — on  section  presenting  a whitish  mottled 
appearance,  without  great  atrophy  of  the  secreting  or  encroachment  on  the  tubular 
substance.  Other  abdominal  organs  healthy. 

Joints. — The  left  sterno-clavicular  articulation  was  carious  and  disarticulated, 
with  matter  burrowing  to  considerable  depths  in  the  surrounding  soft  textures.  The 


904 


DISEASES  OF  THE  BLOOD. 


right  shoulder,  left  elbow,  right  wrist,  both  hip-joints,  both  knees,  and  both  ankle- 
joints,  were  filled  with  dirty  purulent-looking  matter,  which,  in  several  instances,  more 
especially  in  the  left  elbow  and  hip  joints,  had  infiltrated  itself  more  than  half  way 
down  the  forearm  and  thigh.  The  various  articular  cartilages  presented  all  stages  of 
abrasion,  softening,  and  ulceration;  whilst  the  osseous  textures  below  exhibited  a 
carious  and  blackened  necrosed  condition.  The  base  of  the  ulcer  over  the  sacrum 
consisted  of  necrosed  bone,  and  over  the  right  elbow,  right  hip,  and  knee  joints,  bone 
was  exposed  and  necrosed. 

The  Veins  were  carefully  examined,  especially  in  the  right  inguinal  region,  and, 
with  the  sinuses  at  the  base  of  the  brain,  were  everywhere  found  healthy,  and  free  from 
coagula ; indeed,  the  blood  was  everywhere  unusually  fluid — even  in  the  heart  present- 
ing small,  dark,  and  soft  coagula. 

Microscopic  Examination. — The  pus  consisted  of  molecular  and  granular  matter 
with  debris  of  disintegrated  pus-cells,  with  the  exception  of  the  abscess  within  the 
cranium,  the  pus  of  which  was  normal.  The  cartilage  covering  the  joints  was  in 
some  places  healthy,  but  in  others  its  cells  were  enlarged,  filled  with  secondary  cells, 
and  not  uufrequently  with  fatty  granules.  Around  the  articulations  of  the  joints 
were  laminae  of  chronic  exudations,  consisting  of  dense  amorphous  matter,  principally 
composed  of  minute  molecules.  The  blood  was  carefully  examined,  and  everywhere 
found  normal. 

Commentary  — This  was  a case  of  what  is  frequently  called  pyteraia, 
a disease  which  is  not  uncommon  as  the  result  of  mechanical  injuries 
or  suppurative  diseases.  I believe  it  to  be  very  rare,  however,  as  a con- 
sequence of  attacks  of  acute  rheumatism,  such  as  the  symptoms  and  the 
history  of  this  case  prove  it  to  have  been.  The  lad  was  healthy  and  in 
pursuit  of  his  ordinary  occupation,  when,  after  exposure  to  cold  and  wet, 
he  was  seized  with  the  usual  symptoms  of  rheumatic  fever,  including 
violent  action  of  the  heart,  and  on  this  supervened  suppuration  in  almost 
all  the  joints,  with  numerous  abscesses,  accompanied  by  a low  typhoid 
fever,  under  the  effects  of  which  he  sank.  Dr.  Watson  has  recorded 
two  cases  singularly  like  it,  but  in  them  the  constitutional  disease  was 
preceded  by  otorrhoea  and  abscess  in  the  ear,*  to  which  he  theoretically 
ascribes  the  origin  of  the  disease.  In  the  present  case  there  was  no  pri- 
mary abscess,  no  evidence  of  a pre-existing  collection  of  pus  before  the 
attack  of  rheumatism,  and  I think  there  can  be  little  doubt  that  the  con- 
stitutional state  of  the  blood,  whatever  it  may  have  been,  was  dependent 
on  the  abscesses  which  resulted  from  the  acute  inflammation  of  the  joints. 

This  morbid  condition,  so  much  dreaded  by  surgeons  and  obstetri- 
cians, in  which  typhoid  fever  comes  on  after  severe  accidents  or  parturi- 
tion, accompanied  with  purulent  infiltration  or  multiple  abscesses  in  one 
or  more  organs,  has  received  different  explanations.  The  various  obser- 
vations and  experiments  performed  with  a view  of  elucidating  this  subject 
in  modern  times  have  led  to  the  four  following  theories; — 1.  That  this 
condition  is  owing  to  an  admixture  of  the  blood  with  pus  (pyohemia  of 
Piorry),  and  that  the  pus-corpuscles  being  larger  than  the  colored 
ones  of  blood,  are  arrested  in  the  minute  capillaries,  and  give  rise  to 
secondary  abscesses.  2.  That  it  is  owing  to  the  presence  of  some  irri- 
tating body,  which,  not  being  able  to  escape  from  the  economy,  produces 
capillary  phlebitis.  3.  That  it  is  dependent  on  a property  possessed  by 
pus  of  coagulating  the  blood.  4.  That  it  is  caused  by  the  presence  of  a 
peculiar  poison  which  contaminates  the  system.  All  these  views  have 
been  maintained  with  much  ingenuity,  and  they  are  all  supported  by 
experimental  and  clinical  researches.  A knowledge  of  the  circumstances 
* Practice  of  Physic,  vol.  i.,  p.  381,  4th  edition. 


ICHOEH^MIA  OR  PT^MIA. 


905 


previously  detailed  concerning  leucocythemia  will  enable  us  to  criticise 
these  doctrines  from  a new  point  of  view. 

1.  With  regard  to  the  first  theory,  it  must,  I think,  be  granted  by 
all  those  who  have  examined  the  blood  in  leucocythemia,  or  will  study 
the  figures  I have  given  illustrative  of  that  disease,  that  no  dilference 
whatever  can  be  detected  between  the  colorless  cells  of  the  blood  and 
those  of  pus.  Their  general  appearance,  size,  structure,  and  behavior, 
on  the  addition  of  re-agents,  are  identical, — indeed,  so  much  so,  that  in 
the  first  case  I observed  in  1845  I could  not  resist  the  conclusion  that 
the  blood  was  crowded  with  pus  cells.  It  follows,  that  all  explanations 
of  purulent  infection  founded  on  the  mechanical  impaction  of  these 
bodies  in  the  minute  capillaries  must  be  erroneous.  Some  of  these 
colorless  corpuscles  have  been  observed  much  larger  than  ordinary  pus 
corpuscles.  In  one  instance  many  of  them  were  twice  as  large ; and 
although  this  may  in  some  measure  be  owing  to  endosmosis  of  serum, 
there  can  be  little  doubt  that  they  must  have  exceeded  the  usual  size  of 
pus  cells.  In  Case  CXCIX.,  also,  it  was  observed  that  several  of  the 
colorless  cells  were  larger  than  the  average,  and  yet  the  circulation  went 
on,  and  every  drop  of  the  patient’s  blood  contained  hundreds  of  these 
bodies.  The  first  theory,  then,  is  no  longer  tenable. 

Neither  does  there  seem  to  be  anything  peculiar  in  the  nature  of 
good  arid  laudable  pus  which  necessarily  leads  it  to  poison  the  blood ; for 
it  is  a matter  of  common  observation,  that  large  abscesses  are  absorbed 
and  eliminated  without  occasioning  so-called  purulent  infection.  In  all 
such  cases,  the  pus  corpuscles  must,  in  the  first  instance,  be  disintegrated 
and  reduced  to  a fluid  condition ; still  the  matter  or  substance  of  which 
they  were  composed  passes  into  the  blood.  Hence,  while  leucocythemia 
proves  that  corpuscles,  identical  in  form,  size,  structure  and  chemical 
composition  with  those  of  pus,  may  float  in  the  blood  and  circulate  in- 
nocuously, the  well-known  fact  of  the  absorption  of  abscesses  demon- 
strates that  pus,  when  healthy,  does  not  possess  any  poisonous  properties. 
If,  then,  the  fever  and  other  marked  symptoms  are  owing  to  the  absorp- 
tion of  pus,  it  must  be  of  pus  possessing  properties  wholly  diflerent  from 
those  of  what  is  called  good  or  laudable  pus. 

2.  The  second  explanation  was  advanced  by  Cruveilhier,  who,  on 
injecting  mercury,  ink,  and  other  substances  into  the  blood  of  a living 
animal,  found  that  abscesses  were  formed  wherever  these  accumulated. 
From  hence  it  follows,  that  the  impaction  of  certain  substances  in  the 
tissues  may  induce  local  inflammation,  and  lead  to  abscesses ; but  that 
such  is  not  the  necessary  result  of  admixture  of  pus  with  the  blood,  is 
proved  not  only  by  the  previous  observations,  but  by  numerous  experi- 
ments of  Lebert*  and  Sedillot,f  in  which  the  animals  recovered. 

3.  The  third  doctrine  was  advanced  by  Mr.  Henry  Lee,;]:  and  resulted 
from  observing  that  when  pus  was  mingled  with  recently-drawn  blood, 
it  coagulated  more  rapidly  and  more  firmly  than  under  ordinary  circum- 
stances. This  observation  he  connected  with  the  well-known  fact,  that 
phlebitis  was  often  associated  with  coagula  causing  obstruction  of  the 
veins.  Now  it  is  worthy  of  remark,  that  in  decided  cases  of  leuco- 
cythemia the  blood  is  more  highly  coagulable  when  drawn  from  the 

* Physiologie  Pathologique,  tom.  i.,  p.  313. 

f De  rinfection  Purulente,  p.  73,  et  seq. 

X On  the  Origin  of  Inflammation  of  the  Veins.  London,  1850. 


906 


DISEASES  OF  THE  BLOOD, 


arm,  and  after  death  it  often  presents  firm  coagula,  filling  the  vessels,  as 
in  Case  CXCIX.  Figs.  501  to  503  illustrate  these  colorless  coagula, 
as  observed  in  different  parts  of  the  body.  The  same  occurred  in  Case 
CC. ; and  yet,  during  the  life  of  the  patient,  the  blood,  loaded  with 
the  colorless  corpuscles,  rolled  through  the  vessels  without  impediment 
or  the  formation  of  coagula.  It  does  not  follow,  then,  that  because  dead 
pus  is  mingled  with  recently-drawn  blood  about  to  coagulate,  that  there- 
fore it  should  induce  coagulation  of  living  blood  in  the  vessels  of  an 
animal.  Indeed,  numerous  experiments  by  Lebert  and  Sedillot  show 
that  such  does  not  take  place;  for  although  in  some  cases  death  followed, 
in  others  the  animal  lived,  and  the  pus  corpuscles  were  dissolved.* 
Hence,  although  the  fact  to  a certain  extent  must  be  admitted,  that 
when  pus  is  mingled  with  blood  the  coagulum  formed  is  more  firm,  it 
by  no  means  follows  that  it  produces  coagulation  of  living  bloody  and  is 
the  cause  of  phlebitis  or  purulent  infection. 

4.  The  fourth  theory  seems  to  have  been  maintained  by  A.  Boyerf 
and  Bonnet,!  who  believed  good  pus  to  be  innocuous,  and  the  bad 
effects  occasionally  produced  to  depend  on  its  becoming  putrid,  or 
being  otherwise  altered.  This  view  was  also  more  or  less  supported 

* In  1852,  to  determine  this  point  more  definitely,  I performed,  with  the  late  Professor  Barlow 
of  the  Veterinary  College,  the  following  expeidments  : 

Experiment  1. — The  saphena  vein  of  an  ass  was  exposed,  and  a tube  introduced  confined  by  a 
ligature.  Fresh  and  healthy  pus  was  then  slowly  injected  upwards  towai’ds  the  heart,  from  a 
syringe  holding  an  ounce.  A slight  obstruction  was  now  perceived,  and  the  vein  above  the  liga- 
ture could  be  seen  to  be  somewhat  swollen.  This  swelling,  on  being  felt,  was  very  soft ; and  on 
pressing  the  vein  from  below  upwards,  the  mixed  blood  and  pus  was  readily  pushed  before  the 
finger,  when  all  obstruction  to  the  passage  of  pus  from  the  syi'inge  was  removed.  The  syringe 
was  again  filled,  and  another  ounce  of  pus  injected,  without  occasioning  any  fui-ther  local  effects. 
The  animal  was  then  allowed  to  get  up,  and  exhibited  no  change  in  its  normal  condition  whatever. 

Experiment  2. — The  same  ass  was  the  subject  of  this  experiment  a fortnight  later,  having  been 
perfectly  well  in  the  interval.  Six  inches  of  the  jugular  vein  in  the  neck  were  carefully  dissected 
and  exposed  ; and  a minute  aperture  was  then  made  in  the  upper  end  of  the  exposed  vein,  and 
the  bent  tube  of  the  syringe  introduced  without  a ligature.  The  coats  of  the  vein  were  so  trans- 

Earcnt  that  the  flowing  l)lood  could  be  seen  through  them.  An  ounce  of  fresh  and  perfectly 
ealthy  pus  was  then  slowly  injected  downwards  towards  the  heart,  and,  owing  to  the  trans- 
parency of  the  vein,  the  yellow  opaque  fluid  was  seen  to  join  the  blood,  to  continue  a few  moments 
running  side  by  side  with  the  crimson  current,  until  at  length  the  vein  became  full  of  pus.  On 
removing  the  syringe  to  obtain  a fresh  supply,  the  blood  from  above  could  be  seen  to  join  the  pus. 
to  continue  side  by  side  with  that  fluid,  presenting  a streaked  red  and  white  appearance,  without 
any  coagulation,  until  all  the  pus  was  carried  forwards  and  downwards  towards  the  heart,  and 
the  vein  was  again  full  of  blood.  Another  syi’ingeful  of  pus  was  then  injected,  which  could  once 
more  be  seen  first  to  flow  with  the  blood,  then,  as  its  quantity  increased,  to  take  the  place  of  the 
blood,  and  then,  on  the  syringe  being  exhausted,  to  receive  blood  from  above  ; the  two  mixing 
together,  and  continuing  their  course  without  coagulating,  until  once  more  the  vein  contained 
nothing  but  blood.  The  wound  was  now  closed,  and  the  animal  allowed  to  rise,  which  he  did 
without  apparent  suffering.  He  presented  no  unusual  symptoms  whatever  during  the  next  four 
days,  when  he  was  killed,  and  the  parts  carefully  dissected.  The  vein  was  pervious,  presented  no 
thickening,  nor  cording  or  abscesses,  and  the  external  wound  nearly  healed. 

This  experiment  appeared  to  be  so  decisive,  and  so  clearly  opposed  to  the  idea  that  the  contact 
or  mixture  of  pus  and  blood  necessarily  indueed  congulation  in  a living  animal,  that  it  was 
thought  unnecessary  to  repeat  it.  With  regard  to  the  slight  eoagulability  apparently  occasioned 
in  the  first  experiment,  it  was  attributed  to  injecting  contrary  to  gravity,  whereby  the  mixed  pus 
and  blood  were  allowed  to  fall  backwards  and  remain  stationary,  while  the  ligature  prevented  any 
flow  of  blood  from  being  continued.  No  such  phenomenon  was  observed  in  the  second  experiment, 
where  no  ligature  Avas  employed,  and  where  the  effect  of  gravity  was  avoided  by  injecting  down- 
wards. In  a communication,  however,  received  from  Dr.  Hemy  Lee,  I was  informed  that  no 
ligature  was  employed  by  him. 

The  second  experiment  was  in  its  nature  the  same  as  the  seventh  and  eighth  experiments  of 
Dr.  Henry  Lee,  and  yet  none  of  the  appearances  observed  by  that  gentleman  resulted.  There 
was  no  fulness  or  cording  of  the  vein,  no  acceleration  of  respiration  or  constitutional  sjTnpffoms  ; 
and  after  death  no  coagulation  of  the  blood,  no  obliteration  of  the  vein,  nor  local  inflammation. 
What  are  the  cirCAAmstances  which  occasioned  this  difference,  I am  not  prepared  to  say ; but  the 
positwe  fact  of  having  introduced  the  pus  on  two  separate  occasions,  as  recorded  in  Experiment  2, 
of  having  seen  the  pus  mix  with  the  blood  and  the  blood  with  the  pus,  tliA'Ough  the  transparent 
vein,  AvithoAAt  producing  coagulation,  is  srAfficieut  to  negative  the  general  proposition,  that  when- 
ever pus  is  mingled  Avith  blood  in  a living  animal  coagulation  of  the  latter  fluid  is  the  mvarii»‘Wi 
result. 

+ Gazette  Med.  de  Paris,  p.  193.  1834. 

! Ibid.  p.  593.  183'7.  Both  cited  by  Sedillot,  Op.  cit.,  p.  55. 


GLYCOH^MIA. 


907 


by  Darcef* * * §  and  Berard,f  who,  in  order  to  explain  tlie  undoubted 
effects  of  putrid  substances  when  injected  into  the  veins,  separated 
pyohemia  from  purulent  infection.  But  as  pus  corpuscles  do  not  alone 
cause  the  symptoms,  it  is  certainly  more  probable  that,  in  all  cases, 
there  must  be  a toxic  principle  associated  with  pus  when  it  proves  mor- 
tal. Dr.  Millington J has  shown,  on  repeating  Mr.  Lee’s  experiments, 
that  putrid  fluids  prevent  coagulation  of  the  blood,  and  that  the  coagu- 
lum  caused  by  the  addition  of  pus  is  more  perfect  the  fresher  the  purulent 
matter  is.  This  fact  is  opposed  to  the  idea  that  multiple  abscesses  are 
induced  by  the  coagulation,  but  corresponds  with  what  is  observed  after 
death  in  cases  of  purulent  infection.  When,  therefore,  we  consider  the 
typhoid  nature  of  the  symptoms  so  similar  to  that  of  certain  animal  poi- 
sons; the  multiple  abscesses  so  analogous  to  what  occurs  in  glanders, 
plague,  syphilis,  variola,  etc;  and  the  undoubted  fact,  that  the  blood 
may  be  loaded  with  corpuscles  in  every  respect  identical  with  pus  cells 
without  causing  these  symptoms,  the  irresistible  conclusion  is,  that  these 
effects  are  not  owing  to  pus  in  the  blood,  but  to  an  animal  poison. 

This  view  has  been  opposed  on  the  ground  that  fresh  pus,  to  all  ap- 
pearance healthy  and  without  odor,  has  yet  caused  the  death  of  animals. 
But  what  sensible  property  distinguishes  the  pus  of  the  vaccine  from 
the  small-pox  pustule,  and  either  of  these  from  healthy  pus  ? And  yet 
how  different  their  effects  when  introduced  into  the  blood!  The  subject 
of  animal  poisons  is  certainly  obscure;  but  it  is  more  in  accordance  with 
our  actual  knowledge  to  attribute  purulent  infection  to  such  a cause  than 
to  consider  it  as  the  consequence  of  the  mere  mixture  of  pus  with  the 
blood,  or  a so-called  pyohemia. 

This  doctrine,  which  was  first  clearly  put  forth  in  my  work  on 
“ Leucocythemia  ” in  1852,  seems  now  to  be  generally  adopted,  and  the 
condition  of  the  blood  has  been  called  septicaemia  (Vogel)  and  ichorhae- 
mia  (Virchow).  The  so-called  pus  corpuscles,  which  some  observers  have 
thought  they  saw  in  the  blood,  are  identical  with  the  colorless  cells  of 
that  fluid,  and  if  in  excess,  constitute  white  cell  blood.  Virchow  him- 
self, who  has  claimed  so  much  for  simply  denying  that  leucocythemia  can 
be  pyaemia,  is  obliged  to  admit,  when  writing  on  the  latter  subject,^  that 
the  diagnosis  between  pus  and  the  colorless  cells  of  the  blood  is  very 
difficult,  and  frequently  impossible.  In  truth,  these  bodies  are  the  same, 
and  in  the  majority  of  cases,  what  has  been  called  pyaemia  is  not  depen- 
dent on  pus  cells  mingling  with  the  blood,  but  on  a matter  derived  from 
some  kinds  of  pus,  which  poisons  the  blood,  and  occasions  the  secondary 
phenomena. 

GLYCOH^MIA. 

Case  CCV.H — Diabetes  Mellitus^ 

History. — Allan  M‘Clemont,  set.  32,  laborer — admitted  7th  June  1852.  About 
three  weeks  ago,  on  recovering  from  a general  rheumatic  attack,  he  found  himself  much 
reduced  in  strength,  and  somewhat  emaciated.  He  experienced  great  thirst,  and  passed 
a large  quantity  of  urine.  These  symptoms  have  rapidly  increased. 

* These  Inaugurale.  Paris,  1842. 

f Dictionnaire  de  Med.,  tom.  26.  1842. 

\ Monthly  Journal.  November  1851.  P.  486. 

§ Gesammelte  Abhandlungen.  P.  653. 

I Reported  by  Mr.  J.  L.  Brown,  Clinical  Clerk. 


908 


DISEASES  or  THE  BLOOD. 


Symptoms  on  Admission. — On  admission,  tongue  moist  and  clean,  appetite  in* 
creased,  thirst  excessive,  bowels  rather  costive,  skin  dry,  urine  very  pale  and  slightly 
turbid.  On  heating  a portion  of  the  urine  with  an  equal  portion  of  Aq.  Potassae,  a 
deep-brown  color  is  produced.  He  has  passed  during  the  last  24  hours  380  oz.,  spec, 
grav.  1030,  having  drank  460  oz.  of  water  in  that  time.  Other  functions  performed 
normall}'.  His  weight  was  11  stone  8 lbs.  Ordered  pilh  of  Aloes  and  Ipecacuan^ 
and  a mixture  of  Inf.  Quassice  and  Tr.  Aurantii. 

Pkogress  of  the  Case. — On  the  10/A  June  he  was  ordered  the  following  diet : S 
cakes  made  of  bran,  butter,  and  milk,  weighing  half  a pound ; 3 eggs  ; 4 oz.  steak  for 
breakfast,  12  for  dinner,  4 for  supper;  1 cabbage;  3 bottles  of  soda  water;  8 oz.  of 
lime-water;  3 oz.  of  wine.  To  have  a warm  bath  every  third  night.  On  15th  June 
the  amount  of  urine  passed  was  diminished  to  120  oz.  in  the  day,  of  density  1036,  and 
he  drank  during  that  time  150  oz.  His  weight  was  11  stone.  On  the  22d  he  was  or- 
dered 4 oz.  of  steak  additional,  and  anotJier  bran  cake.  From  this  time  the  amount  of 
urine  fluctuated  from  160  to  190  oz.  daily ; but  on  the  5th  July  it  was  reduced  to  160 
oz.,  spec.  grav.  1034,  and  his  drink  was  167  oz.  He  then  weighed  11  stone  2 lbs. ; 
but  being  wearied  of  the  treatment,  he  insisted  on  going  out  on  the  6th. 

Case  CCVI.* — Diabetes  Mellitus — Phthisis  Pulmonalis — Vomica  on 
Right  Pide — Death, 

Histoky. — Robert  Fallow,  a tailor,  set.  24 — admitted  July  8th,  1861.  Last  Decem- 
ber, when  in  America,  was  attacked  with  bilious  fever,  which  continued  ten  weeks. 
Shortly  afterwards  he  observed  that  the  quantity  of  urine  he  passed  was  greatly  in- 
creased, and  that  his  thirst  was  excessive.  Cough  appeared  six  weeks  ago,  followed  by 
purulent  expectoration  ; and  the  skin,  which  had  previously  been  remarkably  dry,  was 
now  covered  with  copious  sweat  during  the  night. 

Symptoms  on  Admission. — Percussion  elicits  no  decided  difference  of  sound  on 
either  side  of  the  chest,  but  there  is  a much  greater  degree  of  resistance  under  the 
right  clavicle  than  under  the  left.  On  auscultation,  cavernous  respiration  is  very  dis- 
tinct under  the  right  clavicle,  but  the  sounds  are  dry.  The  vocal  resonance,  also,  is 
greatly  increased  in  the  same  situation,  and  has  somewhat  of  a metallic  character. 
Under  the  left  clavicle,  inspiration  is  harsh,  and  expiration  prolonged.  On  the  left 
side,  posteriorly  and  inferiorly,  the  inspiration  is  everywhere  harsh,  with  occasional 
cooing  rales  and  prolongation  of  the  expiration.  The  expectoration  is  copious,  muco- 
purulent, and  of  brownish  tint,  without  distinct  traces  of  blood.  Cough  severe.  Tongue 
furred  and  dry,  coated  near  the  base.  Appetite  good.  Thirst  insatiable.  Sour-sweet 
taste  in  the  mouth.  Pulse  108,  small  and  weak.  Has  voided  70  oz.  of  urine  during 
the  last  twelve  hours.  The  addition  of  liq.  potassae,  followed  by  heat,  throws  down  a 
reddish-brown  sediment.  Skin  soft  and  moist. 

Progress  of  the  Case. — On  the  Wth  of  July  gurgling  was  heard  under  the  right 
clavicle.  On  the  20/!A  there  was  complete  loss  of  appetite,  and  repugnance  to  food. 
The  urine^varied  since  last  report  from  170  to  230  oz.  voided  in  the  24  hours.  Profuse 
sweating  at  night.  Mucous  rales  heard  over  the  whole  anterior  surface  of  chest  on  the 
right  side.  Vocal  resonance  still  metallic  under  right  clavicle,  with  cracked-pot  sound 
on  percussion.  August  \.th. — The  amount  of  urine  passed  now  varies  from  100  to  150 
oz.  during  24  hours.  Weakness  and  emaciation  have  greatly  increased  ; sweating  and 
loss  of  appetite  continued.  Died  at  7 p.m. 

As  to  treatment,  he  was  ordered  a diet  consisting  at  first  of  eggs,  boiled  meat,  and 
stale  bread  and  milk ; pills  of  opium  and  hyoscyamus  at  night,  and  cod-liver  oil  in- 
ternally. An  expectorant  mixture,  afterward  combined  with  antispasmodics,  waa 
ordered,  to  relieve  the  cough. 

Permission  to  examine  the  body  could  not  be  obtained. 

Commentary. — Phthisis  pulmonalis  is  a very  common  • complication 
of  diabetes  in  persons  under  80 — a circumstance  which  appears  to  me  to 
support  the  pathological  views  formerly  given  as  to  the  great  importance 
which  should  be  attached  to  derangement  of  the  nutritive  functions  as  a 
cause  of  the  tubercular  disease.  An  animal  and  oleaginous  diet  is  indi- 
cated in  both  disorders;  which,  however,  when  present  in  the  same  indi- 
vidual, may  easily  be  supposed  to  constitute  a hopeless  form  of  malady. 

* Reported  by  Mr.  W.  M.  Calder,  Clinical  Clerk. 


GLYCOH^mA. 


909 


Pathology  of  Piahetes, 

The  excretion  of  sugar  in  large  quantities  by  the  kidney  has  for  a 
lengthened  period  excited  the  attention  of  pathologists,  and  given  rise  to 
abundant  speculation.  It  having  been  shown  by  Mr.  Macgregor  of 
Glasgow  that  sugar  was  formed  in  the  stomach  from  the  digestion  of  food, 
while  that  principle  was  subsequently  detected  in  the  blood  by  the  same 
observer,  as  well  as  by  Ambrosiani,  Maitland,  and  Percy — the  view  of 
Rollo  was,  on  the  whole,  considered  the  correct  one,  and  the  treatment 
he  proposed  has  been,  in  its  main  features,  followed  by  subsequent  prac- 
titioners. This  theory  supposed  that  the  sugar  formed  in  the  stomach 
and  alimentary  canal,  from  the  starchy  and  saccharine  principles  of  the 
food,  instead  of  being  rapidly  converted  into  other  compounds,  as  Prout 
supposed,  was  absorbed  into  the  blood,  and  excreted  by  the  kidneys. 
The  treatment  based  upon  this  theory  was  therefore  directed  to  keeping 
up  nutrition  from  substances  which  were  thought  incapable  of  being  con- 
verted into  sugar ; and  it  is  worthy  of  remark,  that  such  treatment  does 
often  greatly  diminish  the  excretion  of  sugar,  without,  however,  suppress- 
ing it,  and  also  ameliorates  the  other  symptoms.  Dr.  Gray  of  Glasgow 
was  induced  to  give  rennet  in  teaspoonful  doses  after  each  meal,  and  pub- 
lished three  cases,  in  two  of  which  it  occasioned  an  apparent  cure. 
(Monthly  Journal,  January  1853.)  He  argued,  that  if  out  of  the  body 
rennet  converts  a solution  of  sugar  into  lactic  acid,  it  may  have  a similar 
effect  upon  a solution  of  sugar  within  the  body;  and  bearing  in  mind 
that  lactic  acid  is  found  in  the  juice  of  flesh,  and  according  to  Liebig,  is 
a supporter  of  the  respiratory  process,  he  considered  that  if  sugar,  formed 
in  the  body  of  a diabetic  paGent,  could  be  converted  by  the  rennet  into 
lactic  acid,  it  would  be  burned  in  the  lungs;  and  that  if  a larger  quantity 
was  formed  than  could  be  consumed  in  this  way,  that  portion  would  be 
excreted  by  the  kidneys.  In  consequence  of  this  ingenious  theory,  and 
the  facts  in  its  support  adduced  by  Dr.  Gray,  rennet  was  tried  in  several 
cases  admitted  into  the  Royal  Infirmary  of  Edinburgh,  but  without 
success. 

The  researches  of  M.  Bernard  have  given  rise  to  other  views  as  to 
the  origin  of  diabetes.  He  admits  that  sugar  may  be  formed  in  the  pro- 
cess of  digestion,  and  a certain  amount  of  it  may,  as  a result  of  absorption 
from  the  alimentary  canal,  find  its  way  into  the  blood.  But  he  has  de- 
monstrated that,  in  dogs  fed  entirely  on  animal  food,  sugar  may  exist  in 
the  liver  and  in  the  blood  of  the  h'epatic  vein,  while  it  is  absent  in  the 
portal  vein.  Moreover,  he  has  shown  that  sugar  is  a normal  secretion  of 
the  liver  of  all  animals,  from  man  down  so  low  in  the  scale  of  beings  as  the 
mollusca ; and  that,  moreover,  it  is  secreted  by  the  liver  of  the  foetus.  He 
has  proved  experimentally  that  this  secreting  function  is  increased,  and 
diabetes  produced,  by  irritating  the  eighth  pair  of  nerves  at  their  origin 
in  the  fourth  ventricle ; while,  on  the  other  hand,  section  of  these  nerves 
destroys  its  formation.  I have  seen  M.  Bernard  perform  these  experi- 
ments, and  have  repeated  them  myself  in  this  city,  and  have  no  doubt  as 
to  the  accuracy  of  these  results.  That  sugar  does  not  exist  normally  in 
urine  and  in  blood  drawn  from  the  arm  is  explained  by  its  rapid  decom- 
position in  a state  of  health,  and  its  excretion  by  the  lungs.  But  when 


910 


DISEASES  OE  THE  BLOOD. 


it  is  so  increased  in  quantity  that  the  lungs  cannot  excrete  the  whole  of 
it,  the  remainder  passes  off  by  the  kidneys ; and  hence  diabetes.  M. 
Bernard  has  also  ascertained  that  although  section  of  the  pneumogastric 
nerves  destroys  the  formation  of  sugar  in  the  liver,  it  is  restored  by 
artificially  irritating  their  central  cut  extremities ; and  that  diabetes  is 
produced  exactly  in  the  same  manner  as  by  irritating  their  origins  in  the 
brain.  He  was  therefore  led  to  conclude,  that  the  nervous  action  neces- 
sary for  the  secretion  of  sugar  does  not  originate  in  the  brain,  to  be 
transmitted  directly  along  the  pneumogastrics,  but  indirectly  and  by 
reflex  action ; the  vagi  being  incident  nerves,  the  medulla  oblongata  the 
centre,  and  the  spinal  cord,  communicating  with  the  solar  ganglion,  the 
excident  channel.  Following  out  this  theory,  he  found  that  whenever 
the  respiratory  function  is  violently  stimulated  sugar  appears  in  the 
urine ; and  that  whenever  ether  or  chloroform  is  given  a temporary  dia- 
betes is  ocasioned.  He  further  supposes,  that  in  the  same  way  that  the 
lungs  thus  act  by  reflex  nervous  influence  on  the  liver,  so  increased  ac- 
tion of  the  liver  acts  upon  the  kidney ; consequently  that  the  sugar 
produced  in  excess  by  one  organ  is  excreted  by  the  other.  Hence  may 
probably  be  explained  the  occasional  temporary  presence  of  sugar  in  the 
urine  independent  of  the  disease  known  as  diabetes. 

Continuing  his  researches,  M.  Bernard  arrived  at  the  conclusion  that 
the  liver  does  not  secrete  sugar  directly,  but  rather  a substance  which 
presents  all  the  physical  and  chemical  properties  of  hydrated  starch,  and 
which  is  transformed  into  sugar  by  the  aid  of  a ferment.  This  substance 
he  succeeded  in  separa’ting  from  the  liver.  It  has  been  called  liver-starchy 
gliicogeney  or  amyloid  substance  ; zoamylinCy  or  animal  starch  by  Rouget, 
and  amyline  by  Pavy.  It  may  readily  be  obtained  by  pouring  a large 
quantity  of  crystallisable  acetic  acid  upon  a concentrated  and  filtered 
decoction  of  the  liver.  A whitish  precipitate  is  separated,  which  is  this 
glucogenic  substance  or  amyline.  The  ferment  Bernard  presumes  to 
exist  in  the  blood,  so  that  the  starchy  substance  formed  by  the  vital  ac- 
tion of  the  liver  undergoes  a chemicul  transformation  into  sugar  when  it 
comes  into  contact  with  that  fluid.  The  sugar  thus  formed  in  the 
blood,  on  arriving  at  the  lungs,  is  in  its  turn  decomposed  by  the  oxygen 
of  the  air,  and  disappears.  Hence  the  liver  and  the  lungs  are  so  far  op- 
posed to  one  another  in  function  that  the  one  produces  the  substance  out 
of  which  sugar  is  formed,  whilst  the  other  decomposes  the  sugar  which 
in  health  exists  in  that  part  of  the  circulation  only  that  lies  between  the 
liver  and  lungs.  It  follows  that  the  occurrence  of  sugar  in  the  circulation 
generally,  and  its  presence  in  the  urine,  is  probably  dependent  not  only 
upon  excess  of  hepatic,  but  upon  diminution  of  pulmonary  action  also. 
It  is  certain  that  the  great  majority  of  diabetic  patients  die  phthisical. 

These  views  of  Bernard  point  to  the  importance  of  the  observations 
made  by  Virchow,  Busk,  Carter,  and  others,  as  to  the  existence  and  even 
wide  diffusion  of  starch  corpuscles  throughout  the  animal  economy 
(Carter),  and  should  stimulate  organic  chemists  to  ascertain  how  far 
chemical  change  in  the  lung  may  not  be  a cause  of  diabetes. 

According  to  I)r.  Pavy,  amyline  is  only  transformed  into  sugar  after 
death.  On  introducing  a catheter  into  the  right  side  of  a living  animal, 
and  removing  the  venous  blood,  he  found  that  it  contained  no  sugar,  but 


GLTCOH^MIA. 


911 


that  ten  minutes  afterwards  it  does.  He  also  ascertained  that  the  glu- 
cogenic function  could  be  arrested  by  cold  or  by  the  injection  into  the 
portal  vein  of  an  alkaline  solution  (potash).  In  the  same  liver  the  parts 
which  were  so  injected  contained  no  sugar,  while  in  the  uninjected  parts 
it  was  present.  Hence,  according  to  Pavy,  all  previous  experiments  on 
the  dead  tissues  and  dead  blood,  though  correct,  have  led  to  a false 
inference  as  to  what  occurs  in  the  healthy  living  economy.  In  certain 
diseased  conditions,  however,  sugar  is  formed  during  life,  producing  dia- 
betes. Subsequent  experiments  made  by  Hr.  Harley  of  London  showed, 
contrary  to  the  views  of  Pavy,  that  sugar  could  be  found  in  the  liver 
immediately  after  death,  and  that  although  portal  blood  contained  no 
sugar,  it  could  be  found  in  hepatic  blood  at  the  instant  of  death.  Hr. 
Thudicum  also  has  pointed  out  that  when  air,  potash,  and  sugar  are 
mixed  together,  the  sugar  is  decomposed,  and  that  in  this  way  some  of 
Pavy’s  experiments  were  fallacious;  so  that  Bernard’s  view  is  still  the 
one  generally  adhered  to. 

These  researches  of  M.  Bernard  explain  why  Hollo’s  treatment 
diminis.hes  the  excretion  of  sugar,  by  cutting  oif  all  that  enters  the  blood 
through  the  alimentary  canal.  According  to  Traube,  the  intensity  of 
the  secretion  of  sugar  varies  at  different  times  of  the  day,  and  under 
different  circumstances.  Thus  it  is  greatly  increased  after  meals,  and  is 
least  during  the  night.  At  the  commencement  of  the  disease  it  is  prin- 
cipally derived  from  the  food ; in  the  latter  stage  it  is  largely  formed 
by  the  organism.  Hence  why  treatment  directed  to  the  stomach  does 
not  cure,  because  it  fails  to  affect  the  hepatic  organ.  Bernard’s  obser- 
vations appear  to  me  also  capable  of  throwing  light  on  the  good  effects 
of  opium — effects  which  are  universally  recognised — from  its  power  of 
diminishing  nervous  irritability.  No  other  practical  results,  however, 
are  as  yet  derivable  from  them,  unless  the  well-known  symptom  of 
dryness  of  the  skin  be  connected  with  the  cause  of  the  disorder,  in  which 
case  diaphoretics,  though  they  have  often  been  used  with  great  benefit, 
would  be  more  strongly  indicated.  Perhaps,  also,  exercise  and  a cold 
atmosphere,  which  increase  the  oxygenating  power  of  the  lungs,  might 
be  of  some  avail.  Further  researches  are  required  on  these  points,  and 
it  is  to  be  hoped  that  practitioners,  no  longer  exclusively  directing  their 
attention  to  the  digestive  organs,  may,  by  new  efforts,  ultimately  be 
enabled  to  control  this  singular  disorder. 

The  diet  ordered  in  the  Case  CCV.  is  one  which  admits  of  very  slight 
formation  of  sugar  in  the  alimentary  canal,  and,  together  with  opiates 
and  the  occasional  use  of  the  warm  bath,  constitutes  the  best  treatment 
which  has  hitherto  been  adopted.  Its  temporary  good  effects  were  well 
manifested,  although  it  proves,  in  conjunction  with  the  confinement  of 
an  hospital,  very  irksome  to  the  patient.  Indeed,  in  general  hospitals 
it  has  been  found  very  difficult  to  insure  the  continuance  of  an  animal 
diet,  and  this  notwithstanding  the  manufacture  of  various  kinds  of  bread- 
stuffs  deprived  of  starch,  such  as  the  gluten  bread  of  Bouchardat,  the 
bran  biscuits  of  Hr.  Campliu,  the  almond-cake  of  Hr.  Pavy,  and  the 
glycerine  sponge-cake  of  Hr.  Beale.  Further,  it  may  be  well  questioned 
whether  the  diminution  in  certain  symptoms  so  obtained  really  affects, 
in  any  sensible  manner,  the  progress  of  the  disease.  We  may,  it  is  true, 
3ut  off  sugar  from  without,  but  that  formed  from  within  continues  in 


912 


DISEASES  OF  THE  BLOOD. 


excess,  and  ultimately  exhausts  the  patient.  Hence  the  idea  that  sugar 
furnished  to  the  patient,  instead  of  being  injurious,  might,  by  supplying 
him  with  the  material  the  loss  of  which  is  so  deleterious,  serve  to  sup- 
port his  strength.  Piorry  first  showed,  in  a patient  who  was  passing  17^ 
pints  of  urine  daily,  containing  22^  oz.  of  sugar,  that  on  giving  4 oz.  of 
sugar-candy  per  diem,  and  abstaining  from  drink,  the  amount  of  urine 
was  diminished  in  twelve  days  to  4^  pints,  containing  only  4^  oz.  of 
sugar.^  The  treatment  of  diabetes  by  sugar  has  been  further  prosecuted 
by  Drs.  Budd,  Corfe,  Bence,  Jones,  and  others,  with  the  general  result 
of  giving  much  relief,  often  diminishing  the  amount  of  sugar  secreted, 
and  occasionally  improving  the  health.  My  own  experience  of  this  mode 
of  treatment  is  not  deficient  in  interest. 

Case  CCVII. — Liahetes  Mellitus — Apparent  Improvement  from  the  Use 

of  Sugar. 

History. — Alexander  Isset,  aet.  45,  tailor — admitted  November  19,  1859.  Four 
months  ago  he  first  noticed  increased  appetite  for  food,  but  becoming  weak  and  inca- 
pable of  carrying  on  his  work,  came  to  the  Infirmary. 

Symptoms  on  Admission. — An  emaciated  man,  with  distortion  of  the  spine  and 
partial  anchylosis  of  the  left  knee-joint.  Urine  pale,  sp.  gr.  1040,  strongly  impreg- 
nated with  sugar.  Great  debility,  otherwise  healthy. 

INGRESS  OF  THE  Case. — January  23(/. — He  has  been  treated  with  opium,  which 
caused  no  relief,  passing  on  an  average  250  oz.  of  urine  daily.  To-day,  while  at  stool, 
he  became  so  faint  he  could  scarcely  speak.  From  this  condition  he  was  rallied  by 
stimulants.  Ordered  § viij  of  sugar  daily.  March  29<A. — Has  been  taking  the  sugar 
regularly,  with  an  ordinary  mixed  diet.  He  has  gradually  become  stronger,  and  now 
expresses  himself  as  being  quite  well.  For  some  weeks  he  has  passed  most  of  his 
time  in  the  green  behind  the  house,  and  is  reported  to  be  eating  and  drinking  much 
less,  and  to  be  passing  only  from  92  to  112  oz.  of  urine  daily.  As  it  was  discovered, 
however,  that  this  man  frequently  passed  water  out  of  the  house,  and  was  evidently 
wishing  to  deceive,  he  was  dismissed. 

Commentary. — I have  given  this  case  very  shortly,  because  only 
general  results  were  aimed  at,  and  because  nothing  as  to  minute  obser- 
vation could  be  depended  on  in  an  individual  anxious  to  deceive  us.  At 
the  same  time,  the  fact  was  unquestionable  that  the  general  health  on  his 
admission  was  much  broken  down,  and  continued  so  for  upwards  of  a 
month,  when  his  debility  had  much  augmented.  Further,  that  on  ad- 
ministering the  sugar,  not  only  did  the  strength  augment,  but,  what  is 
more  remarkable,  so  far  from  the  diabetes  increasing,  it  was  greatly 
diminished,  although  to  what  extent  could  not  be  ascertained.  These 
facts  appeared  to  me  so  striking  that  I resolved  to  observe  the  next  case 
with  great  attention. 

Case  CCYIII.t — liahetes  Mellitus.,  treated  with  Sugar — Great  Improve^ 
ment  for  a time,  followed  hy  Cataract,  Phthisis,  and  Death. 

History. — James  Campbell,  set.  33,  a shepherd  from  Perthshire,  married,  was 
admitted  into  the  Royal  Infirmary,  November  29th,  1860.  He  has  never  suffered 
from  any  illness  until  about  twelve  months  ago,  when  he  first  noticed  a great 
increase  in  his  thirst,  which  he  satisfied  by  large  draughts  of  water,  or  of  beer  when 
he  could  get  it.  He  noticed  soon  afterwards  that  he  was  passing  much  more  urine 
than  was  natural.  From  this  time  he  began  to  lose  strength,  to  experience  dizziness 
in  the  head,  especially  on  suddenly  changing  his  posture,  and  to  have  occasional 


* Comptes  Rendus,  January  26,  1857. 

f Reported  by  Messrs.  C.  H.  Alfrey,  W.  Turner,  and  A.  Smart,  Clinical  Clerks. 


GLTCOIIJEMIA. 


913 


cramps  in  tlie  legs.  Six  or  seven  weeks  ago  he  became  so  weak  that  he  \^as  obliged 
to  give  up  all  kinds  of  work ; and  since  then  he  has  rapidly  lost  flesh  and  diminished 
in  weight,  which,  in  health,  was  twelve  stone.  His  usual  diet  has  been  oatmeal 
porridge  morning  and  evening,  with  meat  at  noon.  He  has  indulged  freely  in  whisky, 
but  not  to  great  excess.  He  has  been  much  exposed,  in  the  course  of  his  employment, 
to  vicissitudes  of  the  weather,  but  has  always  been  well  clothed. 

Symptoms  on  Admission. — He  complains  of  cramps  in  his  legs,  confined  to  the 
muscles  of  the  ham  and  calf,  which  are  soft  and  flabby.  There  is  considerable 
emaciation  and  great  muscular  weakness.  His  weight  is  8 stone  10  lbs.  The  skin 
is  dry  and  cracked.  There  has  been  no  perspiration  since  the  commencement  of  the 
disease.  Face  and  lips  pale ; an  incipient  arcun  senilis.  Pulse  52,  weak.  Cardiac 
and  respiratory  sounds  healthy.  He  has  no  headache,  but  great  giddiness  on  changing 
his  posture.  Sight  and  hearing  somewhat  impaired.  His  memory  is  also,  he  thinks, 
diminished.  Answers  questions  slowly,  but  is  otherwise  intelligent.  The  tongue  is 
covered  with  a moist  white  fur.  His  appetite  is  ravenous,  and  he  suffers  no  incon- 
venience from  the  increased  quantity  of  food  he  takes.  Bowels  regular.  Passes  daily 
an  unusual  quantity  of  urine,  of  faint  urinous  odor,  sweetish  taste ; sp.  gr.  1040, 
strongly  impregnated  with  sugar,  as  shown  by  all  the  tests. 

Progrkss  of  the  Case. — Up  to  the  22d  of  December  no  treatment  was  commenced, 
but  observations  were  made  to  determine  and  regulate  his  food  and  drink,  the  amount 
of  urine  passed  daily,  and  the  quantity  of  sugar  it  contained.  The  result  of  these  in- 
quiries were  determined,  December  23d,  to  be  as  follows : — 

Daily  Food — Coffee,  9 oz.  ; milk,  16  oz. ; steak,  6 oz. ; tea,  9 oz. ; butter,  1 oz. ; 
eggs,  2 oz. ; bread  16  oz. — the  whole  containing  25  solid  ounces. 

Daily  amount  of  water  drunk — 100  oz. 

Daily  amount  of  urine  passed — 193  oz.  Sp.  gr.  1040. 

Daily  amount  of  sugar  in  each  English  pint — 600  grains. 

He  was  now  ordered  to  take  i lb.  of  brown  sugar  daily,  which  he  did,  partly  dissolved 
in  his  coffee  and  milk,  and  partly  eaten  simply  with  a spoon.  January  ‘12th.,  1861. — 
His  general  condition  is  greatly  improved.  His  weight  has  increased  to  9 stone  1 1 lb. 
His  countenance  is  ruddy  and  more  healthy  in  appearance,  and  his  strength  is  much 
augmented.  Still  slight  headache,  but  no  cramps.  March  l^d. — Has  been  steadily 
improving  in  health.  His  weight  is  now  lo  stone  6 lbs.,  and  he  has  no  pain,  cramps, 
or  other  inconvenience.  Drinks  daily  90  oz.  of  water,  and  passes  190  oz.  of  urine,  of 
the  sp.  gr.  1040.  Dismissed. 

Re-admitted  May  17^/q  1861. — His  vision  and  general  strength  have  somewhat 
diminished,  and  he  again  feels  pains  and  cramps  in  the  legs.  In  other  respects  the 
same.  Was  again  ordered  to  take  the  sugar.  July  12th. — He  left  the  hospital,  say- 
ing he  felt  much  better;  but  the  amount  of  water  he  now  drinks  daily  is  120  oz.,  and 
the  amount  of  urine  passed  from  200  to  250.  His  weight  was  10  stone  4 oz. 

Re-admitted  February  lid,  1862. — Since  leaving  the  Infirmary  has  not  resumed 
his  occupation,  but  his  debility  and  loss  of  flesh  have  increased.  His  weight  has  fallen 
to  8 stone  13  lb.  He  now  complains  of  cough  and  shortness  of  breath,  and  on  ex- 
amining the  pulmonary  organs,  dulness  on  percussion,  with  crepitation  and  increased 
vocal  resonance  on  auscultation,  was  detected  under  the  left  clavicle.  He  has  copious 
expectoration  of  purulent  nummular  sputa,  and  sweats  profusely.  Pulse  80,  weak. 
Daily  observations  as  to  the  effect  of  variously-mixed  diets,  with  analyses  of  the  urine, 
were  made,  during  which  it  was  observed  that  after  every  change  a slight  temporary 
improvement  occurred.  The  phthisis,  however,  made  rapid  progress,  and  feeling  him- 
self incapable  of  recovering,  he  left  the  house,  greatly  emaciated  and  weaker,  June  4th. 
He  died  in  the  following  October. 

Commentary. — It  will  be  observed  that  in  this  as  in  the  last  case, 
the  strength  of  the  patient  at  first  rapidly  rallied,  and  that  he  gained 
weight  under  the  use  of  sugar  and  a mixed  diet,  while  the  diabetic 
symptoms  underwent  little  change.  Phthisis  at  length  appeared,  which 
proved  fatal. 

Case  CCIX.* — Diabetes — Treatment  by  Sugar — Phthisis. 

History.— Mary  Innes,  aet.  22,  a servant— admitted  Nov.  25th,  1862.  States  tha4 
she  enjoyed  good  health  till  the  beginning  of  April  last,  when  she  experienced  unusual 

* Reported  by  Mr.  James  Rhind,  Clinical  Clerk. 

58 


914 


DISEASES  OF  THE  BLOOD. 


thirst,  and  noticed  that  her  urine  was  increased  in  quantity.  Her  weakness  increas- 
ing, she  was  admitted  into  the  Infirmary. 

Symptoms  on  Admission. — Great  thirst.  Appetite  good,  but  not  increased. 
Bowels  disposed  to  constipation.  Does  not  sleep  well.  Catamenia  appeared  last  two 
months  ago.  Urine  pale,  transparent,  acid,  sp.  gr.  104'7 ; answers  very  readily  to  the 
tests  of  sugar.  Pulse  80,  weak.  Other  functions  normal. 

Progress  of  the  Case. — Observations  were  made,  as  in  the  last  case,  to  determine 
in  the  first  place  the  ordinary  condition  of  the  patient  while  eating  an  ordinary  mixed 
diet  and  drinking  as  much  water  as  she  pleased.  § viij  of  sugar  were  then  directed  to 
be  taken  daily.  On  the  24th  of  January  1863  the  sugar  was  omitted,  and  she  was 
ordered  the  following  diet : — No  potatoes  nor  bread.  To  have  tea  without  sugar  20 
oz. ; Dr.  Pavy’s  almond-cake  4 oz. ; milk  1^  lbs.  in  the  morning  and  evening ; at  din- 
ner 20  oz.  strong  beef-tea,  with  4 oz.  of  chop,  fish,  or  eggs.  The  results  of  these  ob- 
servations up  to  the  30th  of  January  are  represented  in  the  following  table: — 


Averages  of  7 Days. 
Diet. 

Fluids. 

Sp.  Gr.  1 
of  Uriuej 

Solids. 

Sugar 

Excreted. 

Weight  of 
Patient. 

Taken. 

Passed. 

Taken. 

Passed. 

1.  Without  Sugar  - 

3 279 

§243 

1043 

27  oz. 

4 oz. 

12,765  grs. 

117  lbs. 

2,  With  Sugar 

287 

243 

1044 

37 

13,881 

116 

3.  With  Sugar 

249 

203 

1045 

3H 

5 

12,864 

116 

4.  With  Sugar 

229 

196 

1045 

31 

6 

12,683 

116 

5.  With  Sugar 

219 

178 

1045 

29 

4 

11,228 

116 

6.  Without  Sugar - 

I78i 

169 

1045 

22 

n 

10,545 

116i 

7.  Animal  Diet 

128 

103 

1037 

m 

4 

4,023 

116 

She  continued  in  the  house  three  months  longer,  during  which  period  phthisis 
made  its  appearance,  and  she  gradually  lost  strength.  Many  changes  of  diet  were 
made,  and  strychnia  was  given  for  some  time  in  small  doses  without  effect.  She  left 
the  hospital  for  ‘the  country  on  April  29th,  in  the  last  stage  of  phthisis. 

Case  CCX. — Diahetes--- Treated  in  various  ways. 

History. — William  Mackay,  aet.  23,  storekeeper — admitted  February  5th,  1862. 
Has  always  enjoyed  good  health  till  July  last,  when  he  felt  unusual  thirst  and  hunger, 
also  a notable  increase  in  the  amount  of  urine  passed  daily.  Owing  to  increasing  de- 
bility he  sought  admission  to  the  Infirmary. 

Symptoms  on  Admission. — The  appetite  and  thirst  much  increased.  Urine  pale 
and  transparent,  sweetish  taste  and  odor,  sp.  gr.  1035  ; readily  answers  to  sugar-tests. 
He  is  much  emaciated.  Features  pinched  and  pale.  Perspires  much  at  night. 
W’’eighs  8 st.  3 lbs.  Height  5 ft.  6 inches.  All  the  other  functions  normal. 

Progress  of  the  Case. — February  21.s^. — Patient  up  to  this  date  has  been  living 
on  “ full  mixed  diet.”  Various  kinds  of  treatment  were  tried  in  this  case,  and  all  the 
facts  recorded  in  the  following  table  were  carefully  made  by  Dr.  Smart,  the  resident 
physician. 


Averages  of  10  Days. 

Fluids.  1 

Sp.  Gr. 
of  Urine 

Solids. 

Sugar 

Weight  of 

Diet,  etc. 

Taken. 

Passed. 

Taken. 

Passed. 

Excreted. 

Patient. 

1.  Full  Mixed  Diet 

2.  Full  Mixed  Diet, 
with  8 oz.  of  Sugar 

§369 

§405 

1039 

66  OZ. 

26  oz. 

17,717  grs. 

116  lbs. 

404 

407 

1040 

52 

14 

17,208 

116 

3.  Full  Mixed  Diet 

398 

447 

1039 

621 

18 

16,616 

116 

4.  Animal  Diet 

237 

275 

1037 

24 

7 

10,063 

113 

6.  Full  Mixed  Diet 
6.  Full  Mixed  Diet, 
with  3 iss  of  Chlo- 

337 

356 

1037 

37 

9 

13,126 

109 

rate  of  Potash  - 

299 

276 

1033 

34 

3 

7,437 

110 

7.  Full  Mixed  Diet 

8.  Full  Mixed  Diet, 

328 

301 

1036 

36 

6 

10,163 

113 

with  8 oz.  of  Sugar 

386 

328i 

1036 

44 

8 

11,083 

108 

His  general  health,  when  these  careful  observations  were  concluded,  April  30th, 
had  undergone  no  alteration.  He  remained  in  the  house  until  the  24th  of  June,  when 
he  went  out,  at  his  own  request,  very  much  the  same  as  when  he  first  entered,  but 
weighing  7 stone  10  lbs. 


CA?E  CCXI. — John  Taylor,  coal  aud  iron  miner,  ast.  33 — admitted  April  5th,  1864.  The  patient  was  in  good  health  up  to  three  months  before  admission.  Hr 
is  emaciated,  and  skin  dry.  Pulse  80,  of  moderate  strength.  Tongue  clean;  bowels  regular.  No  cough  or  expectoration.  Subject  to  slight  dimness  of  sight 
while  reading.  Average  daily  estimate  from  IZth  to  25^/i  of  May^  while  on  ordinary  diet. 


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Ordinary  c?ie^,‘13th  May. — Boiled  beef,  6 oz. ; bread,  32  oz. ; eggs,  4 oz. ; beef-tea,  10  oz. ; sweet  milk,  20  oz. ; butter  milk,  30  oz. ; tea,  20  oz. 
Sugar  (8  oz.  per  diem),  was  added  to  this  diet  on  26th  May. 

Imtead  of  sugar,  8 oz.  fatty  matter  was  given  on  25th  June.  It  consisted  of  butter,  4 oz. ; suet,  ‘r  oz. ; cod-liver  oil.  1 o.:. 


CASE  ccxn. — Matthew  Reilly,  laborer,  set.  24— admitted  February  23d,  1864.  In  good  health  up  to  May,  1868,  when  he  first  noticed  his  thirst  to  be 
very  great,  and  that  he  passed  more  urine  than  usual.  Pulse  92,  rather  weak;  sweats  a good  deal ; slight  fur  on  tongue  ; bowels  regular;  no  cough  ; no 
affection  of  eyes.  Average  daily  estimate  from  13^A  to  May^  while  on  ordinary  diet. 


916 


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CASE  CCXIII. — John  Macdonald,  weaver,  3>t.  46 — admitted  May  lltli,  1864.  He  has  been  getting  weaker  for  the  last  three  or  four  years.  First  noticed  that  he 
made  more  water  than  usual  last  summer,  and  found  that  thirst  became  urgent  at  the  end  of  the  harvest  season.  The  patient  is  much  emaciated  m appearance. 
Pulse  80,  feeble.  Skin  dry,  but  occasional  sweats  at  night.  Tongue  moist ; bowels  regular.  Has  a slight  cough  with  trifling  expectoration.  Long-sighted  : 
arcu&  senilis.  Average  daily  estimate  from  \Zth  to  25  th  May^  while  on  ordinary  diet. 


917 


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OrdinoA'y  diet^  on  13th  May. — Beef-steak,  6 oz. ; bread,  45  oz. ; cabbage,  8 oz. ; eggs,  4 oz. ; beef-tea,  20  oz. ; milk,  40  oz. ; tea,  40  oz. ; water,  310  oz. 
Animal  or  diabetic  diet  on  26th  May. — Steak,  20  oz. ; eggs,  6 oz. ; cabbage,  16  oz. ; port  wine,  3 oz. ; soda-watei-,  30  oz. ; lime-water,  8 oz. ; bran-cake,  24  oz. 


918 


DISEASES  OF  THE  BLOOD. 


Commentary. — The  last  six  cases  of  diabetes  were  observed,  and  all 
the  facts  with  regard  to  them  analysed,  with  the  greatest  care.  My  ob- 
ject was  to  ascertain  the  influence  of  sugar  as  a remedy  in  this  disease ; 
and  it  will  be  seen  by  a careful  study  of  the  results  arrived  at,  that  al- 
though no  cure  was  obtained,  neither  were  the  symptoms  increased. 
The  treatment  directed  to  cutting  off  sugar  from  the  diet  appears  to  di- 
minish certain  symptoms  without  producing  any  influence  on  the  pro- 
gress of  the  disease.  In  the  two  first  cases  in  which  8 oz.  of  sugar 
were  given  daily  (Cases  CCVII.  and  CCVIII.),  the  strength  of  the 
patients  rallied  wonderfully.  Absence  from  work,  rest,  and  the  regular 
meals  of  the  house,  it  is  true,  may  explain  this  result,  although  even  then 
the  fact  remains  that  the  sugar  did  no  harm  whatever.  In  the  third  ease 
(Case  CCIX.),  the  thirst  and  amount  of  urine  passed  steadily  diminished 
during  the  use  of  sugar,  the  other  symptoms  remaining  much  the  same. 
In  this,  as  well  as  in  the  preceding  case,  phthisis  latterly  appeared  and 
caused  death.  In  the  fourth  case  (Case  CCX.),  various  kinds  of  treat- 
ment were  tried,  and  their  influence  on  the  ingesta,  egesta,  weight  of  the 
individual,  and  amount  of  sugar  excreted  daily,  for  three  months,  care- 
fully determined,  without  producing  any  advantage.  The  three  last  cases 
(Cases  CCXI.,  CCXII.,  and  CCXIII.)  were  in  the  ward  at  the  same 
time,  and  the  most  laborious  observations  and  analyses  carried  on  du- 
ring the  three  summer  months  of  1864.  The  results  will  be  seen  at  a 
glance,  as  all  the  facts  arrived  at  are  tabulated.  In  one  case  (Case 
CCXI.),  which  was  only  of  three  months’- standing,  his  health  greatly 
improved,  and  he  increased  in  weight  under  the  use  of,  first,  8 oz.  sugar, 
then  of  a similar  amount  of  fat.  This  I attribute  to  the  case  being  recent. 
Cases  CCXII  and  CCXIII.  were  placed  on  an  animal  diet,  which 
caused  great  diminution  in  the  thirst,  hunger,  amount  of  urine  and  of 
sugar  excreted ; but  in  no  way  benefited  the  case,  as  the  moment  they 
returned  to  an  ordinary  diet,  the  symptoms  returned.  The  conclusion 
I have  arrived  at,  from  the  careful  trials  of  treatment  made  in  these 
seven  cases,  as  well  as  from  ample  experience  of  the  effects  of  an  animal 
diet,  are  as  follows  : — 1st,  We  are  still  ignorant  of  how  to  cure  diabetes  ; 
2d,  That  the  advantage  to  be  obtained  from  a purely  animal  or  non-sac- 
charine diet  is  over  estimated  ; 3d,  That  the  giving  sugar  or  employing 
a mixed  diet  produces  no  injury  ; 4th,  That  a non-saccharine  diet  dimin- 
ishes the  symptoms,  controlling  the  hunger  and  thirst,  and  diminishing 
the  amount  of  urine  and  sugar  passed,  but  does  not  cure  the  disease ; 
5th,  On  this  account  it  should  be  employed  as  a palliative  when  it  can  be 
followed  without  injury  to  the  health,  and  especially  when  frequent  calls 
to  micturition  disturb  sleep  at  night. 

CONTINUED  FEYER. 

A state  of  fever  may  be  said  to  exist  when  we  find  the  pulse  acceler- 
ated, the  skin  hot,  the  tongue  furred,  unusual  thirst,  and  headache. 
These  symptoms  are  commonly  preceded  by  a period  of  indisposition 
varying  in  extent  and  severity,  the  febrile  attack  being  marked  by  a 
rigor  or  sensation  of  cold.  This  rigor,  though  not  invariably  well 


CONTINUED  FEVER. 


919 


characterised,  is  the  symptom  from  which,  when  present,  we  date  the 
commencement  of  the  fe'/er. 

Although  fever  may  in  one  sense  always  he  f?aid  to  evist  when  the 
above  group  of  symptoms  is  present,  such  fever  may  be  idiopathic  and 
essential,  or  symptomatic  of  some  local  lesion.  It  is  to  the  former  con- 
dition that  the  term  fever  is  universally  applied.  Some  pathologists, 
indeed,  have  endeavored  to  show  that  there  is  no  such  thing  as  idio- 
pathic or  essential  fever,  although  they  have  differed  among  themselves 
as  to  the  lesion  of  which  it  is  symptomatic.  Intermittent  fever  has  been 
supposed  to  be  symptomatic  of  diseased  spleen,  and  remittent  fever  of 
intestinal  derangement.  With  regard  to  continued  fever,  some  have 
spoken  of  cerebral,  others  of  intestinal  or  abdominal  typhus.  Another 
class  have  supposed,  from  the  occasional  appearance  of  an  eruption  on 
the  skin,  that  it  is  allied  to  the  exanthemata.  If,  however,  you  care- 
fully watch  the  Edinburgh  continued  fever,  you  will  easily  satisfy  your- 
selves that  it  frequently  occurs  independent  of  any  of  these  lesions. 
Did  we  indeed  adopt  these  views,  we  might,  as  Dr.  Christison  has 
pointed  out,  with  more  plausibility  maintain  the  existence  of  a pulmonary 
typhus,  as  we  observe  the  lungs  to  be  much  more  commonly  affected  in 
this  city  than  any  other  organ  in  the  body  during  fever.  I agree,  there- 
fore, with  those  who  consider  continued  fever  as  an  essential  disease, 
dependent  on  some  unknown  constitution  of  the  blood,  and  occasionally 
accompanied  or  followed  .by  various  local  lesions  of  the  cranial,  thoracic, 
or  abdominal  viscera,  and  with  various  eruptions  on  the  skin. 

Although  this  may  be  considered  as  the  correct  general  view  of  con- 
tinued fever,  it  cannot  be  denied  that  it  assumes  various  forms,  which 
have  been  described  in  different  ways  by  authors  in  this  and  foreign 
countries.  Considerable  confusion  has  consequently  arisen  as  to  whether 
fevers  observed  in  different  places,  and  at  various  times,  were  identical 
or  dissimilar  in  their  nature ; and  whether  the  varieties  they  presented 
were  only  attributable  to  the  concomitant  lesions  which  might  be  present. 
Any  one  who  studies  fever  first  in  this  city,  and  afterwards  in  Paris, 
will  soon  convince  himself  that  there  are  at  least  two  predominant  kinds 
of  fever; — the  one  called  by  us  typhus,  the  other  called  by  the  French 
typhoid, — that  is,  resembling  typhus.  Again,  those  who  have  studied 
fever  in  Edinburgh  for  the  last  twenty  years  consecutively,  are  aware 
that  every  now  and  then  a form  of  the  disease  is  prevalent  which  runs  a 
short  course,  but  has  a tendency  to  relapse  at  pretty  regular  periods. 
Lastly,  there  is  in  fever,  as  in  most  other  diseases,  a kind  which  is  very 
slight,  and  soon  ceases — a so-called  febricula. 

Every  practical  physician  is  acquainted  with  these  forms  of  fever ; 
but  whether  they  constitute  varieties  of  the  disease,  which  can  be  at  all 
times  separated,  which  have  a distinct  and  invariable  course,  the  one 
not  being  protective  of  the  other,  and  so  on,  are  points  that  are  by  no 
means  determined. 

Dr.  Jeimer,  in  a very  elaborate  series  of  papers  inserted  in  the 
“Monthly  Journal”  during  1849  50,  has  endeavored  to  show  that 
febricula,  relapsing  fever,  typhoid  and  typhus  fevers,  are  four  distinct 
diseases.  He  considers  them,  to  use  his  own  language,  “ as  distinct 
from  each  other  as  are  measles,  scarlet  fever,  and  small-pox,  the  poison 


920 


DISEASES  OF  THE  BLOOD, 


of  tho  one  being,  by  no  combination  of  circumstances,  capable  of  pro 
(lueing,  inducing,  or  exciting  the  others.”  He  gives  the  following  char- 
acters which,  according  to  him,  serve  to  distinguish  these  four  kinds  of 
fever.* 

“ Fehricula. — A disease  attended  by  chilliness,  alternating  with  sense 
of  heat,  headache,  white  tongue,  confined  bowels,  high  colored  scanty 
urine,  hot  and  dry  skin,  and  frequent  pulse,  terminating  in  from  two  to 
seven  days,  and  having  for  its  cause  excess,  exposure,  over-fatigue,  etc. 
— i.e.^  the  cause  of  febricula  is  not  specific. 

’''‘Relapsing  Fever. — A disease  arising  from  a specific  cause,  attended 
by  rigors  and  chilliness,  headache,  vomiting,  white  tongue,  epigastric 
tenderness,  confined  bowels,  enlarged  liver  and  spleen,  high  colored 
urine,  frequent  pulse,  hot  skin,  and  occasionally  by  jaundice,  and  termi- 
nating in  apparent  convalescence  in  from  five  to  eight  days ; in  a week 
a relapse — i.e.,  a repetition  of  the  symptoms  present  during  the  primary 
attack.  ‘ After  death,  spleen  and  liver  are  found  considerably  enlarged  ; 
absence  of  marked  congestion  of  internal  organs.’ 

“ Typhoid  Fever. — A disease  arising  from  a specific  cause,  attended 
by  rigors,  chilliness,  headache,  successive  crops  of  rose  spots,  frequent 
pulse,  sonorous  rale,  diarrhoea,  fulness,  resonance  and  tenderness  of  the 
abdomen,  gurgling  in  the  right  iliac  fossa,  increased  splenic  dulness, 
delirium,  dry  and  brown  tongue,  and  prostration,  and  terminating  by  the 
thirtieth  day.  After  death,  enlargement  of  the  mesenteric  glands, 
disease  of  Peyer’s  patches,  enlargement  of  the  spleen,  disseminated 
ulcerations,  disseminated  inflammations. 

“ Typhus  Fever. — A disease  arising  from  a specific  cause,  attended 

♦ The  variable  amount  and  extension  of  fever  at  different  times  may  be  gathered 
from  the  following  table,  showing  the  number  of  cases  which  have  entered  the  Royal 
Infirmary  of  this  city  during  the  present  century. 

Table  showing  the  Annual  Number  of  Fever  Cases  in  the  Royal  Infirmary  since  the 
beginning  of  the  century. 


12  Mons. 

to  Dec. 

1800, 

329 

I 

12Mos.  to  Dec 

.1822,  365 

12  Mons. 

to  Oct 

. 1844,3339 

“ 

u 

1801, 

161 

a 

1823,  102 

“ 

“ 

1846,  683 

“ 

U 

1802, 

156 

u 

u 

1824,  177 

(( 

It 

1846,  693 

u 

1803, 

232 

u 

u 

1825,  341 

a 

It 

1847,3688 

1804, 

323 

9 Mos.  to  Oct 

.1826,  456 

ii 

tl 

1848,4693 

“ 

a 

1805, 

175 

12  Mos.  to  Oct 

,.1827,1875 

it 

(t 

1849,  726 

u 

1806, 

96 

U 

(( 

1828,2013 

it 

tt 

1850,  520 

u 

a 

1807, 

no 

u 

(( 

1829,  771 

t( 

tl 

1861,  959 

u 

u 

1808, 

111 

u 

u 

1830,  346 

a 

It 

1852,  691 

u 

u 

1809, 

186 

u 

(( 

1831,  768 

a 

tl 

1853,  574 

a 

u 

1810, 

143 

(( 

1832,1394 

ii 

tt 

1854,  168 

u 

1811, 

96 

t 

(( 

1833,  878 

ii 

tl 

1855,  201: 

u 

u 

1812, 

103 

u 

ii 

1834,  690 

a 

tl 

1856,  187 

ll 

u 

1813, 

75 

u 

“ 

1835,  826 

ii 

tt 

1857,  132 

1814, 

87 

u 

ii 

1836,  652 

ii 

tt 

1858,  168 

u 

a 

1815, 

96 

u 

ii 

1837,1224 

ii 

It 

1859,  174 

u 

u 

1816, 

106 

iC 

ii 

1838,2244 

ii 

tl 

1860,  153 

i( 

ii 

1817, 

485 

u 

ii 

1839,1235 

it 

“ 

1861,  121 

u 

1818,; 

1546 

u 

ii 

1840,  782 

tl 

tl 

1862,  136 

tl 

(t 

1819,; 

1088 

u 

a 

1841,1372 

It 

tt 

1863,  210 

u 

1820, 

638 

ii 

ii 

1842,  842 

tt 

tl 

1864,  440 

ii 

1821, 

327 

ii 

ii 

1843,2080 

1 

— .j 

CONTINUED  FEVEE. 


921 


by  rigors,  cliilliness,  headache,  mulberry  rash,  frequent  pulse,  delirium, 
dry  brown  tongue,  and  prostration,  and  terminating  by  the  twenty-first 
day.  After  death,  disseminated  and  extreme  congestions;  in  young 
persons,  enlargement  of  the  spleen.” — {Medical  Times — Twentieth  Paper.) 

Dr.  Dundas,  in  1852,*  advanced  another  doctrine,  entirely  opposed 
to  that  of  Dr.  Jenner.  His  views  on  the  subject  of  fever  are  essentially 
these : — Not  only  are  there  no  specific  difierences  between  the  various 
kinds  of  continued  fever,  but  there  are  none  between  continued,  inter- 
mittent, and  remittent  fevers.  All  these  disorders,  according  to  Dr. 
Dundas,  are  essentially  one  disease,  and  may  all  be  cured  by  one  remedy, 
viz.,  quinine.  Given  in  doses  of  ten  grains,  repeated  at  intervals  of  two 
hours,  until  five  or  six  doses  had  been  taken,  he  says  that  it  arrested  or 
cut  short  a continued,  as  it  did  an  intermittent  fever.  These  statements, 
deliberately  brought  forward  and  still  maintained  by  Dr.  Dundas,  who, 
in  Brazil  and  in  this  country,  has  had  abundant  opportunities  of  carry- 
ing out  the  practice,  supported,  moreover,  by  confirmatory  cases,  pub- 
lished by  different  medical  men  in  Liverpool,  determined  me  to  give  this 
practice  a fair  trial. 

During  the  months  of  November,  December,  and  January  1851*52, 
I treated  nineteen  cases  of  continued  fever  in  the  clinical  wards,  of  which 
four  were  febricula,  one  relapsing,  three  typhoid,  and  eleven  typhus 
fever.  In  a disease  so  common  as  fever,  I have  thought  it  necessary  to 
condense  the  facts  as  much  as  possible  from  the  lengthy  and  accurate 
reports  taken  in  the  hospital  books.  All  these  cases,  however,  were 
examined  with  the  utmost  care,  and  all  the  phenomena  noted,  especially 
in  reference  to  the  two  doctrines  I have  placed  before  you, — viz.,  those 
of  Dr.  Jenner  and  of  Dr.  Dundas.  Further,  to  avoid  repetition,  I have 
simply  stated  that  the  quinine  treatment  was  employed  ; but  in  every 
case  this  treatment  was  practised  exactly  in  the  manner  recommended 
by  the  last-named  physician.  The  effects  we  observed  to  be  produced 
by  the  quinine  I shall  notice  afterwards. 


FEBRICULA. 

Case  CCXIY.f — Margaret  Divine,  set.  42 — admitted  26th  November  1851.  Was 
attacked  with  rigors  on  the  23d,  after  complaining  for  two  days  before  of  headache 
and  general  debility.  On  admission  complained  of  pain  in  the  limbs,  and  general  dull 
pains  over  the  body.  Had  no  appetite,  but  great  thirst,  with  a dry  furred  tongue ; 
she  is  very  subject  to  pyrosis  ; skin  was  hot  and  dry,  pulse  80,  strong  ; a slight 
murmur  accompanied  the  first  sound  of  the  heart.  H Sol.  Acetat.  Ammon.  3 j ; 
Vini  Antimon.  | ij  ; Aquae  § iij.  M.  To  take  one  table-spoonful  every  four  hours. 

November  28^/i. — Better  to-day ; pulse  '72  ; a sediment  filling  one -fourth  of  the 
glass  is  deposited  in  the  urine ; still  general  dull  pain  of  surface.  29^A. — The  general 
pains  are  gone.  She  feels  quite  well,  and  wishes  to  rise ; she  was  now  convalescent, 
but,  owing  to  weakness,  was  not  dismissed  until  the  Ibth  of  December. 

Case  CCXV.f — Susan  Rennie,  wife  of  laborer,  jet.  49 — admitted  15th  of  December 
1851.  On  the  11th,  was  seized  with  severe  rigors,  followed  by  pain  in  the  lower  part 


* Sketches  of  Brazil,  including  new  views  on  Fever,  etc.,  1852. 
f Reported  by  Mr.  J.  L.  Brown,  Clinical  Clerk. 


922 


DISEASES  OF  THE  BLOOD. 


of  the  back  and  tlie  limbs,  with  frequent  alternations  of  shivering  and  perspiration 
during  the  day;  there  was  severe  headache,  with  loss  of  appetite,  and  oppressive 
thirst.  On  admission,  the  tongue  was  slightly  furred  ; she  had  constant  nausea,  and 
vomited  nearly  everything  she  took ; the  skin  was  hot,  but  moist ; there  was  no  erup- 
tion on  her  person  ; she  had  a short  cough,  with  trifling  expectoration.  Pulse  76, 
small.  She  continued  in  this  state  till  December  19th,  when,  after  sweating  and  a 
lengthened  sleep,  the  fever  left  her,  and  she  became  convalescent,  and  was  dismissed 
January  1.  The  treatment  consisted  of  salines,  anodynes,  and  stimulants. 

Case  CCXVI.* — Thomas  Stevens,  aet.  21,  servant  of  a cowfeeder — admitted 
November  24,  1851.  On  the  afternoon  of  the  23d,  while  engaged  in  bis  usual  work, 
he  was  seized  witli  severe  rigors,  headache,  and  pain  in  the  back  ; he  passed  a sleep- 
less and  uneasy  night,  and  on  attempting  to  resume  work  next  day,  fouud  himself 
quite  unable  to  do  so,  from  return  of  the  rigors,  and  aggravation  of  the  headache. 
Had  not  been  exposed,  so  far  as  he  knew,  to  contagion.  Had  been  already  a patient 
in  the  house  several  times,  having  suffered  from  fever  on  three  different  occasions. 
On  admission,  the  tongue  was  moist  and  clean,  and  the  appetite  was  not  much  im- 
paired, but  he  had  very  oppressive  thirst.  Bowels  had  been  irregular  some  time 
before  admission.  On  examination  of  the  chest,  slight  bronchitis  of  the  left  side  was 
found  to  be  present,  and  the  sputum  was  thick,  viscid,  and  muco-purulent.  Skin  was 
very  dry  and  hot,  he  complained  of  pain  in  the  head,  principally  in  the  frontal  region, 
and  of  a throbbing  character.  Pulse  72,  of  good  strength.  He  was  ordered  a full 
dose  of  castor-oil,  which  produced  copious  evacuations  from  the  bowels  ; and  the  fol- 
lowing mixture: — IJ  Vini  Antimoni.  38s;  Sol.  Mur.  Morph.  3i;  Aquce  § vss. 
M.  Take  ^ ss  every  second  hour.  He  continued  to  complain  of  headache  and  general 
restlessness,  and  the  pulse  kept  about  80,  very  full  and  strong,  till  the  evening  of  the 
25th,  when  he  began  to  perspire  a little ; and  on  the  forenoon  of  the  26th  he  had 
profuse  sweating.  On  the  30th  the  antimonial  solution  was  stopped  ; he  improved 
rapidly,  and  was  dismissed,  quite  well,  on  the  8th  of  December. 

Case  CCXVII.* — Andrew  Downan,  set.  11,  tobacco-boy — admitted  January  14th, 
1852.  On  the  11th  was  attacked  by  violent  headache,  lost  all  appetite  for  food,  but 
felt  exceedingly  thirsty  ; his  skin  felt  very  hot,  and  he  complained  of  general  languor 
and  debility.  Had  no  distinct  rigors,  or  other  premonitory  symptoms.  Had  suffered 
from  typhus  fever  about  five  years  ago,  at  which  time  he  was  nine  weeks  in  the  house. 
On  admission,  tongue  was  dry,  of  florid  red  color,  but  thinly  coated  with  a white  fur, 
through  which  the  red  papillae  were  very  conspicuous.  No  appetite,  but  considerable 
thirst ; skin  hot  and  dry,  without  eruption  : has  had  no  sweating  since  he  became  ill  ; 
but  had  profuse  diaphoresis  the  morning  after  admission,  when  the  skin  became  cool 
and  moist,  and  the  pulse  fell  to  the  natural  standard.  He  continued  two  days  in  the 
house,  at  the  end  of  which  time  he  felt  well  enough  to  get  out  of  bed,  and  leave  the 
ward.  He  did  not  return. 

Commentary . — Febricula  was  the  most  common  form  of  continued 
fever  during  the  early  part  of  the  winter  session  in  Edinburgh  1851-52, 
and  the  four  cases  above  given  constitute  good  examples  of  the  disorder 
as  it  existed  in  the  city  during  that  period.  It  will  be  observed  that 
the  fever  in  all  of  them  was  very  strong,  and  the  rigors  well  marked, 
although  the  pulse  was  not  greatly  accelerated.  It  is  impossible  to  dis- 
tinguish such  cases  at  the  commencement  from  typhus — a circumstance, 
as  we  shall  see,  of  great  importance,  when  the  question  comes  to  be, 
whether  or  no  we  can  arrest  the  progress  of  a continued  fever  after  it 
has  fairly  set  in.  It  ought  to  be  a sine  qua  non  in  all  such  trials  not  to 
commence  the  treatment  until  the  seventh  day.  If,  for  instance,  we  had 
commenced  Dr.  Dundas’s  treatment  with  the  above  cases,  we  might  have 
been  led  to  believe  in  its  efficacy ; whereas  we  shall  see  that  the  typhoid 
and  typhus  cases  exhibited  a very  different  result. 

* Reported  by  Mr.  J.  L.  Brown,  Clinical  Clerk, 


CONTINUED  FEVER. 


923 


RELAPSING  FEVER. 

Case  CCXVIII.* — Edward  Anderson,  a Swede,  set.  25,  hawker — admitted  Decem- 
ber 15th,  1851.  Seized  with  rigors  on  the  8th ; had  great  pain  in  the  head,  back,  and 
over  the  body  generally,  and  felt  languid  and  depressed,  though  he  was  not  compelled 
to  take  to  bed  till  the  14th.  On  admission,  tongue  thickly  coated  ; no  appetite ; much 
thirst;  bowels  constipated;  slight  pain  of  head;  pulse  VO,  of  natural  strength;  skin 
hot,  but  moist,  presenting  a well-marked  eruption  of  small  roundish  and  oval  spots  of 
a rose-red  tint,  slightly  raised  above  the  surface  of  the  skin,  entirely  disappearing  under 
pressure  ; widely  scattered,  but  most  abundant  on  the  thorax.  December  l^th. — Slept 
badly ; pulse  V5,  natural  strength  ; sweating  a good  deal ; much  thirst,  but  total  dis- 
inclination for  food  ; spots  more  numerous.  To  have  an  effervescing  draught,  and  sis 
ounces  of  wine;  also  half  an  ounce  of  the  following  mixture  at  bed-time: — Tinct. 
Hyoscyami  3 i ; Tinct.  Kino  3 ij ; Kq.  § ij.  Continued  to  improve  daily  after  this 
date;  and  had  no  feverish  accession  while  he  remained  in  the  ward.  Was  dismissed 
on  the  29th  at  his  own  desire,  as  he  was  anxious  to  resume  his  occupation,  though 
still  rather  weak.  The  several  systems  were  carefully  examined  before  dismissal,  and 
found  normal. 

He  was  re-admitted  on  the  hth  of  January  1852.  Had  resumed  his  work,  but  on 
the  1st  inst.,  24  days  after  the  first  rigor  in  the  former  attack,  was  again  seized  with 
shivering,  and  felt  pain  all  over  the  body,  but  especially  complained  of  pain  in  the 
throat,  and  difficulty  of  swallowing.  There  was  also  considerable  dyspnoea.  On  ad- 
mission, tongue  dry  and  coated  ; mucous  membrane  of  fauces  and  pharynx  much  con- 
gested, and  covered  with  a thin  layer  of  pus;  bowels  constipated;  slight  pain  over 
abdomen  generally,  but  especially  in  the  right  iliac  region ; voice  husky  and  indistinct ; 
much  cough  of  a convulsive  character ; little  expectoration  ; no  abnormal  physical 
signs  on  examining  the  chest;  pulse  110,  full  and  hard  ; skin  hot  and  flushed;  and 
over  the  abdomen  there  were  a few  scattered  spots  of  the  same  shape  and  rose-red  tint 
as  before.  Vini  Antimon.  § i ; Aq.  § vj.  M.  § i to  be  taken  every  second  hour. 
January  ^th. — Pain  on  pressure  in  iliac  region  increased ; had  little  sleep ; pulse  90, 
full,  but  softer.  Acetate  of  Ammonia,  with  Morphia — six  leeches  to  right  iliac  region. 
January  %th. — (8th  day,  or  32d  from  first  attack),  sweating  a little  last  night ; no 
change  in  urine ; no  pain  on  pressure  over  the  abdomen.  January  Mh. — Eruption 
very  distinct,  and  continuing  well  marked  for  24  hours,  after  which  it  gradually  faded. 
January  Vlth. — (36th  day)  more  feverish  to-day,  and  complains  of  more  pain  in  the 
throat;  pulse  120,  sharp  and  vibratory ; urine  natural.  After  this  date  he  began  to 
improve  gradually,  and  was  quite  convalescent  on  February  1st. 

Commentary. — I have  called  the  above  a case  of  relapsing  fever, 
simply  because  after  the  febrile  state,  counting  from  the  first  rigor,  had 
continued  for  full  seven  days,  there  was  complete  recovery  ushered  in  by 
diaphoresis.  So  well  was  this  man,  that  he  insisted  on  going  out  and 
resuming  his  occupation  as  a hawker.  On  the  24th  day,  however,  he 
was  again  seized  with  all  the  symptoms  of  the  primary  attack,  including, 
on  both  occasions,  a distinct  exanthematous  eruption  of  rose-colored, 
lenticular,  elevated  spots.  I am  aware  it  may  be  contended  that  this 
was  a case  of  typhoid  fever.  Dr.  Jenner  would  probably  so  consider  it 
on  account  of  the  eruption,  the  iliac  tenderness,  and  its  termination  about 
the  30th  day.  Dr.  Murchison  has  suggested  to  me  the  propriety  of 
calling  it  enteric  fever  followed  by  relapse.  But  if  the  circumstance  of 
a complete  recovery  and  a distinct  relapse  is  to  be  considered  as  a suffi- 
cient cause  for  distinguishing  a fever,  it  is  scarcely  to  be  conceived  that 
these  occurrences  could  ever  be  better  characterised  than  in  the  above 
case.  There  is  this  difference,  that  the  relapse  occurred  on  the  24th, 
and  not  on  the  14th  day.  This,  however  I have  seen  frequently  happen 
in  the  epidemic  of  relapsing  fever  which  occurred  in  this  city  during 
1843.  Though  most  common  on  the  14th  day,  this  period  was  passed 
* Reported  by  Mr.  W.  M,  Calder,  Clinical  Clerk. 


924 


DISEASES  OF  THE  BLOOD. 


over,  and  tlie  first  relapse  occurred  on  the  21st  or  24th  day.  One  or 
more  relapses  are  not  unfrequent,  and  it  would  appear  as  if  the  period 
of  the  first  had  been  passed  over. 

Dr.  Christison  has  pointed  out  that  relapsing  is  identical  with  inflam* 
inatory  fever,  or  the  synocha  of  Cullen,  and  in  his  article  on  Fever  in 
the  Library  of  Medicine  he  has  shown  their  similitude,  especially  as  he 
had  observed  it  in  the  Edinburgh  epidemic  of  1817  to  1820,  and  1826-27. 
During  the  great  epidemic  of  1843-44  I had  abundant  opportunities  of 
studying  it,  not  only  in  others,  but  in  my  own  case,  having  been  attacked 
a fortnight  after  my  appointment  as  Physician  to  the  fever  hospital.  On 
that  occasion  Dr.  Christison,  who  attended  me,  at  once  pronounced  the 
disease  to  be  the  synocha,  which  he  had  seen  twenty  years  previously, 
and  confidently  predicted  the  relapse,  which  occurred  on  the  14th  day, 
when  I imagined  myself  to  be  convalescent.  That  remarkable  epidemic 
has  been  carefully  described  in  the  writings  of  Alison,  Craigie,  Cormack, 
Halliday,  Douglas,  Warded,  and  others. 

TYPHOID  FEVER  TREATED  BY  QUININE. 

Case  CCXIX.* — Miles  Murray,  set.  26,  laborer — admitted  November  7,  1851 . First 
seized  with  rigors  on  the  evening  of  the  2d,  followed  by  strongly-marked  febrile  symp- 
toms. No  contagion.  On  admission,  features  livid  and  anxious;  skin  dry  and  hot; 
no  eruption.  Severe  frontal  headache ; pain  in  the  back,  and  over  the  whole  body. 
Slight  “subsultus  tendinum.”  Tongue  moist,  but  furred;  no  appetite,  but  excessive 
thirst.  Pulse  84,  full,  but  soft,  occasionally  intermittent.  Short  dry  cough,  and  slight 
dulness  on  right  side  of  chest ; no  unusual  rales.  Ordered  an  antimonial  mixture  ; six 
leeches  to  be  applied  to  the  head.  November  %th. — Slept  well  during  the  night ; no  de- 
lirium. Skin  still  dry  and  hot;  no  eruption  ; tongue  more  dry  than  yesterday.  Pulse 
82,  full,  but  soft.  Ordered  quinine.^  in  ten-grain  powders.^  every  second  hour.  Nov. 
9/A,  Vespere  (7th  day). — He  has  taken  the  powders  regularly  since  ordered  ; no  marked 
effect  produced  except  on  the  pulse,  which  has  come  down  eight  or  ten  beats  after 
each  powder,  its  strength  also  being  much  reduced ; there  has  been  much  sweating  to- 
day. Still  severe  headache  ; no  delirium.  Urine  passed  this  afternoon  exhibits,  under 
the  microscope,  amorphous  lithates  ; but  the  deposit,  on  standing,  is  inconsiderable. 
Nov.  l\th. — Has  taken  in  all  205  grains  of  the  quinine.  Slight  tingling  in  the  ears 
this  morning,  but  only  transient.  Is  dull  and  stupid  to-day.  Countenance  has  still  a 
worn  and  exhausted  aspect.  Slight  cough,  and  a few  scattered  sibilant  rales  on  auscul- 
tation. Pulse  7o,  small,  and  soft.  Suspend  the  quinine.  Wine  four  oz..,  mixture  with 
the  sp.  cether.  nitr..,  and  sol.  ammon.  acetat.  Nov.  \9th. — Drowsiness  increased  since 
last  report,  but  wdthout  any  other  marked  change.  No  delirium.  Nov.  20^A  (18th 
day). — Urine  to- day  loaded  with  lithates.  Countenance  rather  livid.  Skin  not  very 
hot;  thirst  moderate.  No  eruption  has  appeared.  Nov.  21s^  (19th  day). — Feverish 
symptoms  returned.  No  decided  delirium,  but  much  drowsiness,  and  total  indifference 
to  what  is  going  on  around  him.  Pulse  80,  full  and  soft.  Nov.  23c?,  Vespere  (21st 
day). — Complains  to-day  of  uneasy  symptoms  in  epigastrium,  with  much  nausea.  Had 
slight  vomiting  in  the  afternoon.  Nov.  24?A. — Had  an  emetic  ordered  last  night,  which 
produced  copious  vomiting ; nausea  and  pain  in  epigastrium  relieved,  followed  by  pro- 
fuse sweating.  Nov.  30//i  (28th  day). — Has  had  considerable  diarrhoea  during  the  last 
four  days ; checked  )iy  the  lead  and  opium  pills,  and  tannin.  Slight  delirium  to-day  ; 
skin  hot  and  dry ; pulse  96,  full,  regular ; cough  more  troublesome ; bronchitic  rales 
abundant  all  over  the  chest.  December  IsL — Much  sweating  to-day  ; strength  greatly 
prostrated ; cough  oppressive,  and  expectoration  brought  up  with  extreme  difficulty ; 
faeces  and  urine  passed  in  bed.  Has  four  ounces  of  wine  daily,  and  an  expectorant 
mixture.  Dec.  ^th. — Weakness  increasing ; almost  constant  sweating,  but  no  further 
change.  Four  oz.  of  brandy  in  addition  to  the  wine.  Dec.  ^th  (36th  day). — Was  more 
restless  than  usual  last  night,  but  there  is  now  no  delirium.  A bed-sore  is  threatening 


* Reported  by  Mr.  W.  M.  Calder,  Clinical  Clerk. 


CONTINUED  FEVER. 


925 


over  the  trochanter  of  the  right  femur.  Pulse  102,  small  and  weak.  Dec.  \0th. — 
Cough  occurring  in  paroxysms  ; weakness  increasing.  Dec.  VMh  (40th  day). — Pulse 
to-day  130,  small  and  vibratory  ; skin  cool  and  moist ; appetite  little  better.  R Quinee 
Disulph.  gr.  iv. ; Fiant  pulv.  tales  vj.  One  every  three  hours.  After  taking  four  of 
the  powders,  the  pulse  fell  to  102,  small  and  jerking.  Quinine  stopped  and  brandy  and 
wine  resumed.  Next  day  (41st  of  fever),  he  began  to  shiver  about  3 p.m.,  and  presented 
all  the  phenomena  of  a paroxysm  of  ague,  the  skin  continuing  pungently  hot  for  about 
three  hours,  but  without  sweating.  In  the  evening  the  skin  was  comparatively  cool, 
and  the  patient  felt  languid  and  drowsy.  He  was  ordered  to  resume  the  quinine,  five 
grains  every  three  hours.  Dec.  lAth  (42d  day). — No  return  of  shivering,  or  febrile 
symptoms.  After  this  date  he  began  to  improve  steadily ; and,  with  the  exception  of 
slight  sore  throat,  and  return  of  short  dry  cough  for  a few  days,  had  not  a bad  symp- 
tom during  the  remainder  of  his  stay  in  the  house.  He  was  dismissed  perfectly  well 
on  the  19th  of  January,  having  been  '73  days  in  the  ward,  and  80  days  having  elapsed 
since  the  occurrence  of  the  first  rigor. 

Commentary. — This  case  was  observed  and  recorded  with  the  greatest 
care,  and  I had  no  difficulty  in  considering  it  to  be  a case  of  typhoid 
fever,  unusually  prolonged,  perhaps  on  account  of  the  pulmonary  com- 
plication. There  were  several  distinct  exacerbations,  coming  on  with 
marked  rigors,  at  intervals  of  seven  days,  followed  by  increased  febrile 
symptoms.  At  one  period  this  man’s  life  was  despaired  of,  the  profuse 
sweatings,  the  diarrhoea,  extreme  prostration,  with  partial  pneumonia, 
and  general  bronchitis,  constituted  symptoms  of  a most  alarming  charae- 
ter,  through  which,  however,  with  the  assistance  of  stimuli  liberally  ad- 
ministered, he  eventually  safely  struggled.  This  also  was  the  first  case 
of  fever  in  which  the  quinine  treatment  was  tried.  It  so  happened,  that 
having  ordered  six  doses,  of  ten  grains  each,  to  be  administered,  and  not 
seeing  him  on  the  following  day,  the  drug  was  by  accident  continued 
consecutively  for  eighteen  doses,  at  intervals  of  two  hours  each.  At  the 
end  of  that  time,  no  effect  having  been  produced  on  the  fever,  it  was 
continued  in  five  grain  doses,  so  that  in  all  he  took  205  grains  of  quinine. 
Notwithstanding,  not  only  did  the  fever  march  on,  but,  as  we  have  seen, 
the  most  alarming  prostration  was  induced.  No  eruption  could  be  de- 
tected during  the  whole  progress  of  the  disease,  though  daily  looked  for 
with  the  utmost  care. 

Case  CCXX.* — Marianne  Howison,  aet.  11 — admitted  January  16,  1851.  Rigors 
appeared  on  the  10th,  followed  by  febrile  symptoms.  Mother  and  sister  had  died  im- 
mediately before  of  fever.  On  admission,  pulse  130,  full  and  strong;  intense  head- 
ache ; tongue  dry  and  brown ; complete  anorexia,  and  great  thirst ; skin  hot,  no  erup- 
tion. On  the  I'Z^A,  the  treatment  with  ten-grain  doses  of  quinine  was  ordered.  18^A. — 
Five  powders  were  given ; and  the  report  to-day  is : headache  gone ; pulse  94,  soft ; 
skin  moist  and  cool;  tongue  moist  and  red.  On  the  197A,  restlessness  and  heat  of  skin 
returned.  On  the  24^/i,  fever  was  as  intense  as  when  she  was  admitted.  2bth. — 
Diarrhoea.  2'77A — Considerable  abdominal  pain  on  pressing  right  iliac  region;  six 
leeches  applied ; ^ vi  of  wine.  31s^. — Diarrhoea,  which  had  formerly  continued  only 
twenty-four  hours,  has  been  present  continuously  for  the  last  three  days.  February  ls<. 
— Pulse  weak ; sordes  on  lips  and  tongue  ; intellect  confused  ; no  diarrhoea.  Feb.  Sd. — 
Pulse  weak  and  irregular,  140;  is  insensible.  Feb.  4th. — Very  restless  during  the 
night;  still  insensible;  pulse  150,  small  and  jerking;  slight  haemorrhage  from  the 
gums.  Died  at  seven  p.m. 

Seciio  Cadaveris. — Fifty -six  hours  after  death. 

The  mucous  surface  of  the  lower  third  of  the  small  intestine  was  scattered  ov« 


Reported  by  Mr.  G.  A.  Douglas,  Clinical  Clerk. 


026 


DISEASES  OF  THE  BLOOD. 


with  round  and  oval  elevations,  becoming  more  crowded  together  nearer  the  caecum 
The  former  were  of  the  size  and  form  of  a split  pea,  the  latter  varied  from  the  size  of 
sixpence  to  that  of  an  almond.  In  the  lower  portion,  some  of  the  elevated  patches 
were  softened  and  sloughing,  and  in  one  or  two  places  the  sloughs  had  separated, 
forming  ulcerations.  Th^e  upper  third  of  the  large  intestines  presented  also  numerous 
round  papular  elevations,  similar  to  those  in  the  smaller  intestines — the  whole  exhibit- 
ing the  various  well-known  changes  of  typhoid  elevations  and  ulcerations  in  a charac- 
teristic manner — the  peritoneum  corresponding  to  some  of  the  ulcerations  unusually 
congested,  but  there  was  no  peritonitis.  Some  of  the  mesenteric  glands  enlarged  and 
softened ; other  organs  healthy. 

Commentary. — This  was  a well-marked  case  of  typhoid  fever,  which 
was  fatal  on  the  twenty-fifth  day  ; and,  on  dissection,  the  intestinal  lesion, 
characteristic  of  the  disease,  was  discovered.  Here  also  the  quinine  treat- 
ment was  tried,  with  the  effect  at  first  of  moderating  some  of  the  symp- 
toms, although  on  the  following  day  they  returned  with  increased  inten- 
sity. As  in  the  last  case,  no  eruption  could  he  discovered  on  this  girl, 
though  carefully  looked  for.  It  is  further  worthy  of  observation  that 
the  mother  and  sister  had  died  of  a similar  disease.  The  contagious  na- 
ture of  this  form  of  fever  is  still  doubtful,  as  many  insist  that  the  intes- 
tinal lesion  is  dependent  on  purely  endemic  causes. 

Cask  CCXXI.* — John  Anderson,  set.  21,  sailor — admitted  29th  December  1861. 
On  the  4ih  of  December,  having  been  exposed  to  cold  during  his  passage  from  Elsinore, 
he  was  seized  with  rigors,  diarrhoea,  and  thirst,  which  continued  several  days.  From 
this  condition  he  was  gradually  recovering  when  the  ship  entered  the  harbor  of  Leith 
on  the  24th.  That  night  he  was  again  attacked  with  rigors,  great  thirst,  and  diarrhoea, 
followed  on  the  2Vth  by  intense  sudden  pain  in  the  abdomen,  vomiting,  and  constipa- 
tion. On  admission  the  features  were  shrunk  and  hard ; skin  cold  and  clammy ; tongue 
red  and  furred ; severe  griping  pain  in  the  abdomen,  which  is  shrunk  ; no  tympanitis ; 
bowels  costive;  scanty  urine;  no  headache;  pulse  126,  feeble  and  vibrating.  Twenty- 
four  leeches  were  applied  to  the  abdomen  ; one  opium  pill  every  two  hours.  Dec.  30. — 
Unrelieved;  mind  wandering;  bowels  freely  opened  without  relief;  pulse  very  rapid, 
and  almost  imperceptible.  Died  at  1 p.m. 

Sectio  Cadaveris. — Twenty -three  hours  after  death. 

Peritoneum  purple,  congested,  having  flakes  of  lymph  upon  the  surface.  It  con- 
tained several  ounces  of  dirty  turbid  yellow  fluid,  having  a slight  foecal  odor.  Stomach 
and  duodenum  normal.  About  the  middle  of  the  jejunum  a small  ulcer  one-half  of  an 
inch  by  one-eighth  in  size,  penetrating  all  the  coats  of  the  intestine ; edges  pale  and 
not  raised.  Mucous  membrane  of  the  lower  part  of  ileum  and  cascum  mottled  with 
slate-colored  patches ; Peyer’s  patches  prominent,  and  several  ragged  ulcers  situated 
in  their  course,  and  in  some  of  the  solitary  glands  ; ulcers  flat,  with  smooth  edges. 
Intestines  contained  fluid  faeces  of  a yellow  color,  resembling  pea-soup. 

Commentary. — This  was  another  undoubted  case  of  typhoid  fever 
with  intestinal  disease,  terminating  by  peritonitis,  the  result  of  a perfo- 
rating ulcer.  The  leading  facts  were  communicated  to  me  with  great 
clearness  after  the  boy’s  death  by  the  captain  of  the  vessel,  in  whose  log 
was  recorded  the  day  of  the  attack,  the  remission,  and  the  renewed  attack 
on  the  twenty-first  day.  He  also  had  observed  no  eruption  on  the  skin, 
but  of  course  his  information  on  such  a point  was  of  no  great  value. 

The  three  cases  now  given  have  enabled  you  to  study  the  principal 
phenomena  presented  by  typhoid  fever.  With  regard  to  its  diagnosis, 
if  you  rely  on  the  characters  prominently  given  by  Dr.  Jenner,  especially 

* Reported  by  Mr.  A.  Dewar,  Clinical  Clerk. 


CONTINUED  FEVER. 


927 


with  regard  to  the  eruption,  it  must  be  evident  you  will  be  frecjuently 
deceived.  It  so  happens  that  in  none  of  the  three  cases  was  an  eruption 
observed,  although  iu  two  it  was  carefully  sought  for ; and  in  one  of 
these  latter  the  nature  of  the  disease  was  placed  beyond  all  doubt  by 
dissection,  which,  after  all,  is  the  only  certain  proof  of  typhoid  fever.  I 
have  been  in  the  habit  of  considering  the  most  trustworthy  symptoms 
distinguishing  this  form  of  fever  from  typhus,  to  be  the  remissions ; a 
peculiar  character  of  the  countenance  expressive  of  abdominal  pain  ; the 
diarrhoea  (especially  when  the  stools  resemble  pea-soup) ; and  marked 
tenderness  on  pressing  deep  down  into  the  right  iliac  region,  I acknow- 
ledge, however,  that  these  symptoms,  in  the  absence  of  an  epidemic  of 
typhoid  fever,  are  often  deceptive,  even  when  the  disease  has  continued 
beyond  the  thirtieth  day. 

Typhoid  fever  was  formerly  a rare  disease  in  Edinburgh,  although 
common  on  the  opposite  coast  of  Fife,  and  at  Linlithgow.  The  late  Dr. 
John  Reid  used  to  remark,  when  he  was  pathologist  to  the  Infirmary, 
‘that  all  the  bodies  he  opened  affected  with  typhoid  ulcerations  of  the  in- 
testines came  from  one  or  other  of  these  places.  On  the  other  hand,  in 
Paris,  and  in  many  places  on  the  continent,  it  has  been  the  prevailing 
form  of  fever.  In  the  fever  wards  of  this  Infirmary  you  have  the  most 
extensive  opportunities  of  studying  typhus ; in  the  hospitals  of  the  con- 
tinent, and  especially  at  Paris,  Berlin,  Prague,  and  Vienna,  you  will  see 
typhoid  or  enteric  fever  on  a large  scale.  These  facts  serve  to  clear  up 
much  of  the  confusion  which  has  entered  into  the  discussions  concerning 
continued  fever  by  foreign  and  domestic  writers.  They  also  explain  why 
the  doctrine  of  Broussais,  who  conceived  typhus  to  be  gastro-enteritis — 
although  everywhere  on  the  continent  adopted  for  a time — ’was,  from  the 
first,  rejected  as  false  by  this  school.  At  the  same  time  there  have  been 
certain  epidemics  in  Edinburgh  during  which  typhoid  fever  has  been 
prevalent,  as  there  have  been  aiways  cases  of  true  typhus  mixed  up  with 
the  enteric  fever  of  the  continent.  Thus,  in  the  epidemic  of  1847-48,  an 
unusual  number  of  typhoid  cases  were  mingled  wutli  the  typhus ; and  I 
have  more  than  once  seen  distinguished  phy.sicians  and  teachers  on  the 
continent  much  puzzled  by  finding  no  morbid  lesion  in  fatal  cases  of  fever, 
which,  from  my  previous  knowledge  of  the  disease  in  Edinburgh,  I had 
no  difficulty  in  recognising  as  being  those  of  genuine  typhus.  During  the 
last  eight  or  ten  years  typhoid  cases  have  been  proportionally  increased. 


TYPHUS  FEVER  TREATED  BY  QUININE. 

Case  CCXXII.* — Mrs.  Macdonald,  a nurse  in  the  Infirmary,  get.  50 — admitted 
N'ovember  10th,  1851.  Seven  days  ago  was  unusually  exposed  to  cold,  and  two  days 
ifterwards  experienced  vomiting,  pain  in  the  back,  and  epigastrium,  with  headache, 
and  prostration  of  strength,  which  last  symptom  was  apparently  increased  by  a pur- 
gative taken  on  the  8th.  On  admission,  the  skin  was  exceedingly  hot ; pulse  102, 
strong  ; tongue  white  and  furred ; great  thirst  and  headache ; anorexia  and  nausea ; 
slight  bronchitis.  On  the  ll^A,  an  emetic  was  ordered^  and  two  hours  after  its  opera- 
tion the  quinine  treatment  to  he  followed.  On  the  12^A,  it  is  reported  that  she  took 
four  quinine  powders  of  10  grains,  at  intervals  of  two  hours,  but  vomited  the  fifth. 
Three  others,  however,  were  retained  during  the  night,  so  that  70  grains  have  been 


Reported  by  Mr.  J.  L.  Brown,  Clinical  Clerk. 


928 


DISEASES  OF  THE  BLOOD. 


administered.  At  present,  she  is  in  no  way  relieved.  Skin  hot  and  dry  ; pulse  100, 
strong;  tongue  furred  ; pains  in  head  and  epigastrium  unabated.  Eight' leeches  to  ba 
applied  to  the  head,  and  Quin.  Sulph.  gr.  v.  every  two  hours.  Nov.  \Wi. — Has  taken 
Jive  more  quinine  powders.  Pulse  now  78,  full ; considerable  vomiting,  and  pains  in 
the  epigastrium  ; other  symptoms  the  same.  Cold  douches  to  the  head ; warm  fomen- 
tations  to  the  epigastrium.  Pill  of  bismuth  and  opium  every  four  hours.  Nov.  14^A. 
— Head  and  stomach  much  relieved.  It  is  reported  that  last  night  the  limbs  were  par- 
tially convulsed,  and  her  eyes  fixed,  a state  that  lasted  seven  minutes.  Nov.  \^th — 
Confusion  of  intellect,  and  restlessness.  Pulse  rapid  and  weak.  ^ iv  of  wine.  Nov. 
I’lth. — Has  remained  in  the  same  condition.  Slight  puffing  of  the  cheeks  observed  on 
expiration,  Nov.  \'$>th. — Puffing  of  the  cheeks  more  marked ; unable  to  move  the 
right  arm  ; great  prostration.  Wine  § vj.  Blister  to  the  head.  Nov.  l^th. — Died 
comatose.  There  has  been  no  eruption. 

Commentary. — No  examination  of  this  woman’s  body  could  be  ob- 
tained, and  we  are  therefore  in  doubt  as  to  whether  an  exudation  had  or 
had  not  taken  place  between  the  membranes  of  the  brain.  The  cerebral 
complication,  however,  was  in  this  case  well  marked.  At  first,  indeed, 
there  was  nothing  more  than  usual;  but  the  vomiting  was  obstinate,  and 
latterly  the  convulsion  and  partial  paralysis  indicated  distinctly  the  organ 
afi’ected.  Having  previously  resolved  to  try  the  quinine  treatment,  it 
was  given  energetically  in  this  case,  but  without  any  effect  on  the  pro- 
gress of  the  fever.  It  may  even  be  contended  that  it  did  harm,  seeing 
we  had  a cerebral  complication  to  deal  with.  Of  this,  however,  at  an 
early  period,  we  could  not  judge,  although  it  appears  to  me  that  the 
quinine  practice  is  contra-indicated  in  such  cases. 

Case  CCXXITI.* — George  Johnson,  boot-maker,  set.  21 — admitted  8th  December 
1851.  Had  severe  rigors  on  29th  November,  which  were  followed  by  the  usual  fever- 
ish symptoms.  No  exposure  to  contagion.  On  admission,  tongue  densely  furred, 
coated,  and  cracked ; no  appetite ; intense  thirst ; skin  hot  and  dry ; confused  in  his 
ideas,  without  great  pain  in  the  head;  pulse  108,  full.  Dec.  ^th. — Slept  very  ill,  and 
continues  the  same  as  yesterday.  Pulse  120,  full.  ^ 01.  Ridni  3 vj.  Vespere. — 

Sulph.  Quince  3 j ; Div.  in  pulv.  vj.  One  every  two  hours.  Bowels  freely  moved 
in  the  afternoon;  great  heat  of  skin ; much  mental  excitement;  pulse  120,  full  and 
strong  ; no  eruption.  Dec.  \Qth. — Slept  well ; no  restlessness  ; skin  cool  and  moist ; 
no  headache ; slight  singing  in  the  ears ; pulse  87,  of  good  strength.  Pulse  rose  to 
88  during  the  day,  and  in  the  evening  was  full  and  strong.  Quinine  repeated ; 10 
grains  given  at  first.,  then  13  grains  every  two  hours.  Dec.  Wth. — Pulse  84,  of  good 
strength;  thirst  great ; skin  moist;  no  eruption.  Dec.  12^A  (14th  day) — thirst  less; 
some  appetite  ; no  eruption ; slight  deposit  in  urine.  Improved  from  this*  time,  and 
was  dismissed  January  5 th. 

Commentary. — This  was  a slight  case  of  fever  from  the  begirmiug, 
with  no  alarming  symptoms,  recovering  on  the  fourteenth  day.  Whether 
this  result  was  in  any  way  owing  to  the  quinine  is  doubtful,  for,  as  we 
shall  see,  there  were  other  cases  very  similar,  in  which  the  fever  was  of 
no  longer  duration.  When  first  given,  it  certainly  brought  down  the 
pulse,  and  all  the  symptoms  abated.  On  their  return,  therefore,  the 
treatment  was  again  had  recourse  to,  and  the  dose  increased  to  thirteen 
grains.  On  this  occasion,  however,  no  further  benefit  was  obtained;  and 
it  appeared  to  me  that  the  disease  terminated  with  critical  sediment  in 
the  urine,  on  the  fourteenth  day,  in  the  usual  manner.  There  was  no  erup- 
tion in  this  case. 

Case  CCXXIV.f — John  Craik,  blacksmith,  aet.  23 — admitted  January  6th,  1852. 
On  December  28th,  had  severe  rigors,  followed  by  feverish  symptoms,  and  during 

* Reported  by  Mr.  A.  Dewar,  Clinical  Clerk. 

f Reported  by  Mr.  W.  H.  Broadbent,  Clinical  Clerk. 


CONTINUED  FEVER. 


929 


the  night,  severe  cough  and  much  expectoration.  On  admission,  tongue  red  and  moist ; 
slight  sore  throat ; no  appetite  ; constipation ; pulse  80,  of  good  strength  ; severe  cough, 
and  considerable  expectoration,  tinged  with  blood  ; mucous  rales  are  heard  over  chest, 
chiefly  at  base  of  lungs ; skin  soft  and  dry ; no  eruption  or  exposure  to  contagion. 
January  1th. — Bowels  freely  opened  ; cough  very  severe.  Ordered  saline  mixture  ; 
blister  to  front  of  chest.  Jan.  %th  (11th  day). — Very  restless ; delirious ; drowsy  and 
stupid;  cough  abated;  pulse  108,  weak.  Vespere. — Pulse  121,  quick;  skin  hot  and 
dry.  Quinine  treatment  ordered.  Jan.  ^th. — Skin  cool  and  moist ; pulse  90,  weak ; 
tongue  moist  and  red;  extreme  deafness.  Jan.  10th. — Slight  diaphoresis.  Jan. 
llth  (14th  day  of  fever). — Skin  hot  and  dry;  flushed  and  delirious;  marked  rose- 
colored  eruption  over  chest  and  abdomen ; great  thirst ; sordes  on  lips  and  teeth ; 
tongue  red  and  moist,  dark  in  centre.  Jan.  I'ith. — Delirious;  eruption  remains; 
sord^es  disappearing ; skin  hot  and  dry  ; cough  severe ; crepitation  distinct  at  base  of 
right  lung ; no  dulness,  but  marked  resonance.  Ordered  antimonial  mixture.  Jan. 
13^/i. — Countenance  flushed ; pulse  rapid  and  weak  ; great  prostration.  Blister  to 
right  side;  wine  § iv.  Jan.  14^4. — Symptoms  urgent.  Jan.  Ihth. — Great  thirst; 
tongue  foul ; crepitation  gone,  and  the  respiration  is  heard  very  indistinctly ; vocal  re- 
sonance well  marked.  Jan.  llth. — Improving;  no  dulness,  nor  increased  vocal  reso- 
nance ; some  sibilant  rales ; slight  deposit  in  urine.  Steady  improvement  until 
February  20,  when  there  was  oedema  of  lower  limbs ; urine  normal.  Is  now  quite 
convalescent.  Dismissed. 

Commentary. — In  this  case  it  will  be  observed  that,  although  the 
quinine  at  first  produced  an  apparent  improvement,  the  fever,  with  de- 
lirium and  the  usual  symptoms,  shortly  returned,  and  ran  a rather  pro- 
tracted course,  owing  to  the  pulmonary  complication. 

Case  CCXXY.* — Anne  Dowie,  aet.  18,  servant — admitted  December  10th,  1851. 
Seized  with  pain  in  the  head,  heat  of  skin,  and  general  debility,  Dec.  3d.  Next  day 
general  pain  over  the  body,  which  has  continued  since.  On  admission,  pulse  120, 
feeble  ; tongue  dry,  red,  and  fissured ; no  appetite  ; great  thirst ; bowels  constipated ; 
skin  hot,  and  covered  with  a clammy  sweat,  and  presenting  on  the  chest  and  arms 
an  eruption  of  numerous  minute  petechial  spots,  which  have  existed  for  some  days ; 
slight  cough  and  expectoration:  scattered  bronchitic  rales  over  chest.  Dec.  llth. 
The  quinine  treatment  was  ordered.  After  the  fifth  dose  of  10  grs.,  slight  deafness, 
ringing  in  the  ears ; one  more  dose  taken,  after  which  the  medicine  was  stopped. 
Dec.  llth. — Pulse  80,  “ excessively  small  and  weak;”  surface  cooler.  In  the  after- 
noon, the  pulse  was  86,  strength  much  increased  ; skin  warm  and  moist ; tongue  dry, 
rough  and  fissured ; much  thirst ; respirations  43  in  the  minute ; slight  subsultus. 
13^/i. — Pulse  84,  of  good  strength  ; skin  moist ; eruption  unchanged  ; lips  covered 
with  sordes  ;*  tongue  dry  and  cracked.  On  the  14^A,  she  had  smart  diarrhoea,  which 
was  checked  by  an  astringent  mixture,  l^th  (12th  day). — Appearance  of  patient  much 
better;  pulse  88,  of  good  strength;  eruption  faded;  tongue  cleaner.  llth  (14th 
day). — Cough  troublesome  ; a good  deal  of  opaque  dirty-looking  muco-purulent  mat- 
ter expectorated  ; moist  rales  heard  on  auscultation ; thirst  and  anorexia  continue ; 
urine  turbid,  but  without  sediment.  10th  (16th  day). — Urine  loaded  with  lithates;  pa- 
tient improving.  After  this  date,  she  recovered  rapidly,  and  was  discharged  on  the 
15th  January,  quite  well. 

Commentary. — This  was  a well-marked  case  of  petechial  typhus,  in 
which  the  quinine  treatment  was  tried  without  apj^arently  in  any  way 
arresting  its  course.  Although  the  physiological  action  of  the  drug 
upon  the  pulse  was  remarkably  characterised. 

Case  CCXXYI.* — Isabella  Adamson,  set.  20,  servant — admitted  December  19th, 
1851,  with  eczema  of  the  scalp  and  face.  Eigors  appeared  January  4^A,  followed  by 
febrile  symptoms.  Rose-colored  exanthematous  spots  appeared  on  the  chest  and  arms 
on  the  0th.  On  the  10th,  the  treatment  by  quinine  commenced.  On  the  11^7i,  the  im- 
mediate effects  of  the  quinine  have  disappeared,  and  the  report  is — Pulse  100,  full 

* Reported  by  Mr.  W.  H.  Broadbent,  Clinical  Clerk. 


59 


930 


DISEASES  OF  THE  BLOOD. 


and  compressible ; had  no  sleep ; pain  in  head  very  intense ; no  sweating ; tono-ue 
furred  and  cracked  ; eruption  darkex\  \Uh. — Confusion  of  intellect ; vertfgo  ; pulse 
110,  weak  and  intermitting;  sordes  on  lips  and  tongue;  subsultus  tendinum.’  \^ah. 
Head  symptoms  have  been  relieved  by  a blister ; and  she  now  began  slowly  to  im- 
prove. On  the  24^A,  pulse  80 ; returning  appetite  ; sordes  disappeared.  On  the  28^/i 
convalescent.  ’ 

Commentary. — This  also  was  a remarkably  well-characterized  case  of 
fever  of  considerable  severity,  evidently  caught  in  the  ward,  runnino-  its 
usual  course,  notwithstanding  the  quinine  treatment  was  commenced  so 
early  as  the  sixth  day.  The  eruption  here  presented  rose-colored  spots 
at  the  commencement,  becoming  darker  afterwards.  Seven  cases  of  con- 
tinued fever  treated  by  quinine  have  thus  been  recorded,  which  we  may 
now  contrast  with  six  cases  treated  in  the  ordinary  way. 

TYPHUS  FEVER  TREATED  WITHOUT  QUININE. 

Case  CCXXYII.* — Anthony  Kerracher,  laborer,  ast.  20 — admitted  November  12, 
1851.  On  the  7th,  had  rigors,  followed  by  confusion  of  head  and  general  feverish 
symptoms.  No  exposure  to  contagion.  On  admission,  tongue  furred  and  white  ; in- 
tense thirst ; no  appetite ; expression  anxious,  only  slight  headache ; no  eruption. 
November  ik — Cough  severe  ; dulness  at  lower  part  of  left  lung;  cough  mixture. 
November  20. — Feverishness  gone ; sleeps  well;  expression  good.  Dismissed  on  De- 
cember 8,  1851. 

Case  CCXXYIII.* — Laurence  Cochrane,  laborer,  aet.  43 — admitted  December  1st, 
1851.  Had  first  severe  rigors,  November  28th,  followed  by  febrile  symptoms.  No 
exposure  to  contagion.  Had  fever  six  years  ago.  On  admission,  tongue  furred  and 
moist ; appetite  gone ; constipation ; pain  in  back  and  loins,  and  great  weakness. 
Complains  of  cough ; no  expectoration  ; chest  resonant,  but  crepitation  is  heard  at 
base  of  left  lung ; pulse  100,  full  and  regular.  December  2d. — Bowels  well  moved ; 
pain  unrelieved  ; appetite  returned ; no  eruption.  December  Vltli. — Fever  disappeared, 
but  very  weak.  Dismissed  January  \2th. 

Commentary. — Both  these  cases,  although  complicated  with  pulmonary 
disorder,  ran  their  usual  course,  and  in  this  respect  resembled  Case 
GCXXV.,  in  which  quinine  was  given.  In  neither  was  there  any 
eruption. 

Case  CCXXIX.f — Isabella  Stevenson,  set.  44,  washerwoman — admitted  November 
10th,  1851.  On  the  3d,  first  experienced  pain  in  the  head,  followed*  by  sweating, 
but  says  she  had  no  rigors.  She  was  in  bed,  complaining  principally  of  cephalalgia, 
during  the  whole  of  last  week.  On  admission,  the  skin  is  dry  and  hot,  but  at  night 
always  bathed  in  perspiration.  No  eruption ; tongue  furred ; no  appetite ; thirst 
moderate;  intense  headache,  with  occasional  stupor;  pulse  120,  small,  threadlike. 
Cold  to  the  head  and  stimulants.  On  the  12^/<,  crepitation  was  heard  in  the  left  lung 
posteriorly.  13^A. — Great  dyspnoea;  moist  and  dry  rales  over  anterior  of  chest. 
These  symptoms  increased,  and  she  died  November  loth. 

Sectio  Cadaveris. — Forty-eight  hours  after  Death. 

Both  lungs  anteriorly  were  emphysematous  in  the  highest  degree,  presenting  nu- 
merous bullae,  with  deep  fissures  between  them,  with  patches  of  collapsed  lung  here 
and  there.  If  anything,  the  left  lung  was  most  affected.  Posteriorly,  both  lungs 
more  or  less  collapsed,  and,  on  section,  the  lining  membrane  of  the  bronchi  was  deeply 
congested,  and  the  tubes,  on  pressure,  yielded  an  abundant  muco-purulent  dis- 
charge. Spleen  small,  weighing  one  ounce  and  a half;  brain  and  other  organs 
healthy. 


* Reported  by  Mr.  A.  Dewar,  Clinical  Clerk, 
f Reported  by  Mr.  J.  L.  Brown,  Clinical  Clerk. 


CONTINUED  FEVER. 


931 


Commentary. — This  woman  came  into  the  ward  on  tlie  same  day  as 
Case  CCXXil.,  the  fever  was  equally  severe,  and,  if  anything,  the 
headache  was  more  violent.  It  was  resolved  to  give  quinine  in  one 
case  and  treat  the  other  in  the  usual  way.  It  so  happened  that  both 
died. 

Case  CCXXX.* — Margaret  Menzies,  ast.  16,  servant — admitted  December  28,  1851. 
Seized  with  lassitude  and  febrile  symptoms  on  the  22d,  but  without  distinct  rigors. 
On  admission,  pulse  100,  full ; tongue  coated ; headache  and  vertigo  ; skin  dry  and 
hot,  with  rose-colored  elliptical  spois  scattered  over  the  abdomen  and  chest,  which  ap- 
peared this  morning ; they  are  of  mulberry  color  on  the  arms.  Janucui'y  1st. — 
Urine  loaded  with  lithates ; eruption  disappeared  ; skin  cool ; pulse  natural.  January 
3d. — Convalescent. 

Case  CCXXXI.* — Christina  Swan,  servant,  ast.  25 — admitted  December  16,  1851. 
Had  rigors  on  the  14th,  followed  by  febrile  symptoms,  but  had  headache  and  other 
premonitory  sytnptoms  on  the  11th,  The  day  before  admission  (l5th)  an  eruption  ap- 
peared on  the  body.  On  admission,  pulse  120,  small;  tongue  florid  at  edges,  furred 
at  the  sides ; no  appetite ; great  thirst ; cough.  The  entire  surface  is  covered  with  a 
mulberry-colored  eruption,  in  small  crescentic  patches,  and  though  not  raised,  strongly 
resembling  that  of  rubeola.  Eyes  red  and  suffused,  not  sensitive  to  light.  December 
\Mh. — Was  delirious  last  night.  Mouth  and  teeth  covered  with  sordes;  tongue  dry 
and  cracked  ; is  now  insensible;  pulse  120,  small.  Subsultus tendinum,  bronchitis  on 
both  sides,  with  pneumonia  on  lower  half  of  right  lung.  December  — Since  last 
report,  constant  low  delirium,  which  to-d-.iy  is  somewhat  diminished.  Cough  and  ex- 
pectoration very  troublesome.  Absence  of  respiration  from  right  back,  with  pealing 
vocal  resonance.  Pulse  rapid  and  weak ; eruption  faded.  Blister  to  head.  Wine 
^ vj.  and  brandy '^\y.  December  29//n — No  delirium,  but  lies  in  a comatose  state,  A 
lateritious  sediment  in  the  urine  has  appeared,  and  a swelling  in  the  right  parotid 
gland.  Pulse  98,  more  full.  January  Isif. — Consciousness  returning ; cough  much 
diminished,  and  respiration  audible  in  right  back ; skin  cool.  An  abscess  forming  in 
the  neck,  below  right  side  of  jaw.  From  this  period  convalescence  was  slowly  estab- 
lished ; the  abscess  was  resolved,  and  she  was  dismissed  February  2d. 

Commentary. — This  was  a very  severe  case  of  typhus,  with  pul- 
monary complication,  which,  however,  by  means  of  stimulants  liberally 
given,  struggled  through  on  the  twenty-first  day.  The  eruption  in  her 
case  was  very  peculiar,  closely  resembling  that  of  rubeola,  which  it  was 
maintained  to  be  by  several  persons  who  saw  it.  It  appeared  on  the 
second  day  after  the  rigor.  But  there  was  none  of  the  intolerance  to 
light,  or  coryza  of  measles ; and  moreover,  she  and  her  friends  stated 
that  she  had  previously  had  the  disease.  Under  these  circumstances, 
it  is  probable  that  it  constituted  the  “ mulberry  rash  ” of  Jenner, 
appearing  early. 

Case  CCXXXII.f — Bridget  M‘Fadyen,  mt.  20,  laboring  woman — admitted  Decem- 
ber 17,  1851,  with  psoriasis  of  the  arms  and  legs.  Rigors  appeared  January  4,  fol- 
lowed by  slight  febrile  symptoms,  which  became  fully  established  on  the  10^/i.  Wth. — 
Delirious  ; face  flushed ; pulse  120,  rather  strong  and  jerking  ; no  eruption.  With. — 
Quite  unconscious.  Head  shaved  and  blister  applied.  \%ih. — Head  relieved;  pulse 
rapid  and  weak.  Ordered  4 oz.  of  wine.  On  the  24fA,  sediment  of  lithates  in  urine. 
She  gradually  improved  after  this  date,  and  on  the  26th  was  convalescent.  No 
eruption. 

% 

Diagnosis  of  Continued  Fevers. 

On  reviewing  the  nineteen  cases  of  continued  fever  previously  given, 
with  a view  of  determining  how  far  we  are  enabled  to  distinguish  its 

^ Reported  by  Mr.  J.  L.  Brown,  Clinical  Clerk, 
f Reported  by  Mr.  W.  H.  Broadbent,  Clinical  Clerk. 


932 


DISEASES  OF  THE  BLOOD. 


varieties  at  an  early  period,  it  will,  I think,  appear  that  this  is  impossi- 
ble. If  there  be  any  fact  connected  with  the  disease  better  established 
than  another,  it  is  that  at  the  onset  we  are  unable  to  say  whether  any 
given  case  will  turn  out  to  be  a febricula  or  a typhus,  a relapsing  or  a 
typhoid  fever.  If  you  study  carefully  the  symptoms  presented  by  Cases 
CCXVI.,  CCXVIII.,  CCXIX.,  and  CCXXIV.,  you  will  be  satisfied  of 
this.  We  may,  indeed,  when  acquainted  with  the  prevailing  type  of  an 
epidemic,  often  be  led  to  guess,  with  more  or  less  correctness,  as  to  its 
probable  course,  but  exactitude  is  impossible.  Should  the  fever  cease 
on  the  seventh  day,  then  it  may  be  febricula  or  relapsing  fever.  The 
latter  is  determined  by  the  return  of  the  disease , but  I know  of  no  cir- 
cumstance, beyond  the  type  of  the  epidemic,  which  can  lead  us  to  pre- 
dict that  event.  On  the  other  hand,  should  the  fever  continue  beyond 
the  seventh  day,  then  we  may  have  to  do  with  typhus  or  the  typhoid 
form.  Notwithstanding  all  that  has  been  said  as  to  the  means  of  dis- 
tinguishing these  varieties,  by  means  of  the  eruption  or  of  the  abdomi- 
nal symptoms,  I believe  that  in  practice  it  will  be  found  to  be  impos- 
sible in  several  cases  before  the  twenty-first  day.  In  many  other  cases, 
however,  the  general  features  of  the  disease  will  enable  us  to  speak  posi- 
tively before  that  time.  We  have  seen,  in  the  three  cases  of  typhoid  fe- 
ver which  have  fallen  under  our  observation,  that  no  eruption  existed  in 
any  of  them.  With  regard  to  the  ten  cases  of  typhus  fever  also,  in  five 
there  was  no  eruption  (Cases  CCXXIL,  CCXXIII.,  CCNXVIL, 
CCXXVIIL,  CCXXXII.) ; in  three  there  were  rose  spots  (Cases 
CCXXIV.,  CCXXVI.,  CCXXX.);  in  one  a mulberry  or  measly 
eruption  (Case  CCXXXI.) ; and  in  one  petechias  (Case  CCXXY."^) 
Then  with  regard  to  diarrhoea,  it  is  only  diagnostic  of  typhoid  fever 
after  the  fourteenth  day.  Thus,  in  case  CCXIX.  it  first  appeared  on 
the  twenty-eighth  day,  and  in  Case  CCXX.  on  the  fifteenth.  In  Case 
CCXXI.  on  the  other  hand,  it  is  said  to  have  been  present  from  the 
first ; but  such  an  occurrence,  however  it  may  excite  our  suspicions,  is 
far  too  common  in  all  fevers  to  be  much  regarded  as  more  particularly 
indicative  of  typhoid  than  of  typhus  fever.  From  all  these  considera- 
tions, the  distinctions  which  have  been  made  out  between  the  various 
forms  of  continued  fever  are  often  retrospective,  and  only  determined 
in  the  advanced  stages.  You  cannot,  therefore,  be  too  careful  in  com- 
ing to  a conclusion  on  this  matter. 

* This  paragraph  has  been  criticised  by  a writer  in  the  “ British  and  Foreign 
Medical  Review  ” for  October  1853,  who  is  a strong  supporter  of  Dr.  Jenner’s  opinion. 
It  may  be  worth  while,  in  turn,  to  analyse  his  arguments.  He  admits  that  if  the 
eruption  is  not  distinctive,  the  objection  to  Dr.  Jenner’s  views  would  be  well  founded. 
He  says,  however,  that  in  cases  CCXXIII.,  CCXXVIL,  and  CCXXXII.,  the  eruption 
may  have  been  absent  simply  on  account  of  the  youth  of  the  patients.  But  typhus  fever 
frequently  attacks  young  people,  and  if  the  diagnostic  eruption  can  only  be  depended 
on  in  persons  after  the  age  of  25,  its  value  cannot  be  very  great.  CCXXII.  is 
declared  to  be  a cerebral  disease,  and  Case  CCXXVIII.  a pulmonary  one.  Cerebral 
and  pulmonary  complications  were  undoubtedly  there,  but  I can  assure  the  critic  that 
they  were  cases  of  typhus  fever  notwithstanding.  Thus,  however,  he  disposes  of  the 
five  cases  which  are  hostile  to  his  views.  Then,  as  to  the  three  cases  of  typhus 
(Cases  CCXXIV..  CCXXVI,,  and  CCXXX.),  with  rose  spots,  he  denies  that  such  spots 
are  ex.anthematous.  But  if  not  exanthematous,  w^hat  are  they?  Certainly,  they  were 
not  macular  or  petechial.  Then,  because  it  is  said  in  Case  CCXXVI.  that  they  became 


CONTINUED  FEVEE. 


933 


The  investigations  of  Wunderlich  on  the  continent,  and  of  Drs. 
Parkes  and  Ringer  in  this  country,  indicate  the  importance  of  thermo- 
metric observations  in  febrile  states  of  the  body.  Continuous  daily 
determination  of  the  temperature,  according  to  them,  exhibits  fixed 
variations  for  ditferent  fevers,  and  forms  a valuable  addition  to  our  means 
of  diagnosis.  Thus  in  typhus,  the  temperature  steadily  rises  from  98“^, 
the  standard  of  health,  to  be  above  103°  in  three  or  four  days,  and  it 
declines  rapidly  when  the  fever  subsides.  In  typhoid  fever,  a high 
temperature  persists  for  a longer  period,  but  peculiar  remissions  in  the 
range  of  temperature  occur,  which  are  specially  marked  towards  the 
latter  end  of  the  fever.  In  intermittent  fever  the  temperature  begins 
to  be  elevated  during  the  sensation  of  chilliness,  and  having  risen  several 
degrees  above  100,  in  a short  period  declines  rapidly  during  the  sweat- 
ing stage.  In  scarlatina.  Dr.  Ringer  concludes  that  the  ranges  of  tem- 
perature indicate  cycles  of  about  five  days  in  that  disease,  and  that  a 
similar  periodicity  prevails  through  the  complications  and  sequelae.  This 
requires  confirmation.  As  a general  rule,  it  may  be  stated  that  in  scar- 
latina the  temperature  attains  its  maximum  from  the  second  to  the  fourth 
day ; it  then  declines  rapidly  with  the  pulse  until  convalescence. 

The  introduction  of  thermometric  investigation  as  an  element  of  clin- 
ical research  being  of  comparatively  recent  date,  there  are  many  points 
of  interest  still  undetermined.  From  some  observations  made  by  Mr. 
T.  Evans,  one  of  my  clinical  clerks  in  1864,  it  would  appear  that 
in  typhus  fever  the  temperature  attains  its  maximum  about  the  latter 
end  of  the  first  week ; that  is,  when  the  eruption,  if  present,  is  most 
marked.  It  begins  to  decline  a few  days  before  the  pulse  does,  and 
falls  rapidly  during  the  last  week — a sudden  diminution  of  two  or 
more  degrees  occurring  on  certain  days.  After  the  subsidence  of  the 
fever,  the  temperature  is  a degree  or  two  below  that  of  health ; and 
subsequently  it  rises  to  be  a degree  or  two  higher  than  the  normal  tem- 
perature. Generally  it  reaches  its  minimum  earlier  than  the  pulse,  in 
the  same  way  as  it  begins  to  rise  and  reaches  its  maximum  earlier. 
The  earlier  the  pulse  and  temperature  begin  to  fall,  the  earlier  the  fever 
may  be  expected  to  subside.  Dr.  Parkes  has  shown  that  the  amount  of 
urea  excreted  has  a certain  correspondence  to  the  temperature ; that  a 
sudden  diminution  of  the  temperature  is  coincident  with  the  occurrence 
of  a “ critical  discharge ; ” and  that  a diminished  excretion  with  a per- 
sistent high  temperature  is  fraught  with  danger,  indicating  the  proba- 
bility of  the  approach  of  inflammatory  complications.  It  is  further  to 
be  observed  that  in  typhus  the  general  height  of  the  range  of  tempera- 
ture does  not  appear  to  be  proportionate  to  the  duration  or  severity  of 
the  attack. 

darker  afterwards,  and  in  Case  CCXXX.  it  is  noted  they  are  of  mulberry  color  on  the 
arms,  therefore  they  must  have  presented  the  ordinary  character  of  a typhus  rash. 
All  I can  say  is,  that  to  me  they  were  in  no  way  distinctive.  The  absence  of  eruption 
in  the  three  typhoid  cases  (CCXIX.,  CCXX.,  and  CCXXI,),  is  thus  explained  by  the 
reviewer  : — “ As  the  rose  spots  only  appear  in  85  per  cent,  it  is  not  impossible  that 
t'liey  might  have  been  absent  in  these  three  consecutively,  and  may  have  been  present 
in  the  next  fifteen.”  But  if  so,  how  is  our  diagnosis  to  be  assisted  by  a supposed  pe- 
culiar form  of  eruption  which  need  not  occur  in  all  the  cases  of  the  disease  admitted 
into  the  clinical  wards  for  perhaps  six  months. 


934 


DISEASES  OF  THE  BLOOD. 


Morhid  Anatomy  of  the  Edinhurgh  Epidemic  Fever  during  the  JFinter 
Session  1847-48,  when  Typhoid  Disease  was  prevalent. 

During  this  epidemic,  I opened  the  bodies  of  sixty-three  indi- 
viduals who  had  died  of  typhus  and  typhoid  fever,  with  the  following 
results  : — 

Spleen. — The  organ  most  frequently  affected  was  the  spleen.  In  the 
majority  of  cases  it  was  more  or  less  enlarged  and  softened,  presenting  a 
mahogany-brown  color  and  creamy  consistence ; so  that,  when  pressed, 
the  whole  of  its  parenchyma  could  be  squeezed  out  of  its  capsule.  In 
ten  cases  the  spleen  contained  yellow  fawn-colored  discolorations  with 
abrupt  margins,  sometimes  diffused  in  masses  varying  in  size  from  a 
walnut  to  that  of  a hen’s  egg,  at  others,  disseminated  in  miliary  spots 
through  the  organ.  In  two  cases,  these  altered  masses  of  the  spleen’s 
substance  had  softened  and  burst  into  the  peritoneum,  causing  fatal 
peritonitis.  In  another  case,  a distinct  line  of  separation  was  observed 
to  be  forming  round  a mass  about  the  size  of  a walnut. 

On  examining  this  altered  texture  in  the  spleen  with  a power  of  350 
diameters  linear  it  was  found  to  consist  of — 1st,  numerous  molecules  and 
granules ; 2d,  free  nuclei ; 3d,  compound  granular  cells  of  various  sizes  ; 


4th,  fragments  of  the  fibrous  tissue  and  fusi- 
form corpuscles  of  the  organ.  The  granular 
cells  were  frequently  ruptured,  more  or  less 
broken  down,  and  appeared  to  me  at  that  time 
to  constitute  the  structural  character  of  a new 
’ formation  which  had  been  described  by  Roki- 


(!)■■  tanski  and  other  German  pathologists,  as  ty 
phus  deposit.  This  deposition,  according  to 


them,  bears  the  same  relation  to  the  constitu- 


i'i4.  'oZo. 


Fir 


tion  of  the  blood  in  cases  of  typhus  fever,  as 
tubercle  and  cancer  do  to  the  tubercular  and  cancerous  cachexiae.  Al- 
though the  facts  described  by  Rokitanski  and  others  are  quite  correct, 
as  well  as  his  description  of  the  structure  of  this  altered  tissue  which  I 
confirmed  in  1847-48,  further  observation  has  convinced  me  that  these 
alterations  are  not  peculiar  to  typhus,  and  do  not  constitute  a distinct 
form  of  exudation.  They  consist,  in  point  of  fact,  of  a peculiar  de- 
generation of  the  splenic  pulp,  which  follows  a greater  or  less  increased 
growth  of  the  glandular  cells,  the  morbid  anatomy  of  which  is  displayed 
in  a series  of  preparations  I placed  in  the  University  Museum,  where 
they  can  be  studied. 

Lungs. — The  organs  most  frequently  affected  after  the  spleen  were 
the  lungs.  The  most  common  lesion  was  bronchitis,  the  bronchial 
lining  membrane  being  of  a deep  mahogany  or  purple  color,  more  or 
less  infiltrated  with  serum  or  exudation.  The  fine  bronchial  tubes 
were  frequently  filled  with  a muco-purulent  matter,  and  in  a few  cases 
were  choked  up  with  a reddish-brown  gelatinous  substance,  more  or 
less  fluid — probably  a modified  form  of  the  exudation  described  by 


Fig.  525.  Structure  of  a decolorized  mass  in  the  spleen. 
Fig.  526.  The  same  after  the  addition  of  acetic  acid. 


250  diam. 


CONTINUED  FEVEK.  ' 


935 


Remak,  as  discovered  by  him  in  the  sputum.  The  apices  of  the  lungs 
were  very  commonly  oedematous,  yielding  on  section  a copious  grayish 
frothy  fluid.  In  fifteen  cases,  the  lungs  were  more  or  less  consolidated 
by  exudation,  which  seldom  presented  the  characters  of  normal  hepatiza- 
tion. It  was  sometimes  of  a dirty  yellow  tint,  at  others  of  a brownish 
chocolate  color,  existing  in  masses  of  irregular  outline,  and  of  variable 
size,  resembling  the  discolored  portions  of  the  splenic  pulp,  formerly 
alluded  to.  In  three  cases  there  was  pulmonary  apoplexy. 

The  dirty  yellow  or  chocolate- colored  exudation  into  the  lungs 
was  ascertained,  on  microscopic  examination,  to  consist  of — 1st,  nume- 
rous molecules  and  granules,  filling  up  the  air  vesicles,  and  infiltrated 
into  the  areolar  tissue;  2d,  naked  nuclei;  3d,  enlarged  and  isolated 
epithelial  cells,  with  multiplying  nuclei ; and  4th,  several  compound 
granular  corpuscles.  This  material  was  also  supposed  to  belong  to  the 


Fig.  527.  Fig.  528.  Fig.  529. 


so-called  typhous  deposits,  but  is  more  probably  in  part  an  altered  exuda- 
tion, dependent  on  the  constitution  of  the  blood,  and  partly  a desquama- 
tion of  the  epithelium,  with  tendency  to  multiplication  of  inclosed 
nuclei. 

Intestines. — The  intestines  presented  the  lesion  so  well  described  by 
Bretonneau,  Louis,  Cruveilhier,  and  others  (dothinenteritis,  typhoid  ulcer, 
etc.),  in  nineteen  cases.  It  consisted  of  a peculiar  alteration  of  the  round 
and  oval  glandular  patches  of  the  small  intestine,  exhibiting  in  its  first 
stage  a flesh-colored  mass,  raised  above  the  mucous  membrane,  presenting 
in  the  round  patches  the  form  of  a pimple  or  a split  pea,  and  in  the  oval 
ones  an  abrupt  elevation  resembling  an  inverted  dish.  In  the  second 
stage  this  mass  was  more  or  less  softened,  especially  round  the  edges, 
exhibiting  a tendency  to  separate  and  slough.  In  the  third  stage,  the 
slough  had  separated,  leaving  an  ulcer,  with  abrupt  edges,  equal  in  area  to 
the  size  of  the  gland  affected,  but  varying  in  depth,  occasionally  passing 
through  the  muscular  and  resting  on  the  peritoneal  coat  of  the  intestine. 
In  this  latter  case,  the  peritoneum  externally  often  presented  a red  or 
violet  patch  of  congested  vessels,  indicating  the  ulcer  below.  The  elevated 
patches  were  observed  occasionally  to  extend  as  high  as  the  duodenum, 
and  as  low  as  the  rectum.  In  one  case  numerous  dothinenteritic  eleva- 
tions, about  the  size  and  shape  of  a split  pea,  extended  over  all  the 

Fig.  527.  Appearance  of  exudation  and  epithelial  cells  in  the  lung  in  a case  of 
typhoid  pneumonia. 

Fig.  528.  Another  portion  of  the  same  lung,  after  the  addition  of  acetic  acid. 

Fig.  529.  Portions  of  normal  epithelium  separated  from  the  air  vesicles.  250  diam. 


936 


DISEASES  OF  THE  BLOOD. 


ascending  and  transverse  colon.  In  a few  cases  the  isolated  follicles  in 
the  large  intestine  were  observed  swollen  and  empty,  presenting  in  their 
centre  a dark  blue  or  black  spot.  In  others,  the  round  and  oval  patches 
of  the  small  intestine  exhibited  a grayish  or  slate-blue  appearance.  Per- 
foration of  the  intestine  from  ulceration,  causing  fatal  peritonitis,  oc- 
curred in  three  cases.  Dysentery,  with  flakes  of  lymph  attached  to  the 
mucous  surface  over  the  ascending  and  transverse  colon,  was  associated 
with  intense  dothinenteritis  in  one  case.  Oval  and  round  cicatrices, 
exhibiting  different  stages  of  the  healing  process  of  the  intestinal  typhous 
ulcer,  were  observed  in  two  cases. 

On  examining  the  matter  found  in  the  intestinal  glands  in  the  above 
cases,  it  was  shown  to  consist  of  numerous  molecules  and  granules 
associated  with  free  nuclei  and  cells  of  the  glandular  sacs,  which  were 
unusually  distended,  and  filled  with  cell  elements  in  various  stages  of 
development  and  disintegration.  In  this  respect  it  closely  resembled  the 
altered  substance  of  the  spleen  formerly  described,  and  indeed  appeared 
to  consist  of  the  same  glandular  lesion. 

Mesenteric  Glands. — In  all  the  cases  where  the  intestinal  ulcerations 
were  recent,  the  mesenteric  glands  were  enlarged,  soft  and  friable,  and 
of  a grayish  or  reddish-purple  color.  Some  of  these  glands  reached  the 
size  of  a hen's  egg.  On  section,  they  presented  a finely  granular  surface, 
of  a dirty  yellow-grayish  or  dark  fawn  color,  and  their  substance  was 
generally  soft  and  friable,  but  sometimes,  in  one  or  more  parts  of  the 
swollen  gland,  broken  down  into  a fluid  of  creamy  consistence. 

On  examining  this  creamy  matter,  or  the  fluid  squeezed  from  the 
gland,  with  a power  of  250  diameters  linear,  it  was  found  to  contain 
numerous  cells,  generally  spherical,  varying  in  diameter  from  the  l-150th 
to  the  l-35th  of  a millimetre.  In  some  cases  numerous  nuclei  were 
contained  in  the  cell,  occupying  three-fourths  of  its  interior,  generally 
about  the  l-200th  of  a millimetre  in  diameter.  At  other  times  from 
one  to  four  of  these  nuclei  were  seen  scattered  within  the  cell.  On  the 
addition  of  acetic  acid  the  cell-wall  was  rendered  very  transparent, 
whilst  the  nuclei  were  unaffected.  Many  of  them  were  free,  and  at 
first  looked  like  altered  blood-corpuscles,  from  which  they  were  at 
once  distinguished  by  the  action  of  acetic  acid.  (See  Figs.  223  to  225, 
p.  209.) 

Blood. — The  blood  in  the  great  majority  of  cases,  was  fluid,  and 
of  a dirty  brownish  color.  In  those  instances,  however,  where  the 
disease  had  been  protracted,  and  especially  in  such  as  presented  well- 
marked  glandular  disease,  firm  coagula  were  found  in  the  heart  and 
large  vessels. 

Other  Lesions. — "With  regard  to  the  other  lesions  observed  in  the  sixty- 
three  bodies,  it  may  be  said  that  in  two  there  were  glossitis,  and  laryn- 
gitis with  tonsillitis ; in  one,  abscess  of  the  kidney  ; and  in  one,  abscess 
of  the  posterior  mediastinum.  The  brain  did  not  appear  to  participate 
much  in  the  disease.  It  presented  only  occasional  congestion,  with  slight 
effusion  into  the  subarachnoid  cavity,  or  into  the  lateral  ventricles.  In 
seven  bodies  no  lesion  whatever  could  be  discovered. 

Such  is  a summary  of  the  appearances  observed  in  sixty- three  bodies 
of  patients  who  died  of  fever  during  the  prevalence  of  the  typhoid  form 


CONTINUED  FEVEE. 


937 


of  the  disease  during  1847-48.  The  proportion  of  typhoid  to  typhus 
cases  has  considerably  increased  of  late  years. 

Pathology  and  Etiology  of  Continued  Fever. 

With  regard  to  the  nature  of  typhoid,  as  of  all  other  forms  of  fever, 
we  know  little ; but,  from  what  has  been  said,  it  is  impossible  to  avoid 
seeing  that  the  spleen,  mesenteric  and  intestinal  glands,  are  especially 
liable  to  be  affected.  Now  these  glands  constitute  part  of  an  apparatus 
which,  I believe,  secretes  the  blood  (see  Leucocythemia) ; and  if  so,  we 
begin  to  catch  a glimpse,  at  all  events,  of  the  connection  between  altera- 
tions of  these  structures  and  of  the  blood  in  fever.  Further  researches, 
however,  are  required  to  determine  the  nature  of  such  connection,  as  well 
as  how  far  in  this  disease  the  glands  operate  upon  the  blood,  and  the 
blood  upon  the  glands. 

The  same  arguments  which  apply  to  the  uncertainty  of  diagnosis 
may  be  raised  against  the  general  doctrine,  that  the  different  forms  of 
fever  are  dependent  upon  separate  poisons,  run  a separate  course,  and 
are  governed  by  laws  as  distinct  as  those  which  regulate  the  various  kinds 
of  eruptive  fever.  Without  denying  the  existence  of  various  kinds  of 
continued  fever,  I am  of  opinion  that  this  doctrine  has  not  been  estab- 
lished. On  the  contrary,  I believe  that  internal  complications,  and  the 
accidental  circumstances  of  season,  diet,  constitution,  and  other  causes  of 
a like  nature,  modify  fever  in  particular  individuals  at  different  times, 
and  that  to  these  the  variations  observed  are  in  many  cases  attributable. 
Moreover  I am  satisfied  that  typhoid  and  typhus  fever  may  occur  to- 
gether epidemically,  run  into  one  another,  and  be  mutually  communi- 
cable. This  was  very  well  shown  in  the  Edinburgh  epidemic  of  1847-48, 
in  which  both  diseases  occurred  together  at  the  same  time  and  in  the 
same  localities,  some  individuals  coming  from  the  same  house  affected 
with  typhus,  and  others  with  typhoid,  the  latter  having  intestinal  lesion 
after  death,  as  proved  by  dissection. 

At  the  same  time,  there  can  be  no  doubt  that  these  different  forms 
of  fever  may  succeed  each  other  just  in  the  same  manner  that  there  may 
be  relapses  or  returns  of  the  same  form  of  fever.  Of  this  the  following 
is  a good  example : — 

Case  CCXXXIII.* — Typhoid  succeeded  hy  Typhus  Fever. 

History. — Sarah  Hewson,  let.  23,  unmarried,  kitchen-maid — admitted  October  23d, 
1864.  She  has  always  enjoyed  good  health  up  to  the  lYth  instant,  when  after  exposure 
to  cold  .she  was  seized  with  febrile  symptoms.  Being  unable  to  work,  she  took  a dose 
of  salts  three  days  afterwards,  but  weakness  and  prostration  increasing,  came  to  the 
Infirmary. 

Symptoms  on  Admission. — On  admission,  skin  hot  and  dry ; no  eruption ; pulse  96, 
of  fair  strength  ; tongue  covered  with  a brown  fur.  No  appetite  ; thirst ; no  diarrhoea 
nor  abdominal  pain ; no  headache.  A saline  mixture.,  and  heef-tea  and  milk  for 
nourishment. 

Progress  op  the  Case. — October  26^A. — Pulse  94,  weak.  To  have  ^ iv  of  wine 
daily.  Oct.  21th. — A few  rose-colored  spots  visible  on  the  abdomen.  Bowels  loose, 
the  stools  of  a pea-soup  character.  From  this  time  the  case  assumed  the  usual  char- 
acters of  typhoid,  a marked  improvement  occurring  on  the  6th  of  November,  being  the 


Reported  by  Messrs.  Wm.  Johnston  and  R.  Mackelvie,  Clinical  Clerks. 


938 


DISEASES  OF  THE  BLOOD. 


21st  of  the  disease.  The  prostration  from  purging  was  extreme,  and  her  convalesence 
greatly  prolonged,  notwithstanding  the  liberal  employment  of  wine  and  food.  Dis- 
missed December  14th. 

Re-admitted  December  l%th,  with  all  the  symptoms  of  typhus  fever,  except  an  erup- 
tion. Face  flushed  and  anxious.  Skin  hot ; temperature  104°,  covered  with  perspira- 
tion. Pulse  128,  weak.  Tongue  white  and  furred  in  centre.  No  appetite;  great 
thirst ; bowels  constipated.  Headache ; great  muscular  depression ; sleep  disturbed  ; 
no  delirium.  Respiration,  35  per  minute,  slight  cough,  and  thick  mucous  expectora- 
tion ; urine  normal.  From  this  time  her  case  went  through  the  usual  course  of  typhus 
fever,  from  which  she  was  convalescent  on  December  26th  (14  days  from  the  rigor), 
and  was  dismissed  quite  well  January  23d. 

It  appears  that  on  December  12th,  two  days  before  she  left  the  house,  she  had  a 
severe  feeling  of  cold  or  rigor,  but  was  much  better  when  she  left  on  the  14th.  She 
remained  in  her  brother-in-law’s  house,  feeling  weak  and  unwell,  which  symptoms  in- 
creasing she  returned  to  the  Infirmary.  She  says  that  for  fifteen  days  bel'ore  leaving 
the  house  she  was  in  the  habit  of  waiting  upon  another  woman  (Boyd)  in  the  ward, 
laboring  under  typhus  fever,  and  frequently  sat  down  by  her  bedside,  and  as  there 
was  no  fever  in  the  brother-in-law’s  house  either  before  or  after  her  visit,  she  supposes 
that  the  disease  was  caught  in  this  way. 

Dr.  Murchison  endeavors  to  prove  that  typhus  and  relapsing  fevers 
are  caused  by  over-crowding,  with  deficient  ventilation  and  destitution. 
Typhoid  fever,  on  the  other  hand,  he  considers  to  be  caused  by  emana- 
tions from  decaying  organic  matter,  or  by  organic  impurities  in  water, 
or  by  both  of  these  causes  combined.  The  arguments  he  has  brought 
forward  in  support  of  this  theory  merit  careful  consideration,  and  were 
steadily  kept  in  view  in  the  inquiry  of  1862-63  and  since.  The  facts, 
however,  which  came  under  my  notice  in  the  remarkable  epidemic  of 
this  city  (1847-48),  already  referred  to,  cannot,  I think,  be  explained,  by 
any  such  supposition.  Further,  in  none  of  the  many  cases  which  have 
entered  the  Infirmary  under  my  care  since  the  views  of  Dr.  Murchison 
became  known,  could  I trace  any  relation  between  the  occurrence  of  the 
typhoid  fever  and  exposure  to  putrid  organic  matter,  although  in  every 
instance  this  point  was  carefully  investigated.  In  one  case  only  has 
there  been  a difference  of  opinion  in  the  class  on  the  subject ; and  as  it 
exhibits  how  easily  one  may  be  misled  and  guided  by  preconceived 
views,  the  facts  may  be  specially  referred  to. 

Case  CCXXXIY.^ — Typhoid  Fever — Convalescent  on  the  ‘list  day. 

History. — Kenneth  Sinclair,  mt.  21,  unmarried,  sailor,  native  of  Caithness — ad- 
mitted 6th  May  1864.  The  patient’s  health  w'as  good  previous  to  the  present  attack  of 
fever.  About  the  middle  of  March  (1864)  he  sailed  from  Wick  to  Dantzic,  in  a schooner 
laden  with  pickled  herrings  in  barrels,  from  the  lower  of  which  the  brine  leaked  into 
the  hold,  producing  an  intolerable  stench.  The  sailors  were  allowed  plenty  of  food, 
with  a fair  supply  of  fresh  vegetables  ; but  the  forecastle  in  which  they  slept,  was  small 
and  ill-ventilated.  The  boat  made  the  voyage  to  Dantzic  in  twelve  days,  and  remained 
there  three  weeks,  during  which  time  the  patient  was  kept  hard  at  work  on  board,  but 
was  supplied  daily  with  abundance  of  fresh  meat.  The  refuse  of  the  town  being  poured 
into  the  harbor  of  Dantzic  produces  abominable  smells  in  it.  About  a week  before 
the  vessel  left,  the  patient  drank  by  accident  some  bad  water  from  a pump,  and  two 
days  afterwards  was  seized  with  diarrhoea,  which  continued  up  to  his  admission — his 
bowels  being  opened  three  times  a day  on  an  average.  The  ship  sailed  from  Dantzic 
to  London,  laden  with  wheat,  and  arrived  in  the  Thames  about  the  26th  of  April.  The 
patient  worked  during  the  whole  voyage,  and  besides  assisted  in  cleaning  the  vessel  for 
two  days  after  her  arrival.  Feeling  exhausted,  he  then  applied  to  an  apothecary 
for  some  medicine  to  check  his  diarrhoea,  but  it  failing,  he  lay  up  for  some  days; 
after  which,  feeling  himself  getting  gradually  worse,  and  having  been  seized  with  a 


* Reported  by  Mr.  J.  M.  Moore,  Clinical  Clerk. 


CONTINUED  FEYEE. 


93G 


rigor,  he  left  London  on  the  4th  May,  in  the  London  and  Edinburgh  steamer,  and 
arrived  in  Edinburgh  on  the  6th. 

Symptoms  on  Admission. — Patient  is  exceedingly  weak,  and  unable  to  answer 
questions.  Tongue  covered  with  a white  creamy  fur,  red  at  the  tip.  Bowels  loose ; 
stools  of  a pea-soup  character.  Tenderness  over  the  whole  of  the  abdomen.  Face 
flushed ; skin  hot ; decubitus  dorsal.  Pulse  96,  incompressible,  and  of  good  volume. 
This  appears  to  be  the  11th  day  of  the  fever. 

Progress  of  the  Case. — From  this  date  to  16th  (21st  day  of  fever)  the  patient’s 
bowels  were  opened  on  an  average  twice  a day,  and  his  pulse  i-anged  from  88  to  96.  On 
the  16th,  pulse  84,  good  strength,  regular,  and  bowels  open  twice.  The  patient  con- 
tinued to  progress  slowly  but  steadily,  and  was  dismissed  perfectly  well  on  27th  June. 

Commentary. — The  history  of  this  case  is  given  exactly  as  it  is 
recorded  by  the  Clinical  Clerk,  which,  though  generally  correct,  conveys 
the  impression  that  the  cause  of  this  man’s  fever  was  the  bad  smells  and 
putrid  emanations  to  which  he  was  exposed.  After  his  convalescence 
he  was  repeatedly  examined  and  cross-examined  by  the  class,  with  a 
view  of  determining  exactly  what  were  the  circumstances  which  pre- 
ceded his  illness.  The  following  were  the  facts  elicited.  He  was  in 
good  health  up  to  the  time  he  left  Wick.  A horrible  smell  did  pervade 
the  vessel  in  consequence  of  some  casks  containing  pickled  herrings 
leaking  into  the  hold.  He  was  ten  days  on  the  voyage  out ; was  two 
days  unloading  at  Hantzic;  was  another  week  in  the  harbor,  during 
which  the  vessel  lay  empty ; was  three  days  loading  her  with  wheat, 
and  remained  other  two  days.  During  these  twenty-four  days  he  was 
in  perfect  health,  and  performed  all  his  duties  on  board  the  vessel. 
During  the  last  two  days  of  his  stay  in  Dantzic  harbor,  on  one  occasion 
when  ashore,  he  applied  his  mouth  to  a pump  in  order  to  drink  ; but 
after  taking  one  mouthful  he  desisted  as  the  water  had  a bad  “ roUen  ” 
taste.  During  this  period  the  crew  were  well  supplied  with  fresh  meat 
and  vegetables.  The  vessel  then  went  to  Fairwater,  six  miles  below 
Dantzic,  where  she  remained  a week.  Two  days  after  arriving  there, 
diarrhoea  came  on.  He  continued  his  work,  however,  and  continued  to 
do  so  during  the  ten  days  occupied  in  the  voyage  to  Loudon,  although 
during  fifteen  days — that  is,  ever  since  the  diarrhoea  commenced — he  had 
about  three  loose  stools  every  day.  On  arriving  at  London,  he  went 
ashore  and  obtained  some  medicine  from  a druggist  to  check  his  bowel 
complaint,  but  he  was  now  seized  with  shivering  and  considerable  pros- 
tration. He  therefore  determined  to  come  to  Edinburgh,  and  arrived 
there  two  days  afterwards  by  one  of  the  General  Steam  Navigation 
Company’s  steamers. 

This  circumstantial  account,  it  seems  to  me,  in  no  way  supports  the 
theory  that  putrid  emanations  were  the  cause  of  this  man’s  typhoid  fever. 
They  were  removed  with  the  cargo  of  herrings,  twelve  days  before  the 
occurrence  of  diarrhoea,  which  seemed  rather  to  be  occasioned  by  the  bad 
water  he  drank.  Again,  if  that  diarrhoea  had  been  properly  treated  and 
checked  at  the  commencement,  would  he  have  had  typhoid  fever  at  all, 
the  febrile  attack  commencing  fifteen  days  after  the  diarrhoea,  with  rigor, 
etc.,  on  his  arriving  in  the  Thames  ? These  questions  are  important, 
and  the  whole  history  of  this  man  shows  how  necessary  it  is  to  analyse 
facts  carefully  before  arriving  at  conclusions  as  to  the  cause  of  disease. 
Considering  the  effluvia  which  pervade  cities,  harbors,  and  ships,  it 


TABLE  OE  TYPHOID  AND  TYPHUS  FEVERS,  1862-63. 


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ccxxxv. 

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I 

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eeXL. 

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CCXLIV. 

eeXLY. 

CCXLVI. 

CCXLVII. 

OCXLVIII. 

CCXLIX. 

CCL. 

CONTINUED  FEVER. 


941 


must  always  be  easy  to  attribute  disease  to  some  such  cause.  But  when 
we  see  how  frequently  these  supposed  causes  are  innocuous,  and  the 
extreme  uncertainty  with  which  they  are  even  coincident  with  their 
presumed  consequences,  we  may  well  ask,  are  they  in  truth  causes  at  all  ? 
In  the  winter  session  of  1862-63,  I reviewed  and  carefully  re-examined 
the  whole  subject  of  fever,  in  consequence  of  the  appearance  of  Drs. 
Tweedie  and  Murchison’s  important  works  on  this  disease.*  Thirteen 
cases  were  the  subject  of  comment,  and  they  were  all  taken  with  great 
care.  As  too  much  space  would  be  occupied  by  recording  them  at 
length,  I give  the  chief  facts  in  a tabular  form,  together  with  two  other  I 
cases  admitted  under  my  care  in  the  summer  of  1863.  In  all  the  cases  j 
the  fever  was  well  marked,  and  the  points  more  especially  investigated 
were  the  residence,  exposure  to  contagion  or  to  putrid  emanations,  as 
causes,  and  the  diagnosis,  more  especially  as  determined  by  the  integu- 
mentary, intestinal,  and  arterial  symptoms  (see  opposite  Table). 

Commentary  on  the  Cases  Tabulated. — Of  these  sixteen  cases  of 
fever,  ten  were  typhoid,  including  Case  CCXLIX.,  the  nature  of  which 
was  long  doubtful,  but  from  its  prolongation  beyond  the  twenty-first 
day  was  at  length  declared  to  be  typhoid.  Five  cases  were  typhus,  and 
one  febricula.  The  residences  of  these  cases  were  widely  diffused,  the 
typhoid  cases  coming  from  no  place  especially  distinguished  for  effluvia 
or  bad  drainage.  The  typhus  cases  originated  in  the  Grassmarket, 
Fountainbridge,  and  the  Infirmary  itself.  Great  pains  were  taken  to 
determine  the  immediate  cause  of  the  disease — whether  contagion  or  ex- 
posure to  noxious  effluvia — ^yet,  except  in  the  two  cases  which  occurred 
in  the  Infirmary,  and  which  therefore  are  presumed  to  be  owing  to 
contagion,  in  none  could  the  fever  be  traced  to  either  cause.  Of  the 
ten  typhoid  cases,  a rose-colored  eruption  was  observed  in  seven.  Of 
the  five  typhus  cases,  a mulberry- colored  rubeolar  eruption  was  observed 
in  four,  so  marked  that  the  cases  were  considered  at  first  by  the  clerks 
to  be  those  of  measles.  Profuse  and  continued  diarrhoea  was  present  in 
five  of  the  ten  typhoid  cases,  was  moderate  in  one,  and  slight  in  four. 
The  pea-soup  stools  were  well  marked  in  four,  while  they  resembled 
coffee-grounds  or  chocolate  in  one — a fatal  case.  Among  the  five  typhus 
cases  there  was  constipation  in  two,  slight  diarrhoea  in  two,  and  coffee- 
ground  stools  in  one.  Of  the  ten  typhoid  cases,  head-symptoms,  amount- 
ing to  excessive  pain  or  delirium,  were  present  in  five  and  absent  in  five. 
One  of  the  former  had  meningitis.  Of  the  five  typhus  cases,  they  were 
present  in  three  and  absent  in  two.  Among  the  ten  typhoid  cases  were 
three  deaths,  in  all  of  whom  the  bodies  were  carefully  examined,  and 
typhoid  ulcerations  of  the  intestines  found.  Of  the  remaining  seven, 
four  were  convalescent  about  the  fourteenth  day,  and  three  only  on  or 
after  the  twenty-first  day — which  is  said  to  be  the  usual  period.  Of  the 
five  typhus  cases,  four  were  convalescent  on  the  fourteenth  day,  while 
one  was  later,  although  the  exact  day  could  not  be  fixed.  All  who 
watched  these  cases  were,  I think,  satisfied,  as  must  be  evident  from  the 
above  analysis,  that  the  systematic  descriptions  of  those  writers  who 

^ Lectures  on  Continued  Fevers,  by  A.  Tweedie,  M.D.,  etc. ; and  Treatise  on  the 
Continued  Fevers  of  Great  Britain,  by  "C.  Murchison,  M.D.,  etc.  1862. 


942 


DISEASES  OF  THE  BLOOD. 


seek  to  draw  marked  distinctions  between  the  various  leading  pheno- 
mena of  these  fevers,  especially  as  regards  modes  of  origin,  eruption, 
intestinal  and  cerebral  symptoms,  and  day  of  termination,  so  far  from 
being  uniform,  admit  of  frequent  and  striking  exceptions.  It  follows 
that  we  should  be  very  cautious  in  hazarding  an  early  diagnosis,  and 
attaching  too  much  importance  to  any  one  of  these  symptoms  in  par- 
ticular. 

In  recent  times  it  has  been  maintained  that  the  gases  originating 
from  decomposing  animal  and  vegetable  matters,  bad  drains,  etc.,  are  not 
only  the  especial  causes  of  certain  specific  fevers,  but  that  bad  smells 
are  the  evidence  of  the  existence  of  these  specific  morbid  causes. 
Sanitarians  and  municipal  authorities  have  succeeded  in  exciting  at  the 
present  time  a public  f urore  on  this  subject,  and  are  producing  effects 
which  for  extravagance  and  uselessness  can  only  be  compared  with 
those  resulting  from  the  railway  mania  which  existed  some  years  ago. 
Gigantic  works  are  being  constructed,  having  for  their  object,  not  the 
utilization  of  human  excreta,  but  channels  by  which  they  may  be  effec- 
tually wasted.  Millions  of  pounds  are  to  be  thrown  away  in  conveying 
that  matter  so  necessary  for  the  land  and  for  agricultural  purposes  into 
our  rivers  and  seas,  under  the  idea  that  the  smells  and  emanations  arising 
from  it  are  the  source  of  pestilence,  and  that  it  should  be  removed  at 
any  cost.  The  following  considerations  may  perhaps  serve  to  correct 
erroneous  views  on  this  subject : — 

1.  Atmospheric  air^  strongly  impregnated  with  odor  of  various  hinds^ 
is  not  necessarily  injurious  to  health.  — This  is  shown — 1st,  In  various  parts 
of  the  world  where  odorous  flowers  are  largely  cultivated  for  the  manu- 
facture of  perfumes.  Strangers,  indeed,  often  complain  of  headaches  in 
such  districts,  but  anything  like  epidemic  diseases  are  unknown.  2.  At 
Paris  there  is  an  establishment  at  Moiitfaucon  for  converting  ordure  into 
a dry  mass  by  simple  evaporation.  It  is  then  called  poudrette,  and  sold 
for  agricultural  purposes.  The  smell  of  this  place  to  visitors  is  at  first 
almost  intolerable ; but  the  inhabitants  of  the  neighborhood  are  uncon- 
scious of  it,  and  it  occasions  no  disease.  3.  The  state  of  the  Thames  in 
1858  was  loudly  complained  of  in  consequence  of  its  putrid  odor,  but 
no  disease  was  caused  by  it.  4.  The  Craigentinny  meadows,  near  Edin- 
burgh, have  for  200  years  been  rendered  fertile  by  causing  the  drainage 
of  the  city  to  flow  over  them.  The  odor  is  often  very  bad,  but  they 
occasion  no  unhealthiness.  5.  The  drains  in  Naples  run  down  to  the  sea, 
having  large  slits  in  them  opening  into  the  streets,  and  the  beautiful  bay 
is  rendered  foul,  close  to  the  shore,  with  the  drainage  of  the  city.  This, 
combined  with  the  sulphuretted  hydrogen  given  olf  from  the  volcanic  soil, 
renders  the  atmosphere  so  unpleasant,  that  the  rents  of  the  dwellings, 
unlike  what  exists  in  other  cities,  augment  as  the  apartments  ascend  in 
the  stair.  The  latrines  in  the  public  hospitals  also  exhale  the  most  foetid 
ammoniacal  gases.  Notwithstanding,  neither  in  the  city  nor  in  the  hos- 
pitals is  fever,  and  especially  typhoid  fever,  so  common  as  in  other  cities 
of  the  same  size.  6.  Drs.  Livingstone  and  Kirk  informed  me,  that  in 
Africa  the  smell  of  the  mangrove  swamps  was  often  intolerable,  but  was 
never  productive  of  disease. 


CONTINUED  FEVER. 


943 


2.  Atmospheric  air,  productive  of  the  most  dangerous  epidemics,  may 
he  quite  inodorous. — This  has  been  proved  in  various  parts  of  the  world, 
as  in  the  marshes  of  Essex  and  Lincolnshire,  the  low  grounds  of  Hol- 
land, the  Carnpagna  of  Rome,  the  Delta  of  the  Ganges,  the  swamps  of 
Louisiana,  the  Guinea  coast,  Jamaica,  and  many  other  places.  It  has 
never  been  known,  that  those  who  catch  intermittent,  remittent,  or  con- 
tinued fevers,  on  visiting  such  localities,  have  connected  the  morbific 
causes  with  peculiar  smells.  It  follows  that — 

3.  There  is  no  necessary  connection  between  smells  and  deleterious 
gases. — Some  of  these  have  smells,  such  as  sulphuretted  hydrogen, 
whilst  others  are  inodorous,  such  as  carbonic  acid  gas.  Now,  it  is  to  be 
observed,  that  what  makes  these  and  other  gases  injurious  is  their  being  so 
concentrated  as  to  exclude  atmospheric  air,  or  their  being  pent  up  in  con- 
fined places,  from  which  they  escape  in  injurious  quantity.  Hence  why 
workmen  going  down  into  pits  expire,  for  the  same  reason  that  dogs  do  in 
the  Grotto  del  Cano.  It  has  been  asserted,  however,  that  smells,  though 
not  injurious  in  themselves,  give  indications  of  danger.  At  a discussion 
on  this  subject  which  took  place  in  the  Physiological  Section  of  the  Rrit- 
ish  Association  in  September  1864,  one  chemist  maintained  that  during 
putrefaction  the  smell  was  given  off  first,  and  the  noxious  vapor  after- 
wards ; whilst  another  declared  that  the  smell  was  given  off  last,  and 
was  the  proof  that  all  danger  had  ceased.  The  first  likened  smell  to  the 
tail  of  the  lion,  which,  when  seen,  gave  evidence  that  the  claws  and 
teeth  were  not  far  off ; while  the  second,  continuing  the  simile,  declared 
that  a sight  of  the  tail  was  the  best  evidence  that  danger  was  departing. 
I do  not  believe  that  smells,  as  smells,  are  injurious  to  health,  nor  are 
they  a nuisance  to  those  who  live  among  them ; yet,  one  of  the  great 
difficulties  in  making  the  sewerage  of  towns  useful  in  agriculture  has 
arisen  from  exaggerated  notions  as  to  the  danger  of  smells,  and  the 
necessity  of  deodorisation. 

4.  Fresh  sewerage  entering  into  running  streams  is  not  dangerous  to 

health. — This  is  shown — 1st,  By  the  state  of  the  Thames  in  1858;  2d, 
By  the  condition  of  the  Water  of  Leith,  which  has  been  proved  by  the 
statistics  of  Dr.  Littlejohn,  officer  of  health  for  the  city  of  Edinburgh, 
to  be  a more  healthy  district  than  others  in  proportion  to  its  population, 
and  by  Dr.  Millar  to  be  equal,  in  point  of  health  and  as  regards  death- 
rates,  to  the  best  parts  of  the  town.  He  shows  from  the  tables  of  the 
Registrar-General  for  Scotland  that  the  death-rate  from  fever  in  the 
Water  of  Leith  district  is  17’G2;  in  the  whole  city  24-5 ; and  in  the 
Canongate  and  St.  Giles’  districts,  29‘1.  Excluding  the  streets  in  the 
Water  of  Leith  district  inhabited  by  the  higher  classes,  the  death-rate  is 
18'80.*  3d,  It  is  not  destructive  to  the  fish,  for  according  to  Dr.  Elliot 

cf  Carlisle,!  the  salmon  have  increased  in  size  and  weight  since  the 
drainage  of  that  city  was  conducted  into  the  Eden ; while  it  is  shrewdly 
suspected  that  the  fkmed  whitebait  of  Greenwich  and  Blackwall  actually 
owe  their  existence  to  the  peculiar  condition  of  the  neighboring  Thames. 

5.  Typhoid  or  other  Fevers  cannot  he  proved  to  originate  from  f cecal 
fermentation  or  emanations. — It  is  true  that  Dr.  Murchison  has  col- 

* Speech  to  the  Town  Council  of  Edinburgh,  March  29th,  1864. 

f Statement  made  to  Brit.  Association  of  Social  Science,  1863, 


944 


DISEASES  OF  THE  BLOOD. 


lected  many  examples  where  typhoid  epidemics  have  occurred  coinci- 
dently  with  the  opening  of  some  drain,  or  with  imperfect  drainage  of  a 
place.  But  an  equal  number  of  facts  might  easily  be  produced  to  show 
that  where  drainage  has  been  very  bad,  no  fever  has  originated,  or  where 
fever  has  occurred  and  drainage  has  been  perfect.  The  great  epidemic 
of  typhus  and  typhoid  fever  in  Edinburgh  in  1847-48  followed  failure 
in  the  potato  crop.  Formerly,  when  there  was  little  or  no  drainage  in 
the  old  town,  typhus  was  the  only  fever  met  with,  and  typhoid  was 
unknown.  Now,  drainage  has  been  largely  introduced,  and  typhoid  has 
become  common.  Dr.  Murchison  endeavors  to  explain  this  by  sup- 
posing that  water-closets,  now  largely  introduced  into  the  houses,  diffuse 
emanations  there  in  consequence  of  a bad  water  supply.  If  such  were 
the  case,  fever  should  increase  largely  in  autumn,  when  the  supply  of 
water  is  scarce ; whereas  it  is  always  most  prevalent  in  winter,  when 
the  water  is  abundant.  Formerly  also  typhoid  fever  was  as  unknown 
among  those  who  had  water-closets  as  those  who  had  not.  Further,  it 
should  be  remembered  that  the  men  who  are  employed  almost  constantly 
in  the  great  London  drains,  though  so  much  exposed  to  their  emanations, 
are  not  particularly  liable  to  fever. 

6.  Ejpidemic  fever j and  especially  typhoid  fever,  therefore,  must  oriyi- 
nate  in  other  causes,  amongst  which,  besides  contagion  and  infection, 
may  be  cited  starvation,  improper  quality  of  food,  bad  water — especially 
from  springs  arising  in  the  neighborhood  of  cess-pools  or  churchyards 
— overcrowding,  bad  ventilation,  and  the.  numerous  ills  arising  from 
poverty  and  dissipation.  Dr.  W.  Budd  of  Bristol  has  with  great  ability 
supported  the  doctrine,  that  the  cause  is  a specific  virus,  always  emanat- 
ing from  the  body,  which  may  be  conveyed  by,  but  never  originates  in 
drains."^  For  my  own  part,  I believe  we  have  yet  to  discover  the  cause 
producing  essential  fevers.  But  while  there  are  so  many  sources  of 
fallacy,  we  cannot  be  too  cautious  in  accepting  plausible  explanations, 
or  in  acting  upon  them,  either  in  our  efforts  to  cure  disease  or  to  im- 
prove the  health  of  towns. 

Another  question  which  will  be  found  discussed  in  systematic  works 


relating  to  the  pathology  and  mode  of  propagation  of  continued  fever  is 
* Papers  in  the  Lancet,  from  1856  to  1868. 


Fig.  630.  A clinical  ward  of  the  Royal  Infirmary  in  1817,  60  feet  by  24,  showing 
the  arrangement  of  fever  beds,  and  the  screen  which  isolated  them. 


CONTINUED  FEVEE. 


945 


important,  namely,  Whether  it  be  or  be  not  advisable  and  right  to  admit 
fever  cases  into  the  general  ward  of  an  hospital.  My  reply  is  decidedly 
in  the  affirmative,  being  satisfied  it  is  far  better  in  every  point  of  view 
to  dilute  the  contagious  element  as  much  as  possible,  rather  than  to 
concentrate  it  by  providing  special  wards  for  typhus  cases.  Previous  to 
1825  a few  fever  cases  were  treated  in  each  clinical  ward  of  this  In- 
firmary without  injury  to  the  other  patients,  the  disposition  of  the  fever 
beds  being  represented  in  shadow  in  Fig.  530.  The  space  around 


them  was  partially  isolated  by  a screen  partition  seven  feet  high,  with  a 
door  at  each  end.  At  present  the  arrangement  of  fever  beds  in  the 
clinical  wards  is  represented  in  Fig.  531.  Each  bed  has  1100  cubic  feet 
of  space,  and  8^  feet  of  head  room.  There  is  a window  on  each  side  of 
every  fever  bed,  and  a space  of  six  feet  between  it  and  the  adjoining 
ones.  The  result  of  this  system  has  been  most  satisfactory,  as  during  the 
last  fifteen  years  there  has  been  no  spread  of  fever  in  the  wards,  except 
on  one  occasion,  which  was  traced  by  Dr.  Christison  to  the  rules  of  the 
house  having  been  neglected.* 

Treatment  of  Continued  Fever. 

The  general  treatment  of  continued  fever  which  I have  found  most 
useful,  and  which  you  have  seen  practised  in  this  Infirmary,  consists, 
during  the  stage  of  excitement,  of  giving  saline  antimonials,  administer- 
ing slight  laxatives  if  occasion  require  them,  and  ordering  the  head  to 
be  shaved  and  cold  applied.  Fluid  nutrients,  such  as  milk  and  beef-tea, 
are  given  from  the  first,  and  wine  and  stimulants  as  soon  as  the  pulse 
becomes  weak.  In  prolonged  cases,  the  effect  of  pressure  on  the  skin 
from  decubitus  must  be  carefully  guarded  against,  whilst  the  different 
complications  which  arise  will  require  careful  management. 

Salines  and  Laxatives. — At  an  early  period  of  the  disease,  when  the 
skin  is  hot,  and  the  pulse  rapid  and  strong,  the  saline  mixture  generally 
ordered  is  the  following: — Sol.  Tart.  Antim.  3 ij ; Lia.  Ammon.  Acet. 

* Monthly  Journal  of  Medical  Science,  March  1850.' 

Fig.  631.  Clinical  ward,  No.  XL,  1858,  81  feet  by  24,  showing  the  present  ar- 
rangement.— ( Chrisiiso7i.) 

60 


946 


DISEASES  OF  THE  BLOOD. 


3 j;  Aqum^  3 vss.  M.  Fiat  mist.^a  talk- spoonful  to  he  taken  every  four 
hours.  Should  a laxative  or  purgative  be  required,  not  otherwise,  castor- 
oil  is  the  one  usually  employed.  Water  or  thin  lemonade  may  be  taken 
ad  libitum. 

Cold  to  the  Head. — The  oppressive  headache  of  fever  is  greatly  alle- 
viated by  cold  applications  to  the  head.  Indeed,  none  but  those  who 
have  experienced  it  can  understand  the  feeling  of  relief  and  grateful 
seasation  of  l;ase  wdiich  is  in  this  way  produced.  The  best  method  of 
applying  cold  I have  found  to  be  as  follows : — A wash  hand  basin 
should  be  placed  under  the  ear  on  one  side,  and  the  head  allowed  to  fall 
over  the  vessel  by  bending  the  neck  over  its  edge.  Then  from  a ewer 
a stream  of  cold  water  should  be  poured  gently  over  the  forehead,  and 
so  directed  that  it  may  be  collected  in  the  basin,  care  being  taken  not 
to  wet  the  dress  or  bed-clothes.  It  should  be  continued  as  long  as  it  is 
agreeable  to  the  patient,  and  repeated  frequently.  In  hospitals,  and 
more  especially  in  fever  wards,  this  method  requires  too  much  attend- 
ance. You  will  have  observed,  indeed,  that  I seldom  order  cold  to  the 
head,  experience  having  taught  me  that  it  is  more  frequently  converted 
into  warmth  to  the  head.  For,  notwithstanding  every  injunction  to  the 
contrary,  all  that  is  done  in  these  cases  is  to  moisten  a piece  of  double 
rag  or  lint  in  cold  water,  and  lay  it  upon  the  warm  head  of  the  patient. 
In  a few  seconds  it  is  converted  into  a warm  and  steaming  fcmentation, 
and  too  frequently  allowed  to  remain  in  this  condition  for  hours.  Hence, 
unless  cold  can  be  applied  properly  (and  in  large  hospitals  that  can 
scarcely  be  expected  without  procuring  a nurse  for  every  two  or  three 
patients),  it  is  better  not  to  order  it  at  all.  It  has  occurred  to  me,  how- 
ever, that  a water-pipe  might  be  conveyed  round  the  walls  of  fever- 
wards,  with  a vulcanised  india-rubber  tube  and  stop-cock  attached,  so 
that  with  a little  contrivance  the  patients  might  procure  a flow  of  cold 
water  and  regulate  it  for  themselves.  I am  satisfied  that  much  relief 
. would  be  in  this  way  obtained. 

To  secure  the  application  of  cold  efficiently,  it  is  necessary  that  the 
head  be  shaved.  In  all  severe  cases  this  is  indispensable.  Such  prac- 
tice, however,  is  often  stoutly  opposed  by  the  friends  of  young  wmmen, 
who  are  unwilling  that  they  should  lose  a handsome  growth  of  hair.  I 
have  occasionally 'compromised  the  matter  by  allowing  the  long  hair  to 
float  in  cold  water,,  and  act  by  capillary  attraction  on  the  scalp,  so  as  to 
keep  up  a refreshing  feeling  of  coolness. 

Regulation  of  Diet. — During  the  early  period  of  fever  the  patient 
generally  loathes  all  kinds  of  food.  Care  must  be  taken,  however,  that 
nourishment  should  be  introduced  in  the  form  of  drink,  and  diluted 
milk,  beef-tea,  toast  and  water,  thin  panada  or  similar  fluids  given  with 
a little  toast  or  biscuit.  Should  collapse  come  on,  together  with  stimu- 
lants, chicken  broth,  good  strong  beef-tea,  or  milk  should  be  administered. 
The  danger  from  fever  is  not  the  result  of  over,  but  of  under  nourish- 
ment, which,  by  reducing  the  strength,  leaves  the  patient  less  capable  of 
struggling  with  the  subsequent  weakness.  I have  especially  noticed, 
with  regard  to  relapsing  fever,  that  those  who  have  fed  well  in  the  in- 
terval have  been  less  attected  by  the  re-accession.  The  body  is  also 
drained  of  its  saline  constituents,  whilst  such  as  enter  with  the  food  are. 


CONTINUED  FEVER. 


947 


witli  it.  cut  off ; hence  I have  found  it  useful  to  add  a large  amount  of 
common  salt  to  the  beef-tea,  which  also  renders  it  more  sapid  and  agree- 
able to  the  patient,  and  serves  to  clear  away  the  accumulation  of  fur  and 
Sardes  that  gather  about  the  mouth.  On  the  other  hand,  when  conva- 
lescence comes  on,  we  should  take  care  not  to  indulge  the  appetite  too 
much.  We  can  never  be  sufficiently  grateful  to  Dr.  Graves,  of  Dublin, 
for  his  able  advocacy  of  the  principle  to  “ feed  fevers.”  It  is  only  to  be 
regretted  he  did  not  apply  it  more  extensively,  and  cause  inflammations 
to  be  fed  also. 

JFine  and  Stimulants. — When,  after  being  rapid  and  strong,  the 
pulse  falters,  becomes  soft  and  weak,  very  often  without  losing  its  fre- 
quency, it  will  become  necessary  to  administer  wine  or  other  stimulants. 
The  quantity  of  wine  usually  given  is  from  three  to  six  ounces  a day ; 
but  in  some  cases  marked  by  unusual  depression,  or  when  the  individual 
has  been  previously  accustomed  to  alcoholic  drinks,  a larger  quantity,  or 
instead,  from  one  to  four  ounces  of  spirits,  may  bo  required.  Nothing 
is  more  difficult  than  to  lay  down  rules  as  to  the  extent  to  which  stimu- 
lants ought  to  be  given  in  certain  cases,  or  as  to  the  period  when  they 
should  be  administered.  The  pulse,  strength  of  constitution,  previous 
habits  of  the  patients,  but  above  all  the  type  of  the  prevailing  epidemic, 
must  be  your  chief  guides.  Nothing,  perhaps,  is  more  indicative  of  ex- 
perience and  practical  tact  in  the  treatment  of  fever  than  the  judicious 
use  of  stimulants  in  this  disease,  and  certainly  there  is  no  other  method 
of  acquiring  the  necessary  knowledge  than  that  of  carefully  watching 
their  elfects  in  a large  number  of  patients.  iVmorig  all  the  agents  at 
your  command,  there  are  none  which  will  enable  you  to  conduct  a case 
of  fever  to  a favorable  termination  more  successfully  than  stimulants, 
when  properly  managed.  Indeed,  it  is  easy  to  conceive  that,  in  a dis- 
ease where  loss  of  appetite  and  abstinence  from  food  constitute  essential 
phenomena,  a period  must  arrive  sooner  or  later  when  artificial  support 
is  absolutely  required.  You  should  be  careful,  however,  not  to  prolong 
their  use  more  than  is  necessary.  Very  singular  anecdotes  still  linger 
about  the  clerks’  rooms  of  this  Infirmary  of  instances  where  whole 
bottles  of  whisky  were  consumed  daily  by  fever  patients,  and  where, 
notwithstanding  their  recovery,  owing  to  some  mistake  in  the  order- 
book,  the  whisky  was  still  supplied,  and  disappeared  with  surjDrising 
regularity. 

With  regard  to  the  complications  of  fever,  I have  nothing  further  to 
say,  than  that  they  must  be  treated  according  to  circumstances ; always 
keeping  in  remembrance  that  active  depleting  means  are  never  useful, 
and  seldom  fail,  by  diminishing  the  vital  powers,  to  augment  the  collapse 
and  increase  the  danger. 

Can  we  cut  short  a Continued  Fever  ? — There  cnn  be  little  doubt  that 
it  is  of  immense  importance  to  cut  short  the  disease,  if  possible.  With- 
out speaking  too  positively,  I have  been  induced  to  believe  in  this  possi- 
bility, under  certain  circumstances,  by  means  of  emetics.  A fortnight 
after  being  appointed  Physician  to  the  Fever  Hospital  of  this  city,  in 
1844,  I experienced  lassitude,  headache,  and  that  peculiar  cold  feeling 
in  the  back,  which  generally  usher  in  fever.  I took  an  emetic  of  anti- 
mony and  ipecacuanha,  and  on  the  following  day  was  well.  Three  weeks 


948 


DISEASES  OF  THE  BLOOD. 


afterwards,  I experienced  the  same  symptoms ; hut  thinking  it  possible 
that,  after  all,  the  emetic  had  not  really  been  the  cause  of  their 
removal,  I allowed  the  disorder  to  proceed,  which  terminated  in  a 
prolonged  relapsing  fever,  with  three  distinct  relapses.  I think  I have 
observed  the  same  thing  in  other  cases ; and  now,  as  a rule,  whenever 
called  in  at  the  early  period  of  fever,  I always  order  an  emetic.  This 
practice,  so  far  as  I have  observed,  never  does  harm,  often  good ; and, 
although  the  point  is  of  course  impossible  to  demonstrate,  it  has,  I think, 
been  successful  in  checking  at  the  onset  many  cases  of  fever. 

With  regard  to  cutting  short  continued  fever  by  quinine,  as  contend- 
ed for  by  Dr.  Dundas,  I regret  to  say  that  the  trial  you  have  seen  made 
of  it  has  entirely  failed.  In  none  of  the  seven  cases  (Cases  CCXIX., 
CCXX.,  CCXXII.,  CCXXIII,  CCXXIV.,  CCXXV.,  and  CCXXVI.) 
in  which  it  was  given,  notwithstanding  the  physiological  action  of  the 
drug  was  well  marked,  did  it  in  any  way  shorten  the  disease,  or  produce 
on  its  progress,  so  far  as  I could  ascertain,  any  amelioration  whatever. 
On  the  other  hand,  it  may  be  argued  that  in  one  case  (Case  CCXXII  ) 
it  was  injurious,  by  increasing  the  cerebral  complication.  Dr.  Christi- 
son  also  tried  it  in  one  case,  and  Dr.  W.  Kobertson  in  eight  cases,  both 
with  a want  of  success.  Thus,  in  sixteen  cases  it  has  been  carefully 
and  energetically  tried,  with  uniform  failure  in  all. 

Therapeutic  Action  of  Quinine  in  Fever. — The  effects  produced  by 
large  doses  of  quinine  are  worthy  of  observation.  With  these  I became 
first  familiar  in  the  wards  of  M.  Piorry,  in  La  Pitie  Hospital,  Paris, 
during  the  year  1838.  At  that  time  quinine  was  given  in  enorm.ous 
doses,  with  a view  of  cutting  short  interm ittents,  and  diminishing  the 
size  of  the  spleen.  In  this  way  I frequently  saw  50  grains  of  quinine  or 
100  grains  of  salicine  given  in  one  dose,  the  administration  of  which 
was  followed  by  the  same  effects  you  have  observed  to  follow  repeated 
doses  of  10  grains  in  the  Royal  Infirmary.  In  both  cases  the  principal 
phenomena  induced  are  vertigo,  dizziness  of  vision,  ringing  in  the  ears, 
often  complete  deafness,  with  confusion  of  ideas,  occasionally  coma  with 
contraction  of  the  pupil.  At  the  same  time  the  force  and  frequency  of 
the  heart’s  contractions  are  diminished,  and  the  pulse,  from  being  120, 
strong  and  full,  was  frequently  reduced  in  a few  hours  to  80  beats,  which 
were  soft  and  even  weak.  The  skin  at  the  same  time  becomes  cool  and 
often  moist  from  slight  diaphoresis.  This  sedative  action  on  the  heart  is 
apparently  the  result  of  the  comatose  condition  produced  by  the  primary 
action  on  the  brain,  as  is  proved  by  the  fact  that  the  disappearance  of 
the  cerebral  induces  cessation  of  the  circulatory  phenomena.  In  large 
doses,  therefore,  quinine  is  a narcotic.  Its  principal  action,  however, 
seems  to  be  on  the  ganglionic  system  of  the  nerves  (See  p.  338),  through 
which  it  operates  on  the  blood-vessels  and  blood.  Of  late  years  it  has 
been  called  an  anti-periodic,  from  the  specific  effects  it  exercises,  not  only 
on  intermittents,  but  on  all  diseases  which  exhibit  a tendency  to  return 
at  periodic  intervals,  as  certain  cases  of  epilepsy,  neuralgia,  and  even  re- 
lapsing fever.  This  property  is  altogether  peculiar,  and  is  distinct  from 
what  ought  to  be  understood  by  febrifuge,  unless,  indeed,  the  statements 
and  views  of  Dr.  Dundas  should  be  subsequently  confirmed. 

Quinine  is  also  spoken  of  as  being  a tonic  when  given  in  small  doses. 


INFANTILE  REMITTENT  FEVER. 


949 


Tins  property  seems  to  have  been  attributed  to  it  on  account  of  its  bitter- 
ness, as  well  as  its  remarkable  effects  in  the  cure  of  ague.  But  whether 
it  increases  the  appetite,  stimulates  the  digestive  organs,  or  in  any  other 
way  operates  by  increasing  the  tone  of  the  system  and  improving  the 
nutritive  powers,  is  a circumstance  which,  though  generally  adopted  as 
true,  admits  of  strong  doubt.  If  quinine  be  a narcotic  in  large  doses,  it 
is  the  only  one  of  that  class  of  remedies  which  is  tonic  in  small  doses. 
No  doubt  it  is  very  frequently  given  to  convalescents  and  weakly  persons, 
who  get  better  under  its  use,  but  whether  this  is  owing  to  the  quinine, 
or  would  not  have  occurred  equally  well  without  it,  is  a matter  very  diflB.- 
cult  to  determine.  Of  one  thing  I am  satisfied,  namely,  that  it  is  far  in- 
ferior in  tonic  properties  to  many  metallic  and  other  vegetable  drugs,  and 
consequently  a medicine  with  such  known  valuable  anti-periodic  proper- 
ties, the  supply  of  which  also  is  yearly  diminishing,  should  not  be  wasted 
in  endeavoring  to  produce  effects  so  very  doubtful  as  the  tonic  virtues 
which  have  been  ascribed  to  it.  For  many  years,  therefore,  I have  not 
given  quinine  as  a tonic,  and  have  yet  to  meet  with  a case  where  it  is 
necessary  to  administer  it  in  order  to  increase  the  strength  of  the  system. 

INFANTILE  KEMITTENT  FEVER— CAN  IT  BE  SEPA- 
RATED FROM  ACUTE  HYDROCEPHALUS? 

Case  CCLL* — Blanche  Seott,  set.  3 years,  of  scrofulous  habit — admitted  into  the 
clinical  ward  November  10th,  1851.  Her  mother  states  that  she  enjoyed  good  health 
until  a fortnight  ago,  when  she  was  attacked  with  severe  diarrhoea — the  stools  being 
thin,  of  a dirty  green  color,  offensive  odor,  and  mingled  with  slimy  matter.  She 
became  dull  and  peevish  during  the  day,  but  restless  and  uneasy  at  night,  when  the 
skin  became  hot,  and  the  countenance  flushed.  The  diarrhoea  and  fever  continued 
eight  or  ten  days,  accompanied  with  los3  of  appetite  and  great  thirst.  During  the 
last  four  days  there  has  been  delirium;  loss  of  consciousness ; oceasional  moaning ; 
uneasy  gestures  in  demand  for  drink  ; hands  frequently  raised  to  the  head,  with  a 
slight  scream  ; constant  picking  of  the  nose  and  angles  of  the  mouth  with  her  fingers ; 
latterly,  retching  and  vomiting,  and  passage  of  the  urine  and  faeces  in  bed. 

Symptoms  on  Admission. — On  admission  she  presents  the  following  symptoms : 
— Unconsciousness  of  surrounding  objects,  not  recognising  even  her  mother ; pupils 
not  contractile  to  light ; slight  strabismus  of  right  eye  ; frequently  puts  her  hands  to 
the  head,  which  is  rolled  about  uneasily  ; continual  grinding  of  the  teeth,  low  moan- 
ing, and  occasional  muttering.  Tip  of  tongue,  which  is  all  that  can  be  seen,  very 
dry,  and  of  scarlet  color ; loss  of  appetite  ; constant  thirst ; vomiting ; involuntary 
disebarges  of  fasces  and  urine ; on  pressing  the  abdomen  uneasiness  evidently  experi- 
enced, and  moaning  increased.  Skin  hot  and  dry  ; no  eruption  ; a small  abscess  at 
the  back  of  the  neck,  with  a sanious  discharge.  Action  of  heart  feeble  and  flutter- 
ing. Pulse  140,  small,  and  occasionally  intermittent.  Breathing  short  and  hurried  ; 
no  rales.  The  head  to  he  shaved,  and  a blister  to  be  applied  over  the  scalp.  To  have 
§ ij  of  sherry  wine. 

Progress  op  the  Case. — November  l^th. — The  fever  increased  towards  night,  and 
she  was  very  restless.  This  morning  it  has  abated.  Skin  now  cool;  pulse  120, 
stronger  and  regular  ; no  strabismus ; still  unconscious.  Pus  has  formed  below  the 
blistered  cuticle.  Nov.  \^th. — Accession  of  fever  last  night;  the  pulse  rising  to  160, 
and  becoming  sharp.  This  morning  consciousness  has  returned ; fever  abated ; 
tongue  dry,  brown,  and  cracked  ; swallows  without  difficulty  ; pulse  120.  Nov.  l^th. 
— There  are  still  accessions  of  fever  at  night,  and  remissions  in  the  morning.  The 
scalp  is  swollen  and  boggy  to  the  touch,  and  pus  oozes  from  it  on  making  pressure. 
All  movement  of  the  head  causes  the  child  to  cry.  No  tenderness  of  abdomen. 
Bowels  are  opened  three  times  daily.  Faeces  are  more  consistent,  of  dull  green  color, 
and  offensive  smell.  Pulse  110,  more  full.  Three  parallel  incisions  were  made 


* Reported  by  Mr.  W.  M.  Calder,  Clinical  Clerk. 


950 


DISEASES  OF  THE  BLOOD. 


through  the  infiltrated  scalp,  by  which  a considerable  quantity  of  pus  was  evacuated. 
To  take  3j  o/  cod-liver  oil  three  times  a-day.  Chicken  diet.  Continue  the  wine. 
From  this  period  she  rapidly  improved.  The  remittent  fever  ceased  on  the  18th. 
Extensive  sinuses  formed  in  the  scalp,  covering  the  occiput  and  neck,  which,  however, 
gradually  healed  on  the  application  of  a sulphate  of  copper  lotion.  Slight  bronchitis 
appeared  on  the  26th.  The  appetite  soon  after  became  very  good  ; her  strength  im- 
proved. The  incisions  in  the  scalp  had  perfectly  cicatrised  on  the  1st  of  December  ; 
on  the  11th  she  was  discharged,  the  abscess  in  the  neck,  however,  not  havins:  quite 
healed. 

Commentary. — In  this  case  the  fever  was  of  a distinctly  remittent 
type — the  accessions  being  very  marked  at  night,  and  the  remissions  very 
considerable  in  the  morning.  It  commenced  with  intestinal,  which  were 
followed  by  cerebral  symptoms.  Was  it  a case  of  gastro-enteritis,  or  of 
cerebral  meningitis,  or,  as  these  disorders  are  called  by  some,  remittent 
fever,  or  acute  hydrocephalus?  No  doubt  these  two  separate  diseases 
exist ; but  if  you  ask  me  by  what  symptoms  you  may  distinguish  one 
from  the  other  in  children  at  an  early  period,  I should  be  at  a loss  to 
reply.  In  the  whole  range  of  practical  medicine,  this  must  be  allowed 
to  constitute  a question  of  the  greatest  difficulty  to  decide.  Indeed,  I 
am  inclined  to  consider  that  it  cannot  be  done  until  the  disease  is  so  far 
advanced  as  to  render  the  cerebral  symptoms  unequivocally  predominant. 
In  systematic  works  on  the  practice  of  physic  you  will  find  the  diagnos- 
tic characters  of  the  two  diseases  set  forth  with  wonderful  order  and 
propriety ; but  if  you  depend  on  these  at  the  bedside,  you  will,  in  the 
majority  of  cases,  be  greatly  disappointed. 

Now,  if  the  symptoms  observed  in  the  case  before  us  be  taken  into 
consideration,  it  will  be  seen  that  they  partake  of  the  characters  of  both 
diseases.  Such  I believe  to  be  really  the  case — the  old  distinctions 
between  remittent  fever  and  hydrocephalus  having  no  basis  on  morbid 
anatomy.  The  former,  however,  is  connected  with  irritation  in  the 
digestive  organs,  the  latter  with  cerebral  congestion  or  inflammation. 
It  is  clear  that  these  two  lesions  may  be  conjoined  in  different  cases  in 
various  degrees,  and  hence  the  different  aspects  presented  in  practice. 
The  so-called  remittent  fever  and  acute  hydrocephalus  of  authors,  then, 
cannot  be  separated,  and  in  most  instances  are  mingled  together.  The 
case  of  Scott  was  one  of  this  description,  commencing  with  symptoms  of 
intestinal  derangement,  accompanied  by  fever  of  a remittent  type,  com- 
plicated at  a later  period  by  cerebral  congestion  of  an  asthenic  charac- 
ter; in  short,  the  hydrocephaloid  disease  of  Marshall  Hall. 

The  treatment  was  in  accordance  with  this  view  of  the  case,  consist- 
ing of  small  quantities  of  wine,  good  nourishment,  blisters  to  the  scalp, 
and  subsequently  cod-liver  oil.  Several  of  you  expressed  the  opinion 
that  this  was  a case  of  hydrocephalus,  and  a few  were  inclined  to  give 
mercury.  As  to  hydrocephalus,  much  depends  on  what  is  meant  by  that 
terra.  If  by  it  is  understood  cerebral  meningitis,  then  it  was  not  hydro- 
cephalus; but  if  it  means  certain  cerebral  symptoms,  independent  of  any 
particular  lesion,  then  it  was.  Such  symptoms,  however,  may  arise  from 
exhaustion,  as  well  as  from  over-excitement,  and  the  one  we  had  to  do 
with  was  certainly  a case  of  this  kind,  coming  on,  as  it  did,  after  pro- 
tracted diarrhoea  and  fever. 

As  to  mercury,  I have  no  hesitation  in  saying,  had  we  depended  on 
it,  as  some  recommend  should  be  done  in  similar  cases,  the  patient  would 


INTERMITTENT  FEVER. 


951 


never  have  recovered.  It  has  been  said  that  mercury  is  the  sheet  anchor 
of  the  practitioner  in  hydrocephalus.  I have  never  seen  it  beneficial  in 
undoubted  cases  of  cerebral  meningitis,  and  the  diagnosis  in  the  vast 
majority  of  instances  is  so  uncertain  as  to  warrant  the  suspicion  that  the 
recoveries  which  have  taken  place  were  not  those  of  true  inflammation. 
In  this  little  girl,  notwithstanding  the  delirium,  the  coma,  the  screams, 
the  tossing  the  hands  towards  the  head,  the  strabismus,  and  the  insensible 
contracted  pupil — all  of  which  have  been  placed  among  the  principal 
evidences  of  hydrocephalus,  the  treatment  was  brought  to  a successful 
conclusion  by  stimulants  and  nourishment.  I do  not  tell  you  that  this 
will  always  succeed;  but  whenever  such  symptoms  follow  protracted 
diarrhoea,  and  are  accompanied  by  remittent  fever,  I am  satisfied  you 
may  place  more  reliance  upon  such  treatment,  aided  by  the  powers  of 
nature,  than  upon  the  vaunted,  but  in  my  opinion  hypothetical,  powers 
of  mercury. 


INTERMITTENT  EEYER. 

Case  CCLII.'^ — Tertian  Intermittent  cured  hy  Quinine. 

History. — John  Kelly,  a laborer — admitted  into  the  clinical  ward  October  20th, 
1851.  Had  always  enjoyed  good  health  until  three  months  ago,  when  he  was  attacked 
with  intermittent  fever  in  Lincolnshire,  while  working  at  the  harvest.  At  first  it 
assumed  the  quotidian  type,  but  after  three  weeks  it  became  tertian,  and  continued 
three  weeks  longer.  Then  being  at  Morpeth,  there  was  an  interval  of  a fortnight.  Un 
leaving  Morpeth  he  was  much  exposed  to  cold  and  wet ; the  disease  returned,  and  has 
continued  up  to  the  present  time. 

Progress  op  the  Case. — The  day  after  admission  he  had  a well-marked  attack  of 
fever.  The  cold  stage  continued  fifteen  minutes,  and  the  hot  and  sweating  stages 
three  quarters  of  an  hour,  followed  by  languor  and  depression.  He  was  ordered  to  take 
five  grains  of  sulphate  of  quinine  three  times  a day,  and  a scruple  of  the  drug  two  hours 
before  the  next  expected  paroxysm.  He  had  two  other  attacks  on  the  24th  and  26th, 
the  latter  being  very  slight.  On  the  28th  there  was  no  attack,  and  the  scruple  dose 
was  suspended.  Discharged  cured  November  6th. 

Commentary. — The  cause  of  intermittent  fever  is  tolerably  well  ascer- 
tained. It  is  found  in  all  countries  which  are  low,  swampy,  and  humid, 
and  in  localities  where  the  ground  is  marshy,  and  presents  a moist  alluvial 
soil,  especially  in  the  neighborhood  of  extensive  woods.  We  must  not 
suppose,  however,  that  marshes  and  a moist  alluvial  soil  are  the  only 
causes  of  intermittent,  for  in  India  it  sometimes  prevails  in  hilly  dis- 
.tricts,  at  a considerable  elevation,  and  is  known  by  the  name  of  hill-fever. 
We  may  therefore  conclude  with  Dr.  Fergusson,  that  the  cause  of  inter- 
mittent is  a condition  of  the  atmosphere  occasioned  by  evaporation  from 
the  earth’s  surface,  by  solar  rays  rather  than  by  currents  of  air.  The 
frequency  of  the  disease  during  the  autumn  months  is  in  favor  of  this 
theory. 

The  occurrence  or  absence  of  intermittent  fever  in  particular  dis- 
tricts, according  as  the  circumstances  just  alluded  to  be  present  or  absent 
— be  induced  or  prevented — is  another  proof  of  its  correctness.  Thus  it 
is  not  a common  affection  in  Paris,  but  in  1838  I saw  it  very  frequent 
in  the  wards  of  M.  Piorry,  at  La  Pitie  Hospital.  It  arose  among  the 
workmen  of  the  St.  Germains  and  Paris  Railway,  who,  at  a particular 

* Reported  by  Mr.  W.  M.  Calder,  Clinical  Clerk. 


952 


DISEASES  OF  THE  BLOOD. 


part  of  the  line,  which  was  low  and  marshy,  caught  the  disease  in  great 
numbers.  They  nearly  all  came  to  La  Pitie,  as  M.  Piorry  cured  the 
disease  rapidly  by  large  doses  of  quinine,  and  was  in  consequence  cele- 
brated among  them;  and  thus,  whilst  numerous  cases  were  always 
present  in  that  hospital,  it  was  very  rare  in  Paris  generally.  On  the 
other  hand,  there  are  many  places  in  which  ague  was  once  common 
where  it  is  now  rare,  from  the  draining  of  marshes,  or  local  improvements 
in  cities.  Thus  it  was  formerly  common  in  London,  in  the  district 
which  surrounds  the  Tower,  but  disappeared  when  the  ditch  was  allowed 
to  become  dry.  I have  also  been  told  that,  in  Edinburgh,  when  the 
valley  which  now  separates  the  old  from  the  new  town  was  a marsh,  ague 
was  frequent.  At  present  it  is  very  rare,  and  never  met  with  except  in 
individuals  who  have  caught  the  disease  elsewhere  and  travelled  to  this 
city. 

With  regard  to  the  nature  of  intermittent  fever  we  know  nothing, 
although  we  infer  that  the  peculiar  condition  of  the  atmosphere  alluded 
to  causes  a peculiar  change  of  the  blood,  on  which  the  disease  essentially 
depends — but  the  nature  of  that  change — why  it  should  occasion  an  in- 
termittent instead  of  a continued  effect — why  it  should  produce  in 
different  people  a quotidian,  a tertian,  or  a quartan,  etc.  etc., — of  all  this 
we  are  ignorant.  I cannot  see  that  its  pathology  has  in  any  way  been 
advanced  by  endeavoring  to  connect  it  with  diseased  spleen.  No  doubt 
this  organ  is  frequently  enlarged  in  ague,  and  in  chronic  cases  becomes 
hypertrophied  and  indurated.  But  it  is  also  especially  liable  to  undergo 
changes  of  texture  in  continued  fever,  as  we  have  already  seen,  p.  934. 
Piorry  contends  that  congestive  enlargement  of  the  spleen  is  the  primary 
change,  and  that  the  general  fever  is  a result.  He  has  brought  forward 
numerous  cases,  showing  that,  in  ague,  this  organ  may  be  demonstrated 
by  percussion  to  be  enlarged,  and  that  recovery  is  commensurate  with 
its  diminution  in  bulk.  He  cites  one  case  where  an  individual  was 
knocked  down  in  the  street  by  the  shaft  of  a carriage,  which  struck  him 
on  the  left  side  over  the  spleen,  and  in  whom  the  resulting  fever  was 
distinctly  intermittent.  This  may  have  been  a coincidence.  Careful 
observation,  however,  has  satisfied  me  that  there  is  no  uniform  relation 
between  the  enlargement  of  the  spleen  and  the  intensity  of  intermittent 
fever,  as  M.  Piorry  supposes.  We  have  seen  that  in  leucocythemia  the 
spleen  has  been  much  hypertrophied,  and  no  ague  occasioned.  On  the 
other  hand,  without  denying  that  lesions  of  the  spleen  are  very  common 
in  connection  with  ague,  we  are  unable  in  the  present  state  of  pathology, 
to  determine  whether  this  be  a cause  or  an  effect,  or  to  indicate  why 
lesion  of  this  organ  should  sometimes  be  connected  with  an  intermittent, 
at  others  with  a continued  fever. 

The  treatment  which  experience  has  proved  to  be  most  certain  and 
rapid  is  that  by  quinine ; and  I am  satisfied  that  tolerably  large  doses 
are  more  efiicacious  than  small  ones  frequently  repeated.  I usually  give 
five  grains  three  times  a day,  and  a scruple  two  hours  before  the  occur- 
rence of  the  attack,  and  have  never  seen  a case  which  resisted  this  treat- 
ment. Much  larger  doses  have  been  given.  Thus  I have  seen  Piorry 
give  fifty  grains  for  a dose,  with  the  effect  in  recent  cases  of  at  once 
cutting  it  short,  and  rapidly  reducing  the  engorgement  of  the  spleen ; 


ERUPTIVE  FEVERS. 


953 


but  a permanent  and  quick  cure  I believe  to  be  equally  well  effected  by 
the  medium  dose  formerly  recommended.  Quinine  in  large  doses  pro- 
duces very  inconvenient  effects,  such  as  cephalalgia,  vertigo,  tinnitus 
aurium,  deafness,  and  other  symptoms,  which,  should  any  cerebral  com- 
plication exist,  may  render  it  fatal.  During  the  prevalence  of  intermit- 
tent at  La  Pitie  in  1838,  a man  was  treated  with  large  doses  of  the  drug, 
and  the  head  symptoms  attributed  to  its  stimulant  action.  He  died,  and 
on  examination  acute  meningitis  was  found,  with  exudation  of  lymph  on 
the  membranes. 

Some  years  ago  Dr.  Douglas  Maclagan  introduced  the  sulphate  of 
bebeerine  as  a substitute  for  quinine,  and  at  the  time  I tried  it  with 
great  success.  Of  late  years,  however — whether  from  change  in  the  mode 
of  preparation  or  otherwise,  I do  not  know — its  good  effects  have  not 
been  so  uniform.  Salicine  is  a useful  drug  in  intermittent,  and  from 
numerous  experiments  I saw  made  with  it  in  the  wards  of  La  Pitie  in 
1838,  it  may  be  depended  on  when  given  in  double  the  quantity  of  quinine. 
In  some  chronic  cases  which  have  resisted  quinine,  arsenic  has  been  found 
useful.  I have  frequently  seen  in  the  south-west  of  England  a case  cured 
at  once  by  a scruple  of  Cayenne  pepper  suspended  in  water.  Indeed,  a 
vast  number  of  remedies  have  been  found  occasionally  beneficial  in  inter- 
mittent fever,  but  there  are  none  so  uniformly  successful  as  quinine. 


- EKUPTIVE  FEVERS. 

There  are  certain  diseases  which,  in  an  arbitrary  classification,  may 
be  considered  as  febrile  eruptions,  or  as  eruptive  fevers.  They  compre- 
hend especially  scarlatina,  erysipelas,  variola,  and  rubeola.  Occasionally 
roseola,  herpes,  or  other  cutaneous  eruptions  maybe  attended  with  fever, 
but  they  are  separated  from  the  others  by  their  non-contagious  or  non- 
infectious  nature.  Plague  and  glanders,  on  the  other  hand,  are  true 
eruptive  fevers ; and  with  the  others  mentioned,  obey  certain  laws,  which 
may  be  shortly  noticed. 

1.  They  may  be  infectious  and  contagious.  By  infection  is  under- 
stood the  power  of  being  propagated  through  the  inhalation  of  air  tainted 
by  the  breath  or  perspiration  of  the  affected  person.  By  contagion  is 
understood  communication  of  disease  by  actual  contact. 

2.  The  present  theory  with  regard  to  the  cause  of  these  diseases  is, 
that  it  depends  upon  a morbid  poison,  a small  quantity  of  which  entering 
the  blood  produces  in  that  fluid  a peculiar  change  which  is  analogous  to 
that  of  fermentation.  To  distinguish  this  change  in  animal  from  what 
occurs  in  vegetable  fluids,  the  term  zymosis  has  been  introduced  by  Mr. 
Farr  (from  fv/xoo),  to  ferment). 

3.  Some  of  these  animal  poisons,  if  excluded  from  the  air  or  care- 
fully dried,  will  retain  their  communicating  property  for  a longer  or 
shorter  time.  This  enables  us  to  preserve  matter  for  artificial  inocu- 
lation. Hence  also  they  have  been  supposed  capable  of  attaching 
themselves  to  fomites — that  is,  substances  of  a rough  surface  or  downy 
texture,  such  as  wool,  cotton,  wearing  apparel,  dust,  etc.  It  is  on  this 
theory  that  quarantine  regulations  are  founded,  the  whole  of  which. 


954 


DISEASES  OF  THE  BLOOD. 


together  with  the  facts,  real  or  supposed,  that  support  them,  require  a 
thorougli  revision. 

4.  All  the  animal  poisons  are  distinguished  by  peculiarities  in  their 
mode  of  incubation  and  development.  Thus  a period  of  latency  exists 
between  exposure  to  the  poison  and  accession  of  the  fever,  or  first  rigor. 
Again,  the  eruption  appears  at  different  periods  after  the  fever  is  declared. 
Tims — • 

Period  of  Latency  Appears  after  first  Eigor 

from  from 

Scarlatina, 4 to  8 days 18  to  24  hours. 

Erysipelas, 4 to  1 days 24  to  60  hours. 

Variola, 8 to  14  days  48  hours. 

Rubeola, 7 or  8 days  72  hours. 

5.  All  the  eruptive  fevers,  strictly  so-called,  invariably  run  a natural 
course,  and  cainot  be  cut  short.  It  follows  that — 

6.  The  treatment  of  febrile  eruptions  has  for  its  object  conducting 
these  cases  to  a favorable  termination.  To  this  end  exactly  the  same 
general  rules  are  to  be  followed  as  I previously  gave  when  speaking  of 
continued  fever,  and  the  same  indications  exist  for  the  use  of  salines  and 
laxatives,  cold  to  the  head,  wine  and  stimulants,  and  regulation  of  the 
diet.  The  56  I need  not  again  repeat,  and  I shall  confine  my  observations 
at  present  te  the  more  special  treatment  of  the  diseases  we  have  studied 
in  the  wards. 

Scarlatina. 

Ca.se  CCLTII.* — Mary  Clark,  aet.  17,  servant — admitted  20th  December  1851.  On 
the  afternoon  of  the  17th  her  throat  became  sore,  and  in  the  evening  she  was  attacked 
with  rigors,  followed  by  pain  in  the  head  and  back,  and  other  febrile  symptoms.  Last 
night  she  first  observed  a red  rash  upon  her  chest  and  arms;  this  is  of  a reddish-brown 
color,  and  resembles  the  ordinary  eruption  of  scarlatina ; it  disappears  upon  pressure. 
Pidse  12i5  and  feeble;  fauces,  tonsils  and  back  of  pharynx  red  and  congested;  has 
great  thirst  and  anorexia;  tongue  moist,  with  a white  fur  in  middle,  through  which  the 
red  papilhe  project ; bowels  costive ; urine,  sp.  gr.  1030,  contains  no  albumen — a deposit 
takes  place,  containing  epithelial  scales  and  crystals  of  triple  phosphate.  Tinct. 
Hjov'.tjvn.  3ss;  Z/jV/.  A,n  non.  Acet.  et  Aquce  puree  ^ iij.  M.  3J  tertid  quaque 
horoL.  Dic.  22 — Rash  disappeared  from  arms,  but  is  still  visible  on  the  chest;  pulse 
86,  and  soft, ; less  pain  in  the  throat,  although  fauces  and  palate  are  still  congested. 
Ddc.  24. — Goiivalescent,  and  she  was  dismissed  on  the  27th  of  December  cured. 

Case  CCLIV.j- — Isabella  Husketh,  aet.  22,  a woman  of  abandoned  character,  and 
addicted  to  intemperance,  was  admitted  19th  December  1851,  in  a state  of  high 
delirium.  It  was  ascertained  that  on  the  14th  she  had  been  seized  with  rigors, 
followed  by  great  debility,  catarrh,  and  general  febrile  symptoms.  On  the  following 
day  an  eruption  appeared  on  her  skin.  On  admission  she  was  in  a state  of  violent 
delirium,  and  required  to  be  tied  down  in  bed.  Her  eyes  were  suffused,  and  very 
sensitive  to  light;  pulse  120;  tongue  dry  and  parched,  florid-red  at  the  edges,  with 
the  papillae  projecting  through  a white  fur  in  the  centim;  teeth  covered  with  sordes; 
great  pain  in  throat,  increased  on  swallowing  ; submaxillary  glands  tender  on  pres- 
sure, but  not  enlarged;  eats  nothing,  but  has  great  thirst ; bowels  costive  ; skin  hot 
and  pungent ; arms  and  chest  covered  with  a bright  scarlet  exanthematous  eruption. 
S X leechea  applied  to  the  throat — saline  mixture.  Dec.  20. — Delirium  continues ; 
pulse  125  ; p lin  in  throat  relieved.  Vespere. — Delirium  greatly  increased.  Nine  leeches 
anplied  to  te>nples,  and  to  have  a drauc/ht  of  solution  of  morphia  and  some  wine. 
Dec.  21. — Slept  during  night,  and  is  nearly  sensible  to-day ; tongue  dry  and  florid ; 
eruption  fading  ; considerable  sore  throat.  Blister  to  he  applied  to  the  throat.  On  the 

* Reported  by  Mr.  W.  H.  Broadbent,  Clinical  Clerk. 

\ Reported  by  Mr.  J.  -L.  Brown,  Clinical  Clerk. 


SCARLATINA. 


955 


23d  the  eruption  had  quite  disappeared.  The  throat  symptoms,  however,  gradually 
increased.  On  the  evening  of  the  26th,  the  breathing  was  observed  to  be  very  short 
and  hurried,  and  on  the  morning  of  the  27th  the  patient  died. 


Commentary. — The  first  case  is  an  instance  of  mild  scarlatina  running 
its  ordinary  course,  and  terminating  in  recovery  on  the  seventh  day.  The 
second  case  is  an  example  of  severe  scarlatina,  occurring  in  a woman  ad- 
dicted to  intemperance,  and  in  whom  all  the  symptoms  of  typhus  fever, 
associated  with  sore  throat,  were  present,  proving  fatal  on  the  thirteenth 
day.  Of  all  the  eruptive  fevers,  scarlatina  is  the  most  rapid  in  its  inva- 
sion and  the  most  variable  in  its  course.  Great  watchfulness  is  therefore 
demanded  on  the  part  of  the  practitioner,  especially  when  the  crisis  is  to 
be  expected,  so  that  if  prostration  comes  on  rapidly,  or  other  untoward 
symptoms  appear,  he  may  be  prepared  to  meet  them.  Perhaps,  also, 
scarlatina  is  the  most  infectious  of  the  eruptive  fevers ; so  that  complete 
separation  of  the  patient  from  the  other  members  of  a young  family  is  at 
all  times  to  be  insisted  on  as  soon  as  possible. 

A chief  peculiarity  of  scarlatina  is,  that  in  addition  to  the  general 
fever  and  characteristic  eruption,  the  tonsils  and  mucous  membrane  of 
the  mouth  and  pharynx  are  also  apt  to  be  inflamed.  This  occasions 
difficulty  of  deglutition,  with  soreness  of  the  throat,  symptoms  which 
require  for  relief  topical  remedies,  such  as  fomentations,  astringent  and 
slightly  acid  gargles,  or  a linctus,  etc.  If  sloughing  or  ulceration  occur, 
the  application  of  the  stronger  acids,  or  the  nitrate  of  silver,  is  often 
necessary.  The  difficulty  of  deglutition  sometimes  impedes  the  intro- 
duction of  food  into  the  stomach,  and  in  this  way  assists  in  producing 
prostration,  and  prevents  the  administration  of  stimulants  or  medicine. 
It  may  also,  in  severe  cases,  impede  respiration,  and  assist  in  producing 
asphyxia  directly.  A fatal  result,  however,  when  it  does  occur  during 
the  primary  attack  of  scarlatina,  is  generally  dependent  on  the  same 
causes  which  induce  it  in  typhus  fever — namely,  congestion  of  the  brain, 
as  indicated  by  delirium,  passing  into  coma,  and  followed  by  prostration 
of  the  vital  powers.  In  addition  to  the  throat  complication,  there  are 
various  others,  all  of  which  may  require  a special  treatment.  In  the 
vast  majority  of  cases,  a general  treatment,  directed  in  the  first  place  to 
subduing  the  excess  of  fever,  and  afterwards  to  supporting  the  strength, 
is  indicated. 

Many  efforts  have  been  made  by  different  practitioners  to  check  or 
modify  the  intensity  of  the  disease  by  administering  various  drugs,  or 
carrying  out  particular  kinds  of  treatment.  Hence,  during  certain  epi- 
demics, or  in  its  visitations  to  particular  educational  institutions,  various 
practitioners  have  been  sanguine  enough  to  believe  that  their  especial 
mode  of  practice  has  been  more  successful  than  any  other.  I do  not 
consider  it  necessary  to  direct  your  attention  to  the  numerous  plans 
which  have  been  thus  proposed,  because  all  of  them  have  been  only  par- 
tial in  their  operation,  and  no  one  of  them  has  been  more  successful 
than  another.  You  must  remember  that  the  causes  of  scarlatina  are  as 
mysterious  ard  unknown  as  are  those  producing  any  kind  of  fever ; and 
that  its  fatality,  like  that  of  fever,  is  to  be  traced  to  constitutional  cir- 
cumstances in  individuals,  to  unhealthy  localities,  or  to  the  so-called 


956 


DISEASES  OF  THE  BLOOD. 


type  of  the  particular  epidemic.  Nothing,  therefore,  is  more  difficult, 
under  such  circumstances,  than  to  judge  whether  the  non-fatality  ob- 
served at  one  time,  or  in  a certain  establishment,  is  referable  to  this  or 
that  practice.  At  all  events,  I have  been  unable  to  satisfy  myself  that 
any  general  rule  of  empirical  or  rational  practice  is  to  be  derived  from 
the  contradictory  accounts  which  have  from  time  to  time  been  made 
public  on  this  subject. 

Dr.  Andrew  Wood,  who  has  had  great  experience  as  physician  to 
Heriot’s  Hospital  and  other  educational  establishments  in  this  city, 
recommends  the  following  treatment : — Several  common  beer  bottles 
containing  very  hot  water,  are  placed  in  long  worsted  stockings,  or  long 
narrow  flannel  bags,  wrung  out  of  water  as  hot  as  can  be  borne.  These 
are  to  be  laid  alongside  the  patient,  but  not  in  contact  with  the  skin. 
One  on  each  side,  and  one  between  the  legs,  will  generally  be  sufficient ; 
hut  more  may  be  used  if  deemed  necessary.  The  patient  is  to  lie  be- 
tween blankets  during  the  application  of  the  bottles  and  for  several 
hours  aftei  wards.  In  the  course  of  from  ten  minutes  to  half  an  hour, 
the  patient  is  thrown  into  a most  profuse  perspiration,  when  the  stock- 
ings may  be  removed.  In  mild  cases,  the  effect  is  easily  kept  up  by 
means  of  draughts  of  cold  water,  and  if  necessary,  by  the  use  of  two- 
drachm  doses  of  Sp.  Mindereri  every  two  hours.  In  severe  cases,  where 
the  pulse  is  very  rapid — the  beats  running  into  each  other — where  the 
eruption  is  either  absent  or  only  partial,  or  of  a dusky  purplish  hue — 
where  the  surface  is  cold — where  there  is  sickness  or  tendency  to  diarrhoea 
— where  the  throat  is  aphthous  or  ulcerated,  and  the  cervical  glands 
swollen,  then  he  follows  up  the  use  of  the  vapor-bath  by  four  or  five 
grain  doses  of  carbonate  of  ammonia,  repeated  every  three  or  four  hours. 
Should  this  be  vomited,  then  brandy  may  be  given  in  doses  proportioned 
to  the  age  of  the  patients.  Carbonate  of  ammonia  he  considers  to  act 
beneficially  : 1st,  by  supporting  the  powers  of  life ; 2d,  by  assisting  the 
development  of  the  eruption ; and  3d,  by  acting  on  the  skin  and  kidneys. 
Where  the  vapor-bath  was  used  early  in  the  disease,  and  its  use  con- 
tinued daily,  or  even  twice  or  thrice  a day,  according  to  circumstances, 
he  has  found  that  the  chance  of  severe  sore  throat  was  greatly  obviated. 
In  regard  to  supervening  dropsy,  he  considers  that,  by  the  use  of  the 
vapor-bath,  with  the  other  necessary  precautions  as  to  exposure,  diet, 
etc.,  its  recurrence  is  rendered  much  more  rare.  In  the  treatment  of 
the  dropsical  cases,  it  was  also  very  useful,  and  in  some  instances  might 
be  trusted  to  entirely.  Dr.  Wood  also  condemns  all  depleting  treat- 
ment, and  even  purgatives,  during  the  first  ten  days,  thinking  them  not 
only  not  required,  but  positively  dangerous,  as  tending  to  interfere  with 
the  development  of  the  eruption.  In  the  later  stages,  as  well  as  in  the 
dropsy,  however,  he  thinks  purgatives  are  often  beneficial.  Shortly  after 
this  treatment  was  proposed  at  a meeting  of  the  Medico-Chirurgical 
Society  of  this  city,  I tried  it  in  the  following  case  : — 

Case  CCLY. — Margaret  Walsh,  set.  18 — admitted  2d  July  1852.  She  is  a servant 
girl,  and  had  always  enjoyed  good  health  until  June  29th,  when  she  experienced  dis- 


* Reported  by  Mr.  J.  R.  Williams,  Clinical  Clerk. 


SCARLATINA. 


957 


tinct  rigors,  followed  by  sore  throat  and  febrile  symptoms.  She  admits  having  called 
previously  on  a family  in  which  the  disease  existed.  On  the  evening  of  the  30th  a 
bright  red  rash  appeared  on  the  skin,  and  has  continued  ever  since.  On  admission, 
the  scarlatinal  eruption  is  well  characterised  on  the  chest  and  arms.  The  skin  is  hot ; 
pulse  full,  hard,  and  132  in  the  minute.  Tongue  furred,  with  elongated  red  papillae 
projecting  through  the  white  crust ; great  difficulty  in  deglutition  ; sore  throat ; ton- 
sils and  mucous  membrane  of  pharynx  swollen  and  red.  There  are  also  cephalalgia, 
slight  deafness,  and  restlessness  at  night.  Respiratory  functions  normal ; urine  healthy ; 
catamenia  regular.  She  was  ordered  by  the  resident  clerk  eight  leeches  to  the  head, 
a saline  antimonial  mixture,  and  eight  grains  of  Dover’s  powder.  On  first  seeing  her 
the  following  day,  3i  JuXy^  I found  her  in  much  the  same  condition  as  is  described  in 
the  previous” report ; the  skin  still  being  hot  and  dry,  and  the  eruption  very  vivid  on 
the  chest  and  arms.  Hot  bottles  were  ordered  to  be  applied,  encased  in  worsted  stock- 
ings wrung  out  of  hot  water,  as  recommended  by  Dr.  Andrew  Wood.  July  Mh. — A 
slight  perspiration  followed  the  use  of  the  vapor-bath  last  night  To-day  the  rash  has 
partly  disappeared  from  the  arms,  but  is  now  present  on  the  legs  as  well  as  chest. 
Pulse  130,  small;  urine  not  coagulable.  An  astringent  gargle  for  the  throat — the 
vapor-bath  to  be  again  applied.  July  5th. — Profuse  perspiration  resulted  last  night 
from  the  use  of  the  vapor-bath.  To-day  the  rash  has  entirely  disappeared ; but  there 
is  great  tenderness  of  the  skin  and  in  the  joints  on  motion.  July  9th. — Has  continued 
much  in  the  same  condition,  but  to-day  the  appetite  has  somewhat  returned,  and  she 
has  eaten  a good  breakfast.  Her  joints  are  swollen,  and  there  is  considerable  pain  on 
moving  them.  Desquamation  commencing ; throat  ulcerated,  and  to  be  touched  with 
a weak  solution  of  nitric  acid ; pulse  84,  soft ; § iv.  of  wine  daily.  July  26^A. — Since 
last  report  has  been  slowly  gaining  strength,  but  is  still  far  from  well.  The  urine  has 
been  carefully  examined  daily,  and  has  never  presented  coagulability  on  the  addition 
of  heat  or  nitric  acid.  To-day  a distinct  blowing  murmur  was  discovered  with  the  first 
sound  of  the  heart,  loudest  at  the  base,  and  propagated  along  the  vessels  of  the  neck ; 
pulse  76,  of  good  strength.  August  Mh. — Went  out  a little  to-day,  and  in  the  evening 
the  feet  commenced  to  swell.  August  ^th. — Swelling  of  feet  increased.  To  have  a 
squill  and  digitalis  pill  three  times  a day.  August  9th. — (Edema  of  feet  continues ; 
urine  healthy.  Venesectio  ad  3 viij.  August  llth. — (Edema  of  feet  disappeared.  This 
morning  had  a rigor.  Was  ordered  an  emetic.  August  \9.th. — To-day  is  feverish,  with 
great  thirst  and  heat  of  skin;  pulse  128,  strong.  A saline  mixture  ordered.  August 
Vlth. — Febrile  symptoms  continue,  with  tenderness  over  epigastrium;  ^Vi^eight  leeches 
were  ordered  to  be  applied  there.  The  cardiac  dulness  is  extended.  No  friction,  but 
a blowing  murmur,  as  formerly  noticed,  at  the  base  of  heart ; respiration  somewhat 
embarrassed.  August  9S)th. — Respiration  normal ; no  tenderness  over  epigastrium  ; 
pulse  100,  regular  and  soft.  The  urine  all  this  time  has  been  tested  daily,  but  has 
never  been  coagulable.  To-day,  however,  a deposit  existed  in  the  urine,  and  several 
casts  of  the  tubuli  uriniferi  may  be  observed  in  it  with  a microscope.  September  ^fJi. — 
Since  last  report  she  has  been  convalescent,  and  all  her  symptoms  have  gradually  dis- 
appeared. The  blowing  murmur  over  base  of  heart  is  still  present,  but  not  so  loud, 
and  the  increased  dulness  has  disappeared.  Dismissed. 

Commentary. — Iq  this  case  tlie  disease,  instead  of  being  shortened  or 
rendered  milder,  was  unusually  prolonged,  and  was  followed  by  rheuma- 
tism, dropsy  of  the  inferior  extremities,  and  by  pericardial  effusion.  The 
febrile  symptoms  terminated  by  critical  deposition  in  the  urine  so  late  as 
the  fifty-second  day.  Although  admitted  June  29,  she  was  not  strong 
enough  to  be  dismissed  from  the  Infirmary  until  September  7th.  This 
was  certainly  an  unfortunate  case  to  commence  the  trial  of  a new  treat- 
ment ; and  yet  the  girl  has  been  always  healthy,  and  there  was  nothing 
to  indicate  at  the  commencement  that  the  sequelae  would  be  so  severe  or 
so  prolonged. 

I persevered  with  this  plan  in  four  or  five  other  cases,  but  in  all  of 
them  it  failed  to  bring  about  speedy  resolution.  At  last  I came  to  the 
conclusion  that  the  heat,  damp,  and  exposure,  which  it  was  difiicult  to 
avoid,  tended,  especially  in  the  class  of  servants  and  young  women  who 
entered  the  Infirmary,  to  rheumatism.  I then  adopted  quite  an  opposite 


958 


DISEASES  OF  THE  BLOOD. 


treatment,  kept  the  skin  dry  and  cool,  and  have  had  every  reason  to  be 
satisfied  with  the  result.  Several  very  severe  cases  which  entered  the 
wards  during  the  winter  and  summer  mouths  of  1856-57  were  treated  in 
this  way  with  the  best  results,  of  which  the  following  are  examples : — 

Case  CCLVI.*— Thomas  Corrigan,  set.  19,  a laborer— admitted  September  19th, 
1856.  He  first  felt  sore  throat  on  the  evening  of  the  16th,  followed  on  the  18th  by 
rigors  and  febrile  symptoms.  To-day  the  rash  first  appeared,  and  on  admission  pre- 
sents a dusky-red  color,  covering  the  face,  neck,  arms,  haunches,  and  thighs.  The 
throat  is  much  swollen  externally  on  both  sides.  The  mouth  is  with  great  difficulty 
opened,  when  the  tonsils  are  seen  greatly  enlarged  and  ulcerated.  The  back  of  the 
tongue  is  swollen  and  covered  with  a thick  crust ; anteriorly  it  is  red  and  dry.  Pulse 
116,  full  and  bounding.  Respirations  21  in  the  minute.  Deglutition  difficult.  Skin 
dry  and  pungently  hot.  Urine  turbid,  and  of  a reddish-brown  color,  not  altered  on 
the  addition  ot  heat.  Chlorides  scanty.  Other  organs  healthy.  Warm  fomerdationa 
to  be  applied  to  the  throat,  and  to  use  the  steam  inhaler.  Vin.  Antim-.  3 ss  ; Aqum 
Acet.  Ammon.  §j;  Aquce  ivss.  M.  Sumat  quartd  qudque  hord.  September 
2Qth. — Has  been  occasionally  delirious.  Other  symptoms  the  same.  2h  omit  fomen- 
tations, inhalations,  and  mixture.  ^ Acid.  Sulph.  DU.  3 ij  ; Syrupi  ^ j ; Inf  us.  Rosar. 
§ vij.  M.  Sumat  3 ss  quartd  quaque  hord.  September  21s#. — Delirium  has  been 
violent  during  the  night.  At  present  pulse  76,  full  and  strong.  Deglutition  and  respira- 
tion somewhat  easier.  Vin.  Colchici  3 ij  ; Spirit.  .xRther.  Nit.  | iij  ; Aquce  ^vss.  M. 
Sumat  semiunciam  quartd  qudque  hord.  September  22d. — Urine  to-day  clear:  chlor- 
ides more  abundant ; no  albumen.  Pulse  60,  not  so  full.  Tongue  still  dry.  Rash 
has  disappeared.  Sept.  2Zd. — Urine  natural.  Desquamation  of  the  skin  commencing. 
Swelling  of  tonsils  and  sore  throat  greatly  diminished.  Prom  this  time  he  rapidly  re- 
covered, and  was  dismissed  quite  well  October  9th. 

Case  CCLYII.* — Eliza  Campbell,  set.  24,  a married  woman,  ©f  weak  constitution, 
with  two  children,  the  eldest  of  whom  is  recovering  from  scarlatina,  was  admitted 
December  19th,  1856.  On  the  12th  she  experienced  lassitude  and  general  malaise. 
On  the  15th  she  had  rigors,  followed  by  febrile  symptoms,  and  pain  in  the  back.  On 
the  morning  of  the  16th  a rash  appeared  over  the  breast  and  other  parts  of  the  body. 
On  the  18th  her  husband  observed  that  her  mind  was  wandering,  and  next  day  brought 
her  to  the  Infirmary.  On  admission  there  is  a uniform  scarlatina  eruption  over  the 
back,  abdomen,  and  arms.  On  the  legs  there  are  numerous  spots  of  purpura  extend- 
ing up  the  thiglis.  Skin  hot  and  dry.  Mouth  dry.  Tongue  brown  and  cracked  in 
the  centre.  The  jaws  are  separated  with  difficulty,  showing  the  uvula  and  fauces  of  a 
scarlet  color,  without  swelling  of  the  tonsils.  Bowels  costive.  Pulse  108,  small  and 
weak.  Is  conscious,  though  rather  confused,  and  very  restless.  Other  organs  healthy. 
Ordered  § iij  of  Sherry  wine  and  3 iv  of  lemon  juice,  to  be  taken  during  the  day  with 
strong  beef-tea.  An  injection  of  loarm  water  to  unload  the  bowels.  December  20th. — 
Violent  delirium  during  the  night.  At  the  visit,  pulse  160.  Head  to  be  shaved  and 
cold  applied.  December  21s# — Had  several  hours’  sleep  during  the  night,  and  awoke 
better.  Pulse  110.  Eruption  fading.  Urine  dark  and  turbid,  with  a copious  sedi- 
ment of  urates.  To  have  3 ss  of  Sp.  JEthcr.  Nit.  every  two  hours,  and  § ij  0/  brandy, 
in  addition  to  the  wine  daily.  December  22d. — The  rash  is  fainter.  Desquamation 
commencing.  Purpuric  spots  also  disappearing.  Still  dryness  of  mouth  and  cracked 
tongue.  Deglutition  easy.  Continue  nutrients  and  diuretics.  Prom  this  time  she  be- 
came convalescent.  On  December  24th  there  were  still  traces  of  the  eruption  in  some 
places,  while  desquamation  was  advancing  in  others.  On  the  29th  the  cuticle  sepa- 
rated from  the  hands  entire.  She  remained  weak  for  some  time,  and  was  not  strong 
enough  to  be  dismissed  until  January  24th,  1857. 

Commentary. — In  tlie  first  of  these  two  cases  there  was  violent 
angina  in  addition  to  the  severe  fever,  with  delirium,  and  yet  the  dis- 
ease pursued  its  natural  course,  crisis  occurring  on  the  seventh  day,  and 
he  rapidly  recovered  without  an  untoward  symptom.  In  the  second 
case,  occurring  in  a woman  of  a weak  habit  of  body,  who  had  been 
under-fed,  tlie  scarlatina  was  associated  with  purpura,  violent  head  symp- 
* Reported  by  Mr.  H.  M.  Maclaurin,  Clinical  Clerk. 


SCARLATINA. 


959 


toms,  but  DO  angina.  Strong  stimulants  and  nutrients  were  administer- 
ed from  the  first,  with  diuretics  to  assist  elimination,  and  ultimately  she 
did  well,  without  any  sequelae,  although  from  her  previous  weak  con- 
dition, convalescence  was  prolonged. 

It  has  frequently  been  observed  that  the  urine  in  scarlatina,  espech 
ally  when  dropsy  supervenes,  becomes  albuminous.  Dr.  James  W. 
Begbie,  who  has  with  great  pains  tested  the  urine  in  a considerable  num- 
ber of  cases,  considers  its  presence  almost  uniform.  Aware  of  what  he 
has  written  on  this  subject,  I have  tested  the  urine  daily  in  certa,in  cases 
without  observing  it.  This  non-persistent  coagulability  of  the  urine,  as 
well  as  various  deposits  which  appear  in  it  on  critical  days,  must,  when 
they  occur,  be  considered  as  an  evidence  of  the  excretion  of  morbid  pro- 
ducts which  have  circulated  in  the  blood.  Hence  they  are  common,  not 
only  in  scarlatina,  but  in  all  inflammatory  affections  as  well  as  fevers. 
This  point  you  must  have  seen  me  very  observant  of  in  watching  for  the 
resolution  of  inflammations  and  fever  at  the  bed-side  (see  p.  174).  It 
sometimes  happens,  however,  that  the  critical  discharge  is  comparatively 
slight,  and  that  the  organic  elements  are  not  dissolved  so  as  to  constitute 
fluid  albumen.  This  appears  to  have  occurred  in  the  following  case, 
for  whilst  morphological  evidence  of  the  crisis  existed  in  the  urine,  in  the 
form  of  cells  and  casts,  no  albumen  could  be  detected  by  heat  and 
nitric  acid. 

Case  CCLVIII.* — Alexander  Johnston,  oBt.  14 — admitted  June  23,  1851.  Three 
days  ago  he  experienced  distinct  rigors,  followed  next  day  by  a general  scarlatinal 
eruption.  On  admission  there  was  restless  delirium,  and  constant  mo^  ing  of  the  head 
from  side  to  side  on  the  pillow.  He  was  apparently  conscious  when  spoken  to,  but 
could  not  answer  questions ; the  tongue  was  protruded  wii,h  difficulty,  dry,  and  of 
bright  red  color,  studded  with  florid  elevations ; deglutition  was  much  impeded ; 
bowels  open;  pulse  130,  weak;  urine  voided  with  difficulty,  and  diminished  in  quan- 
tity, sp.  grav.  1025 — not  acted  on  by  heat  and  nitric  acid ; skin  hot  and  dry,  covered 
with  the  bright-red  Scarlatinal  eruption.  Ordered  salines  and  slight  diuretics.  He  con- 
tinued in  the  same  condition,  the  angina  increasing,  and  the  coma  alternating  with 
delirium  becoming  more  pronounced  until  the  sixth  day.  During  this  period  all  the 
urine  passed  was  carefully  examined.  The  amount  was  diminished  (17  oz.  per  day), 
but  it  was  free  from  deposit,  and  unaffected  by  heat  or  nitric  acid.  Sp.  .jEther, 
Nit.  3 iij  ; Pot.  Acet.  3 ij  ; Tr.  Colchici  ^ ss  ; Aquae  f iij.  Fiat  mist.  A tea-spoon- 
ful to  he  taken  every  four  hours.  On  the  folio  v/ing  day  all  coma  and  delirium  had  dis- 
appeared. He  answers  questions  when  put  to  him  ; skin  cool ; eruption  faded  ; pulse 
96,  weak;  passed  30  oz.  urine,  which  is  turbid,  with  small  flakes  of  a membranous 
character  floating  in  it.  On  the  eighth  day  the  quantity  of  urine  excreted  was  50 
oz.,  and  it  was  still  more  loaded  with  sediments.  On  examining  the  urine  with  a 
microscope,  it  was  seen  to  contain — 1st,  membranous  flakes,  composed  of  aggregated 
rounded  particles,  apparently  agglutinated  together,  and  strongly  resembling  some 
forms  of  vegetable  tissue ; 2d,  rounded  and  irregular  masses  with  spicula ; 3d, 
amorphous  molecular  masses.  (See  Fig.  104,  p.  104,  as  observed  in  this  case.)  The 
whole  of  these  elements,  on  being  analysed  chemically  by  Mr.  Drummond,  were  found 
to  consist  of  urate  of  ammonia.  Next  day  the  urine  was  only  slightly  turbid,  and 
on  the  following  one  it  was  perfectly  clear.  From  this  time  the  boy  gradually  re- 
covered. 

Commentary. — This  was  a very  severe  case  of  scarlatina.  The 
angina  was  intense,  occasUnally  rendering  deglutition  impossible. 
There  was  delirium  on  the  third  day,  alternating  at  night  with  coma, 
which  was  often  profound.  The  worst  result  was  apprehended.  It 
occurred  to  me  that  the  head  symptoms,  in  this  as  in  several  cases  of 
* Reported  by  Mr.  G.  Scott,  Clinical  Clerk. 


960 


DISEASES  OF  THE  BLOOD. 


typhus,  might  probably  depend  not  so  much  upon  inflammation  of  the 
brain  as  upon  absorption  of  and  poisoning  by  urea,  an  idea  that  ap- 
peared supported  by  the  diminished  quantity  of  the  renal  excretion,  as 
well  as  its  freedom  from  all  deposit.  Kemembering  the  alleged  virtues 
of  colchicum  in  increasing  the  elimination  of  this  excretion,  I ordered 
it,  in  combination  with  diuretics,  and  the  result  was  remarkable ; for 
on  the  next  day  not  only  had  the  fever  diminished,  but  the  urine  was 
increased  in  amount,  and  loaded  with  urates  to  an  extent  and  in  a form 
I had  never  previously  seen.  It  may  be  argued  that  the  fever  had  ter- 
minated by  a natural  crisis  on  the  seventh  day  ; but  I cannot  help  think- 
ing that  in  this  case  nature  was  assisted  by  the  colchicum  and  diuretics. 

I have  tried  the  wet  sheet  in  several  cases  of  scarlatina,  but  never 
could  satisfy  myself  that  it  either  shortened  the  progress  of  the  disease, 
or  mitigated  in  any  way  the  symptoms  of  the  patient.  In  the  summer 
of  1864,  Mr:  Thomas  Evans,  one  of  the  clinical  clerks,  was  good  enough 
to  make  a series  of  careful  observations  upon  the  pulse  and  temperature 
of  the  body,  before,  during,  and  after  the  wet  sheet  was  applied  in  three 
cases,  in  all  of  which  the  rash  was  present,  the  pulse  high,  and  the 
heat  of  skin  great.  They  appeared  to  me  favorable  cases  for  the  trial. 
The  following  are  the  results  : — 

Effects  of  the  “ Wet  Sheet  ” on  Pulse  and  Temperature  {of  Axilla)  in  Three  Cases  of 

Scarlatina. 


The  patients  were  wrapped  in  a sheet  wrung  from  cold  water,  which  was  afterwards 
surrounded  by  blankets,  etc.  The  observations  were  made  from  7 to  10  p.m., 
during  June  and  July  1864. 


Name,  etc. 

Case  CCLIX. 

Adamson, 
Female,  age  19— 
copious  rash  on 
trunk  and  ex- 
tremities on  aa- 
mission,  6th  day ; 
convalescent]  0th 
day. 

i 

Case  CCLX. 
Morrison, 

Female,  age  16— copious  rash 
on  trunk  and  extremities 
on  admission,  5th  day ; 
convalescent  10th  day. 

CaseCOLXI. 

Baxter, 

Female,  age  19 — scanty  rash 
appeared  on  legs  on  4th 
day— convalescent  9th  day. 

Day  of  fever.. . . 

6th  day 

7th  day 

6th  day 

7 th  day 

8th  day 

3d  day 

5th  day 

6th  day 

Length  of  time  \ 

sheet  was  ap-  > 

An  hour 

45  min. 

54  mm. 

45  mm. 

30  min. 

30  min. 

30  mm. 

30  mm. 

plied ) 

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Before  appli-  \ 

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cation  of  | 

138  lor 

130 

lOOf 

116 

1021° 

100 

101^° 

100  102° 

114 

104° 

100 

100|° 

83 

100}° 

sheet 1 

5 min.  after-  * 
wards 1 

— 

— 

- 

— 

- 

102i° 

- 

- 

92  101f° 

— 

92 

99^° 

73 

99}“ 

10  min 

_ 

_ 







102^° 

— 

— 

92  1011° 

— 

1 

92 

100° 

73 

99^ 

15  min 

— 

— 

— 

100° 

— 

102^° 

— 

loir 

92  101f° 

104  1014° 

94 

100}° 

76 

99^* 

?i0  Tnin 







100J° 

108 

102|° 



101^° 

96  102' 

104 

104° 

94 

100i° 

80 

99|* 

45  min 



_ 

_ 

102f° 

An  hour 

5 min.  after  \ 

taking  off  > 

94 

99i° 

76 

98^° 

sheet.. • ••*...  / 
10  min 

138 

lor 

102 

100^° 

96 

100° 

74 

98} 

15  miTi 





100J° 







104° 

92  104° 



ini» 

94 

100}° 

80 

994' 

30  min 

138 

101^“ 

_ 

1001° 

— 

102° 

— 

96  102° 

110  104° 

94 

1004° 

78 j 99}° 

An  hour 

' — 

— 

— 

1004° 

108  102^° 

— 

— 

96  102§° 

112  104° 

94 

100|" 

78 

99}° 

An  hour  and  ) 
half. S 

— 

— 

120  1001° 

- 

— 

- 

- 

94  102}° 

2 hours 

1 

2 hours  and  half  — 

1 

1004° 

ERYSIPELAS. 


961 


It  follows  from  these  observations  that,  as  regards  the  pulse,  it  was 
diminished  two  or  three  beats  after  the  sheets  had  been  applied  half  an 
hour,  but  that,  on  taking  it  off,  it  became,  in  another  half  hour,  exactly 
the  same  as  before  it  was  put  on.  With  regard  to  temperature,  the 
immediate  effect  of  the  sheet  was  to  produce  a diminution  of  half  a 
degree,  but  that,  after  thirty  minutes,  the  former  temperature  was 
regained.  On  taking  off  the  sheet,  the  temperature  sank  one  degree, 
but  in  thirty  minutes  had  again  risen  to  its  previous  standard ; in  an 
hour  and  a half  was  half  a degree  higher  ; and  in  two  hours  and  a half 
was  again  the  same  as  before.  Slight  diaphoresis  occasionally  occurred 
about  an  hour  after  taking  off  the  sheet.  I frequently  interrogated  these 
patients  as  to  whether  they  experienced  any  relief  from  its  application, 
and  it  was  clear  that  they  did  not.  They  were  pleased  on  its  removal, 
and  then  felt  cool  and  comfortable  for  a short  time,  but  soon  after  were 
as  warm  as  before.  In  short,  the  result  of  this  careful  trial  led  me  to 
the  impression  that  the  wet  sheet  in  scarlatina  was  of  no  benefit  whatever. 


Erysipelas. 

Case  CCLXIL* — Marion  Smails,  set.  28 — admitted  January  8th,  1851.  She  stated 
that  on  the  morning  of  the  6th  she  was  quite  well,  but  that,  after  being  out  for  some 
time,  she  felt  a burning  pain  in  her  left  cheek,  and  observed  a red  spot  upon  it.  This 
redness  gradually  extended  down  towards  the  neck,  and  was  accompanied  with  con- 
siderable swelling.  She  applied  a mustard  poultice  to  her  cheek,  which  relieved  the 
pain  somewhat  at  first,  but  afterwards  caused  a great  aggravation  of  it.  On  admis- 
sion, besides  the  local  pain,  she  complained  of  great  thirst  and  of  a bad  taste  in  her 
mouth.  The  tongue  was  moist ; bowels  regular ; pulse  66,  full  and  sti'ong.  The 
cheek  was  ordered  to  be  fomented  with  a lotion  of  lead  and  opium.  January  Wth. — 
Swelling  and  redness  are  much  less,  as  is  also  the  pain.  January  I'lth. — Redness  of 
the  skin  completely  disappeared.  Complains  only  of  a slight  soreness  in  the  throat. 
Dismissed  cured. 


Case  CCLXTII.f — James  Maclaren,  aet.  59,  a porter,  of  intemperate  habits — ad- 
mitted November  16th,  1851.  Eight  days  ago,  was  seized  with  rigors,  followed  by  in- 
tense febrile  symptoms,  which  prevented  sleep.  On  the  13th  he  experienced  pain  in 
the  left  side  of  his  nose,  accompanied  by  redness  of  the  integuments,  which  rapidly 
spread  over  the  cheek,  eye,  and  brow  of  the  same  side.  On  the  following  morning 
the  redness  appeared  on  the  right  cheek,  and  in  the  evening  had  covered  the  whole 
face.  On  admission  there  is  great  thirst;  loss  of  appetite;  furred  tongue ; hot  skin ; 
full  and  burning  pulse,  100  in  the  minute ; great  headache,  with  drowsiness ; tingling 
pain  in  the  face,  which  is  of  a deep  red  color,  in  some  places  approaching  purple.  The 
blush  extends  over  the  forehead  and  anterior  part  of  the  scalp,  and  pits  on  pressure. 
Two  bulljs  have  broken,  and  recently  formed  scabs  on  the  right  side  of  nose.  Ordered 
an  antimonial  saline  mixture^  and  the  face  to  he  dusted  with  flour.  November  VUh. — 
Last  night  there  was  low  muttering  delirium,  and  this  morning,  vomiting.  In  the 
evening,  pulse  of  the  same  frequency,  but  more  soft.  To  omit  the  mixture.  November 
\%th. — Redness  more  extended  over  the  scalp,  and  fresh  bullae  have  appeared  on  the 
forehead.  Pulse  80,  soft ; constipation.  To  have  § iij  q/  brandy  daily,  and  to  take 
at  present  half  an  ounce  of  castor-oil.  November  l^th. — To-day  much  better.  Pulse 
80,  of  good  strength  ; swelling  of  eyes  diminished  ; redness  fading ; bullae  scabbing. 
From  this  time  he  gradually  got  well,  and  was  dismissed  cured,  November  30th. 

Commentary. — The  first  of  these  cases  was  so  mild  as,  perhaps,  to 
merit  the  name  of  erythema.  The  latter  was  a very  severe  one,  occurring 
in  a man  of  intemperate  habits,  but  terminating  in  convalescence  on  the 
twelfth  day.  In  this  latter  case  a study  of  the  symptoms  will  show  we 


* Reported  by  Mr.  T.  M.  Lownds,  Clinical  Clerk, 
f Reported  by  Mr.  A.  L.  Mackay,  Clinical  Clerk. 


962 


DISEASES  OF  THE  BLOOD. 


have  again,  as  in  scarlatina,  all  the  phenomena  of  typhus  fever  ; and  when 
erysipelas  proves  fatal,  so  in  like  manner  it  is  by  coma  and  subsequent 
collapse.  Erysipelas,  however,  is  opposed  to  scarlatina,  in  being  the  least 
infectious  of  the  eruptive  fevers,  in  being  the  least  fatal,  and  in  running 
a much  slower  course.  In  many  other  respects  there  is  a close  analogy 
between  them  observable  in  the  kind  of  fever,  the  sequelae,  and  critical 
discharge  of  coagulable  urine.  The  general  indications  for  treatment  are 
the  same.  The  special  treatment  is  directed  by  means  of  topical  applica- 
tions to  diminish  the  local  inflammation.  For  this  purpose  numerous 
remedies  have  been  tried — such  as  dusting  the  part  with  flour,  lotion  of 
acetate  of  lead  and  opium,  cerates,  oil,  etc.  etc. — any  of  which  serve  the 
purpose  of  cooling  the  surface,  rendering  it  more  soft,  and  diminishing 
irritation. 

There  can  be  no  doubt  that  erysipelas  is  occasionally  a fatal  disease, 
from  the  intensity  of  the  fever,  and  amount  of  integument  involved.  It 
is  generally  supposed  that,  when  it  attacks  the  face  and  scalp,  it  is  more 
dangerous  than  when  a similar  amount  of  surface  in  any  other  part 
is  affected.  This  opinion  does  not  appear  to  be  founded  on  very  exact 
observation.  Even  when  the  scalp  is  extensively  invaded,  death  from 
erysipelas  is  a rare  occurrence.  On  going  round  the  wards  of  the  Hotel 
Dieu  in  May  1851  with  M.  Louis,  I saw  several  severe  cases  of  erysipe- 
las of  the  scalp,  which,  I was  told,  were  under  no  treatment  whatever — 
because,  as  M.  Louis  informed  me,  according  to  his  experience,  erysipelas 
of  the  scalp  was  never  fatal,  unless  it  occurred  in  individuals  of  bad  con- 
stitutions, or  was  associated  with  some  complication.  I need  not  say 
that  without  forming  any  such  exclusive  opinion  as  this,  it  must  be  very 
difficult,  in  a disease  that  so  generally  tends  to  recovery,  to  judge  how 
far  this  or  that  remedy  is  beneficial.  Mr.  Hamilton  Bell  has  recommend- 
ed fifteen  to  twenty-five  drops  of  the  Tr.  Ferri  Muriatis  every  second 
hour,  as  a most  beneficial  remedy  in  erysipelas.  But  how  this  medicine 
is  more  successful  than  the  spontaneous  operation  of  nature  he  did  not 
endeavor  to  demonstrate. 

Variola. 

Case  CCLXIY.* — Mary  Hogan,  aet.  7,  was  admitted  December  9th,  1851.  Never 
had  been  vaccinated.  Felt  slightly  indisposed  December  4th  ; and  on  the  following 
day  complained  of  severe  headache,  pain  in  the  back,  nausea,  loss  of  appetite,  and  great 
thirst.  These  symptoms  continued,  and,  on  the  afternoon  of  the  Vth,  a bright  red 
blush  was  observed  on  the  face  and  chest,  gradually  spreading  over  all  the  body.  On 
the  8th  the  red  blush  became  covered  with  numerous  minute  elevated  papulae  ; and  on 
the  9th  when  admitted,  numerous  vesicles  could  be  detected  on  the  face,  arms,  and 
legs.  Tongue  furred,  but  moist.  No  dysphagia.  TFus  ordered  a purgative  of  sul- 
phate of  magnesia,  December  IMh. — The  vesicles  are  numerous  and  close  together  on 
the  face,  and  in  some  places  confluent.  Eyelids  much  swollen  and  nearly  closed. 
Bowels  are  open ; pulse  140  ; tongue  florid.  The  hair  was  cut  short,  and  mild  mer- 
curial ointment,  thickened  with  starch,  spread  over  the  face.  She  was  also  vaccinated. 
December  12>th. — Pustules  fully  matured  and  umbilicated  over  the  trunk  and  extremi- 
ties. The  mercurial  paste  forms  a thick  indurated  crust  over  the  face.  December 
\Mh.  Many  of  the  pustules  over  the  body  have  burst  and  discharged  their  contents. 
No  constitutional  disturbance.  No  pain  or  itching  of  the  face;  all  swelling  of  the  eye- 
lids disappeared.  December  18^4. — Pustules  have  all  burst,  except  a few  on  the  feet. 
Was  dismissed  January  6th,  cured.  The  face  scarcely  presented  any  trace  of  the  dis- 
ease, and  afforded  a remarkable  contrast  to  those  other  parts  of  the  skin  which  had 
not  been  covered  with  the  paste. 

* Reported  by  Mr.  J.  L.  Brown,  Clinical  Clerk. 


VARIOLA. 


963 


Case  CCLXV.* — Michael  Hogan,  aet.  9,  admitted  December  10, 1851,  a brother  of 
die  former  case,  and  also  never  vaccinated,  Felt  unwell  on  the  8th,  with  shivering, 
pain  in  the  head,  and  unusual  febrile  symptoms.  On  the  next  day  vomited,  and  then 
observed  an  eruption  on  tiie  skin.  On  admission,  the  face,  trunk,  arms,  and  legs  are 
spotted  with  bright  papules  at  considerable  distance  from  each  other,  and  he  says  the 
fever  has  considerably  abated.  On  the  16th  the  pustules  on  the  face  were  fully  ma- 
tured, and  here  and  there  a few  of  them  were  observed  to  be  confluent.  On  the  18th 
those’on  the  inferior  extremities  were  in  the  same  condition.  Last  night  he  experi- 
enced again  considerable  headache,  and  to-day  the  pulse  is  120,  full ; the  skin  hot,  and 
febrile  symptoms  well  developed.  19i:A.— Headache  violent  last  night,  with  great 
restlessness  and  insomnia ; but  to-day  these  symptoms  have  abated.  From  this  time 
convalescence  commenced,  but  he  recovered  slowly,  and  was  not  strong  enough  to  go 
out  until  January  19th.  A few  pits  existed  on  the  face,  where  the  pustules  had 
been  confluent. 

Commentary. — The  general  treatment  of  small-pox  is  similar  to  that 
of  the  other  eruptive  fevers.  There  is  a special  treatment,  however, 
applicable  to  it,  which  deserves  some  consideration. 

The  Ectrotic  Treatment  of  Variola. 

Various  methods  have  been  proposed  for  the  purpose  of  arresting 
the  development  of  the  eruption  in  variola,  and  preventing  the  cicatrices 
which  are  likely  to  form.  The  treatment,  called  ectrotic  {^iKrirpMcrxoy,  to 
render  abortive),  has  been  practised  principally  in  France.  Serres, 
Bretonneau,  and  Velpeau,  cauterised  each  vesicle  as  it  appeared  with 
nitrate  of  silver,  which  immediately  arrests  its  further  progress.  This  is 
a very  tedious  process,  while  painting  the  surface  with  a solution  of  the 
caustic  causes  so  much  pain  and  febrile  disturbance  that  it  cannot  be 
safely  employed.  Sir  Joseph  Oliffe,  of  Paris,  recommended  the  vigo- 
plaster  of  the  French  Pharmacopoeia;  and  having  seen,  in  some  of  the 
journals,  that  mercurial  ointment,  thickened  with  starch,  had  proved 
very  serviceable  in  the  practice  of  M.  Briquet  and  others,  in  the  Paris 
hospitals,  I tried  it  in  numerous  cases  which  were  admitted  into  the 
wards,  and  have  seen  the  good  effects  of  the  practice.  The  two  cases 
you  have  just  had  an  opportunity  of  observing,  however,  especially 
demonstrate  this.  Case  CCLXIV.  presented  the  most  confluent  form 
of  the  disease  I ever  saw.  The  entire  face  was  so  crowded  with  the 
papules  and  minute  vesicles  of  the  incipient  stage,  that  there  was 
literally  not  room  to  place  a pin’s  head  anywhere  on  the  sound  skin.  It 
was  evident  that  the  whole  surface  of  the  face  would  be  one  mass  of 
suppuration ; and  such  of  you  as  have  had  an  opportunity  of  observing 
a similar  case  of  the  disease  must  be  aware  of  its  horrible  aspect,  the 
excessive  agony  produced,  the  great  swelling  of  the  eyelids,  the  dreadful 
suppuration  and  foetor  of  the  discharge,  the  violent  secondary  fever, 
and  the  frightful  cicatrices  with  which  the  countenance  is  afterwards 
covered.  In  this  case  none  of  these  symptoms  were  present,  and  there 
can  be  no  doubt  that  the  ectrotic  treatment  really  checked  the  progress 
of  suppuration  and  modified  the  disease.  From  the  moment  the  plaster 
was  applied,  all  smarting  and  pain  in  the  face  ceased ; the  eyelids 
were  never  swollen  ; no  suppuration  occurred ; there  was  no  secondary 
fever ; and  on  the  mask  leaving  the  face  there  was  no  pitting  or  suppu- 
ration. In  other  parts  of  the  body  the  eruption  passed  through  its 

* Reported  by  Mr.  W.  M.  Calder,  Clinical  Clerk. 


964 


DISEAS'ES  OF  THE  BLOOD. 


usual  stages,  and  the  girl  was  dismissed  from  the  house  well,  thirty  days 
after  the  first  commencement  of  the  eruption.  Considering  this  case  was 
likely  to  be  a very  severe  one,  I felt  myself  authorised  to  use  every 
means  in  my  power  to  check  the  disease ; and  as  it  has  been  asserted 
that  vaccination,  even  after  the  commencement  of  the  eruption,  modifies 
its  progress,  I caused  the  girl  to  be  vaccinated  on  first  seeing  her.  At 
that  time  the  face,  as  we  have  seen,  va^  closely  covered  with  papulse  and 
vesicles ; and  I do  not  think  that  vaccination  alone  could  have  produced 
the  remarkable  result  we  have  witnessed.  I do  not  mean  to  deny  alto- 
gether the  influence  of  vaccination  in  such  cases,  but  I have  no  hesitation 
in  ascribing  the  beneficial  result  almost  entirely  to  the  ectrotic  treatment. 

To  satisfy  yourselves  still  more,  if  possible,  as  to  the  great  advan- 
tage of  this  treatment,  the  case  of  the  boy  (Case  CCLXV.)  may  be  con- 
trasted with  that  of  the  girl  (CCLXIV.)  who  also  had  never  been  vacci- 
nated. His  was  evidently  a very  mild  case,  the  eruption  discrete,  and 
t.he  constitutional  disturbance  slight.  I allowed  it  to  run  its  natural 
course,  and  the  result  was  in  every  respect  different  from  that  in  which 
the  plaster  had  been  applied  to  the  face.  The  secondary  fever  was  toler- 
ably smart,  the  subsequent  prostration  proportionally  severe ; recovery 
was  delayed  to  the  thirty-ninth  day,  and  notwithstanding  the  generally 
discrete  character  of  the  eruption  a few  pits  existed  on  the  face. 

Since  I first  practised  this  ectrotic  treatment  in  small-pox,  I have 
met  with  numerous  instances  in  which  slight  salivation  followed  the 
use  of  the  mercurial  plaster.  Dr.  George  Paterson,*  formerly  of 
Tiverton,  however,  published  a case  in  which  salivation  from  the  em- 
ployment of  the  strong  mercurial  ointment  was  excessive  and  danger- 
ous. I quite  agree  with  that  physician  in  thinking  the  occasional 
occurrence  of  such  violent  salivation  would  seriously  compromise  the 
otherwise  remarkable  advantages  of  the  ectrotic  treatment. 

But  it  may  be  asked  whether,  after  all,  the  mercury  is  in  any  way 
necessary  to  the  success  of  this  treatment.  Its  original  propounders  in 
Paris  may  indeed  have  supposed  that  the  absorbent  powers  of  the  drug 
constituted  the  true  cause  of  its  success,  but  it  seems  to  me  that  another 
explanation  may  be  ofiered.  There  is,  for  instance,  a close  analogy 
between  the  mode  of  healing  of  wounds  and  ulcers,  so  well  described  by 
Dr.  Macartney  of  Dublin — that  is,  the  so-called  “ modelling  process  ” — 
and  what  takes  place  in  the  ectrotic  treatment  of  small-pox.  In  the 
former,  cicatrices  are  far  less  liable  to  be  produced  than  after  healing  by 
the  first  or  second  intention,  and  in  the  latter  the  pitting  or  cicatrisation 
is  prevented.  The  artificial  plaster  therefore  takes  the  place  of  the 
natural  scab  or  clot  of  blood,  protects  the  parts  below,  and  enables  them 
to  heal  slowly  but  more  perfectly  than  if  exposed  to  the  air  uncovered 
and  uncompressed  by  superjacent  crusts.  If  this  be  the  correct  theory  of 
the  ectrotic  treatment,  the  mercurial  might  be  discarded,  and  any  kind  of 
plaster  which  would  concrete  on  the  face  might  be  expected  to  produce 
the  same  beneficial  results.  In  1854  I determined  to  try  the  effects  of 
such  a plaster,  and  after  two  or  three  failures  succeeded  in  procuring  one 
that  answers  perfectly.  The  first  case  I treated  with  simple  lard,  thickened 
with  starch  and  powdered  charcoal,  but  it  was  so  little  coherent,  that 
* Monthly  Journal,  Dec.  1852. 


VARIOLA. 


965 


the  patient,  during  the  night,  rubbed  it  off  on  her  pillow  or  with  her 
hands,  and  on  her  recovery  she  was  pitted  all  over.  In  auother  case  I 
tried  carbonate  of  magnesia  saturated  with  oil.  But  this  also  failed. 
In  a third  case,  however,  common  calamine  {zinci  carhonas),  saturated 
with  olive  oil  (proposed  by  Mr.  Bird,  one  of  the  clinical  clerks),  formed 
a coherent,  tough  crust,  which  remained  on  the  face,  and  was  found  to 
answer  well.  Numerous  cases  of  natural  small-pox  have  been  since 
treated  in  this  manner,  with  the  result  not  only  of  preventing  the  pitting, 
but  of  diminishing  the  local  and  general  symptoms,  exactly  in  the  same 
manner  as  I have  formerly  detailed  as  being  the  effect  of  the  mercurial 
plaster.  The  following  is  one  of  these  ; — 

Case  CCLXVI.* — Alexander  Ross,  ast.  13,  never  been  vaccinated,  was  seized  with 
shivering  on  the  7th  January,  followed  by  the  usual  symptoms  of  fever.  Entered  the 
Infirmary  on  the  9th,  when  a few  papules  were  observed  on  the  face  and  arms.  On 
the  12  th  the  face  was  thickly  covered  with  vesicles,  which  from  their  closeness  would 
certainly  have  become  confluent.  The  mask  of  calamine  and  oil  was  now  applied. 
The  disease  ran  its  usual  course,  the  eruption  being  confluent  on  the  arms  and  trunk. 
Throughout  the  progress  of  the  case  the  application  of  calamine  saturated  with  oil 
preserved  a firm  and  coherent  crust,  and  was  renewed  from  time  to  time.  The  patient 
experienced  no  smarting  of  the  face,  there  was  no  swelling  of  the  eyelids,  no  purulent 
discharge,  or  local  unpleasant  symptoms  of  any  kind.  The  secondary  fever  was 
tolerably  smart,  delirium  being  present  two  days.  On  the  22d  the  mask  came  off, 
leaving  a clean  smooth  surface,  free  from  all  trace  of  pitting.  Dismissed  quite  well  on 
the  26  th. 

The  following  formula,  after  numerous  trials,  has  been  found  to  con- 
stitute a most  efficient  plaster  : — Carbonate  of  zinc,  3 parts;  oxide  of 
zinc,  1 part,  rubbed  in  a mortar  with  olive  oil  to  a proper  consistence. 
Dr.  Wallace  of  Greenock,  in  pursuing  this  treatment,  ascertained  that 
the  tincture  of  iodine,  which  has  been  recommended  as  an  ectrotic,  is  of 
little  use,  and  was  led  to  employ,  as  the  best  application,  a solution  of 
gutta  percha  in  chloroform,  first  used  by  Dr.  Stokes,  and  recommended 
by  Dr.  Graves  of  Dublin.  This  answers  very  well,  but  caoutchouc,  from 
being  more  ductile,  is  still  better. 

The  general  subject  of  small-pox  opens  up  to  our  consideration  a 
multitude  of  facts,  of  which  we  may  notice  three. 

1.  There  can  be  very  little  doubt  that  of  late  years  small-pox  has 
again  become  frequent  amongst  us,  a circumstance  which  some  have 
attributed  to  a deterioration  of  the  vaccine  lymph.  That  this  cause  does 
operate  to  a certain  extent  is  very  probable ; but,  for  my  own  part,  I 
have  been  led  to  the  conclusion,  that  the  terror  of  the  disease  which 
formerly  prevailed  among  the  public,  has,  through  the  protective  dis* 
covery  of  Jenner,  and  the  energy  with  which  vaccination  was  originally 
pursued,  in  a great  measure  declined,  and  that  this  is  the  principal 
cause.  For  some  time  multitudes  of  the  lower  orders  did  not  have  their 
children  vaccinated,  and  hence  why  our  hospitals  are  so  frequently 
encumbered  with  cases  such  as  those  we  have  just  witnessed.  The 
universal  feeling  that  we  had  no  remedy  for  this  but  rendering  vaccina- 
tion imperative  by  penal  enactments  at  length  led  to  the  Vaccination 
Act,  of  which,  as  it  has  only  been  in  operation  since  last  June,  it  would 

* Reported  by  Mr.  Bird,  Clinical  Clerk. 


966 


DISEASES  OF  THE  BLOOD. 


be  premature  to  speak.  I am  informed,  however,  by  Dr.  Husband,  who 
takes  charge  of  the  vaccinations  of  the  Royal  Dispensary  of  this  city, 
that  the  Act  is  working  well.  Each  parent,  on  registering  the  birth  of 
a child,  receives  a notice  that,  unless  it  be  vaccinated  before  the  expiry 
of  six  months,  a penalty  of  one  pound  will  be  inflicted.  This  has  been 
found  amply  sufiicient.  The  people  generally  admit  the  propriety  of  the 
law,  and  readily  bring  their  children  to  submit  to  the  operation.  A 
large  increase  in  the  vaccinations  has  already  been  established,  and  the 
best  results  may  be  anticipated. 

For  the  mode  of  vaccination,  I must  refer  you  to  the  account  given 
in  systematic  works  on  the  practice  of  medicine.  It  consists, 
as  you  know,  of  making  a puncture  just  sufficient  to  penetrate 
the  epidermis  of  the  skin,  and  to  enable  the  vaccine  lymph  to 
be  applied  to  the  vascular  dermis.  For  doing  this  surely  and 
rapidly,  the  little  instrument  I now  show  you,  invented  by  Dr. 

G-raham  Weir,*  is  the  best  you  can  employ.  It  consists  of  a 
small  handle  of  ivory,  with  four  needle  points  projecting  from 
one  extremity,  and  a small  curved  knife  for  collecting  and  sepa- 
rating the  vaccine  matter  at  the  other  (as  shown  in  the  cut). 

The  skin  is  opened  by  a crucial  scratch  with  the  needle  points, 


'jyi'f Clab/i  J8s^6 


-T-T+ 


Fig.  533. 

simple  invention 


of 


i 

h 

Fig.  534. 

Dr.  Husband. 


It 


which  are  held  verti- 
cally, and  are  lightly 
applied,  so  as  merely 
to  remove  the  cuticle. 

The  advantages  of 
this  instrument  over 
the  lancet  are  said  to 
be  that  the  operation 
is  done  more  speedily, 
and  that  it  opposes  a 
larger  surface  for  the 
absorption  of  the 
lymph.  The  lancet, 
however,  is  still  pre- 
ferred in  the  hands  of 
some  skilled  practi- 
tioners. In  all  cases  the  lymph 
is  more  liable  to  be  washed 
away  when  too  great  an  effusion 
of  blood  has  been  caused. 

The  method  of  preserving 
lymph  is  a matter  of  great  na- 
tional importance,  and  has 
been  much  improved  by  the 
consists  in  employing  straight 


Fig.  532. 


* Monthly  Journal,  184Y-48,  p.  69. 


Fig.  532.  Dr.  Weir’s  scarificator  for  vaccination.  Real  size. 

Fig.  533.  Dr.  Husband’s  tubes  charged  with  vaccine  lymph,  and  their  extremities 
hermetically  sealed — (a),  various  kinds  of  tubes  ; lymph  should  not  be  introduced  at 
an  expanded  end  {b) ; (c),  charged  from  two  cases  ; (c^),  charged  from  three  cases. 

Real  size. 


VARIOLA. 


967 


glass  tubes,  from  2|  to  3 inches  long,  and  l-28thof  an  inch  in  diameter, 
which,  when  dipped  nearly  horizontally  into  the  vaccine  matter,  permit 
its  entrance  by  capillary  attraction.  The  two  ends  of  the  tube  are  then 
closed  by  simply  melting  the  glass  with  the  flame  of  a candle  or  of  a 
gas  jet  (Fig.  533).  When  used,  the  two  ends  of  the  tube  are  broken 
off,  and  the  lymph  blown  out  on  the  punctured  or  scratched  arm.  Dr. 
Husband  informs  me  that  experience  has  shown  that  good  lymph  may  be 
preserved  in  this  way  for  two  years,  even  in  warm  climates,  with  the  cer- 
tainty of  succeeding  in  90  per  cent,  of  the  cases  in  which  it  is  used.  This 
failure  of  one  case  in  10  may  be  still  further  reduced  one-half  by  charg- 
ing the  glasses  from  two  cases  instead  of  one  (Fig.  534,  c).  It  may  be 
even  charged  from  three  or  more  cases  (Fig.  534,  d) ; and,  by  blowing 
each  portion  out  on  separate  punctures,  the  chances  of  failure  are  still 
further  diminished.^  It  is  admitted  that  the  system  now  so  generally 
practised  at  the  various  stations  throughout  the  country,  of  vaccinating 
from  arm  to  arm — when  the  lymph  is  quite  fresh — admits  of  very  few 
failures. 

2.  Sometimes  small-pox  occurs  epidemically  in  a remarkably  benign 
form.  It  then  presents  all  the  characters  described  by  some  authors  as 
varioloid.  Occasionally  it  occurs  twice,  or  becomes  what  is  called  re- 
current ; and  it  has  been  known  to  arise  frequently  after  vaccination. 
In  all  these  circumstances,  when  mild,  it  so  resembles  chicken-pox  as 
not  to  be  distinguished  from  it.  But  more  than  this,  it  was  observed  in 
the  epidemic  that  prevailed  in  Edinburgh  in  1819  and  1820,  that  small- 
pox and  chicken-pox  existed  together  frequently  in  different  individuals 
inhabiting  the  same  room,  and  sleeping  in  the  same  bed.  Well-authenti- 
cated cases  occurred  of  individuals  inoculated  with  small-pox  in  whom 
the  eruption  assumed  the  appearance  of  chicken-pox  ; and  again  persons 
inoculated  with  chicken-pox  had  small-pox  well  characterised.  The 
work  of  Dr.  John  Thomson,  entitled  “ An  Account  of  the  Varioloid 
Epidemics  in  Scotland,  1820,”  contains  many  facts  of  this  description, 
which  were  well  known  at  the  time,  and  an  account  of  numerous  experi- 
ments carried  on  in  the  Castle  garrison  of  this  place,  which  have  never 
been  controverted,  and  which  fully  establish  an  essential  unity  in  the 
nature  of  the  two  affections.  It  is  evidently  inconsistent  to  suppose 
that  two  distinct  contagions  should  exist  at  the  same  time,  each  of  which 
is  protective  against  the  other.  Those  who  admit  this  doctrine  must 
maintain  that,  whenever  the  chicken-pox  contagion  prevailed,  the  small- 
pox contagion  was  excluded,  or  the  reverse ; or,  on  the  other  hand,  they 
must  admit  that  variola  is  produced  by  the  same  contagion  that  gives 
rise  to  chicken-pox.  The  work  of  Dr.  Thomson  furnishes  ample  proof 
of  the  correctness  of  the  latter  proposition.  Dr.  Gregory  and  others 
who  oppose  this  opinion  do  so  on  the  ground  of  the  incubative  stage 
being  shorter,  the  whole  disease  less  prolonged,  and  the  constitutional 
symptoms  being  mild.  These  circumstances,  you  will  observe,  only 
point  to  difference  of  degree  and  intensity,  not  of  kind.  Dr.  Gregory 
also  alleges  that  he  has  seen  variola  occur  after  cow-pox,  and  cow-pox 

* See  Exposition  of  a Method  of  Preserving  Vaccine  Lymph,  etc.,  by  William 
Husband,  12mo,  Edinburgh,  1860;  and  Second  Report  of  the  Medical  Officer  of  the 
Privy  Council,  1860. 


968 


DISEASES  OF  THE  BLOOD. 


after  variola,  and  therefore  they  cannot  be  identical.  So  far,  however, 
does  this  appear  to  me  no  argument,  that,  if  possible,  it  confirms  Dr. 
Thomson’s  observations.  The  variola  he  speaks  of  occurring  after  cow- 
pox  is  evidently  modified  small-pox;  and  cow-pox  may,  in  the  majority 
of  cases,  be  reproduced  at  pleasure. 

3.  Dr.  Jenner,  through  life,  was  of  opinion  that  cow-pox,  the  grease 
in  horses,  swine-pox,  and  small-pox,  were  only  modifications  of  each 
other.  He  believed  that  in  giving  to  man  cow-pox,  he  was  in  reality 
giving  to  him  small-pox  in  its  primitive  and  mildest  form.  Whether 
cow-pox  or  small-pox  is  the  original  form  has  been  disputed.  It  occurs 
to  me  as  more  probable  that  cattle  caught  it  from  man,  rather  than  man 
from  cattle — an  opinion  confirmed  by  the  experiments  of  Mr.  Ceely  of 
Aylesbury,  recorded  in  the  “ Transactions  of  the  Provincial  Medical  and 
Surgical  Association”  (vols.  viii.  and  ix.)  He  showed  that,  by  operating 
on  the  mucous  surfaces  of  the  animal,  the  cow  readily  receives  the  poison 
of  human  small-pox,  which  the  constitution  of  the  animal  converts  into 
the  vaccine.  I need  not  enter  at  length  into  the  discussion  which  has 
been  raised  on  this  subject.  Suffice  it  to  say,  that  the  identity  of  the 
two  diseases  appears  to  me  to  be  established  by  the  following  incontro- 
vertible facts : — 

1.  The  prevalence  at  the  same  period  of  the  cow-pox  among  cattle, 
and  the  small-pox  among  men. 

2.  The  transmission  by  contagion  of  the  small-pox  to  cattle,  and  the 
consequent  development  of  cow-pox  in  those  animals. 

3.  The  transmission  by  inoculation  of  the  small-pox  to  cattle,  and  the 
resulting  development  of  cow-pox  in  those  animals. 

4.  The  transmission  by  inoculation  of  the  cow-pox  to  man,  and  the 
development  thereby  of  a pustule  similar  in  character  to  the  vaccine  pox 
of  the  cow. 

5.  The  transmission  by  inoculation  of  the  cow-pox  to  man,  and  the 
consequent  development  of  an  eruption  similar,  if  not  identical  with 
small-pox. 

All  these  propositions  have  been  established  by  numerous  facts,  which 
you  will  find  ably  stated  in  the  “ Report  of  the  Vaccination  Section  of 
the  Provincial  Medical  Association.”  See  also  Mr.  Simon’s  Government 
Report  on  the  “ History  and  Practice  of  Vaccination,  1857.” 


DIPHTHERIA. 

Case  C C LX VII.* — Diphtheria — Recovery, 

History. — Isabella  Speers,  aet.  81,  married — admitted  January  6th,  1865.  The 
patient  had  scarlatina  when  a child,  and  has  been  somewhat  deaf  ever  since,  but  other- 
wise remarkably  healthy,  till  her  present  illness.  On  18th  December  1864  she  lost  a 
child  from  “ diphtheria,”  and  on  the  22d  she  began  herself  to  complain  of  pain  in  the 
throat,  accompanied  with  difficulty  in  deglutition.  On  the  24th,  two  medical  men 
saw  her,  and  prescribed  for  her  a gargle  of  dilute  Condy’s  solution — a mixture  con- 
taining chlorate  of  potash,  also  Tr.  ferri  muriatis  and  brandy,  at  the  same  time 


* Reported  by  Mr.  W.  Johnston,  Clinical  Clerk. 


DIPHTHERIA. 


969 


applying  caustic  to  the  throat.  About  31st  December  four  dirty  white  patches 
appeared  on  her  lower  lips,  and  two  small  ones  under  the  tongue,  which  were  also 
treated  with  caustic ; but  her  throat  continuing  to  get  worse,  she  applied  for  admis- 
sion to  the  Royal  Infirmary. 

Symptoms  on  Admission.— The  posterior  wall  of  pharynx  and  the  greater  part  of 
both  tonsils  are  covered  with  patches  of  yellowish  white  purulent-looking  matter, 
a little  of  which,  when  removed,  is  found  to  be  very  tough,  and  when  subjected  to 
microscopic  examination  is  seen  to  be  composed  of  pus-cells  embedded  in  mucus. 
Great  difficulty  and  pain  on  deglutition.  Appetite  bad.  Headache.  Patient  is  very 
deaf,  and  her  spirits  depressed.  Voice  reduced  to  a whisper.  Pulse  130,  smaU  and 
weaL  Urine  copious.  No  albumen.  Other  functions  normal.  Ordered  an  injection 
of  four  ounces  of  beef -tea  and  one  ounce  of  wine  four  times  a day.  Her  throat  to  he 
gargled  with  diluted  Condfs  liquid,  and  poultices  to  he  applied  externally. 

Progress  of  the  January  lO^A.— The  patient’s  throat  looks  cleaner,  and 

she  expresses  herself  as  feeling  on  the  whole  easier.  To  have  some  arrow-root  with 
milk  and  beef-tea,  and  the  injections  twice  a day.  From  this  time  the  patient  began 
to  mend  both  in  strength  and  spirits.  The  nutritive  enemata  were  suspended  on  the 
20th  January,  as  she  was  then  able  to  swallow  a sufficient  quantity  of  food.  On  the 
7th  February  she  was  dismissed  quite  well,  except  that  her  voice  was  still  rather  husky. 

Case  CCLXVIII.^ — Diphtheria  complicated  with  SmallrPox — Death — 
Diphtheritic  membrane  covering  the  Mucous  Membrane  of  the  Pharynx^ 
Epiglottis,  Larnyx,  Trachea,  and  Right  Bronchus — Pulmonary  Apo- 
plexy. 

History. — Francis  Carroll,  aet.  28,  married,  performer  in  a circus — admitted  No- 
vember 18th,  1860.  Has  enjoyed  general  good  health  up  to  the  14th  instant,  when 
in  the  afternoon  he  felt  a sensation  ot‘  weight  in  the  abdomen  succeeded  by  a restless 
night.  On  the  following  morning  he  experienced  shooting  pains  in  the  back  and 
limbs,  headache,  nausea,  loss  of  appetite,  and  great  thirst.  He  went  to  a I’ehearsal 
at  the  circus  notwithstanding,  when  he  was  seized  with  shivering  and  vomiting,  and 
went  home  to  bed.  On  the  following  day  he  took  a warm  bath,  and  noticed  red 
spots  upon  his  face,  arms,  and  legs.  From  the  commencement  there  has  been  coryza, 
cough,  and  expectoration,  which  on  the  morning  of  his  admission  was  tinged  with 
blood. 

Symptoms  on  Admission. — The  face  is  swollen,  of  a dusky  red  color,  dotted  over 
with  very  closely  set  elevated  purple  and  red  papules,  mingled  with  vesicles  and  pus- 
tules the  size  of  small  peas,  some  of  which  are  depressed  in  the  centre.  Over  the  chest, 
abdomen,  groins,  and  extremities,  are  livid  and  dusky  red  patches,  also  dotted  over 
with  smaller  pustules,  which  are  very  numerous  in  the  groins.  The  tongue  is  foul, 
the  gums  spongy,  tonsils  swollen,  fauces  and  pharynx  covered  with  what  appears  to 
be  a dirty  slough.  Complains  of  sore  throat  and  difficulty  of  deglutition.  No 
appetite  ; great  thirst ; no  nausea  or  vomiting.  Bowels  freely  open  just  before  ad- 
mission. Pulse  100,  weak.  Heart’s  sounds  normal.  There  is  much  cough.  Is  con- 
stantly spitting  a watery  frothy  fluid,  tinged  with  blood.  On  percussion  there  is 
dulness  over  the  lower  third  of  right  lung,  posteriorly,  where  there  is  crepitation, 
tubular  breathing,  and  increased  vocal  resonance.  Over  the  chest  generally  inspira- 
tion is  harsh,  and  expiration  prolonged.  No  headache  or  wandering  of  mind.  Sleep 
disturbed.  Urine  high  colored  and  turbid,  of  natural  quantity,  coagulable  by  heat 
and  nitric  acid,  and  deficient  in  chlorides.  R Pot.  Acetatis  3 ij  ; Sp.  fEiher.  Nit.  3 ij  ; 
Mist.  Camph.  § vss.  Ft.  Mist.  A table-spoonful  to  be  taken  three  times  daily.  R Sodce 
Chloruret.  |j;  Aquae  § xi.  Ft.  gargarisma.  To  be  used  frequently.  Beef -tea  for 
drink.  Wine  | iv  a day. 

Progress  op  the  Case. — November  20<7i. — Tongue  brown  and  dry.  Lips  and 
teeth  covered  with  sordes.  Has  taken  nourishment  well.  Pulse  at  the  visit  74,  of 
good  strength.  Sibilations  heard  all  over  the  chest.  Pustules  on  the  skin  more 
raised  and  umbilicated.  Throat  and  other  symptoms  the  same.  Has  experienced 
considerable  relief  from  sucking  lumps  of  ice.  Urine  the  same.  Face  to  be  smeared 
frequently  with  oil.  Nov.  21s^. — No  change.  Nov.  22c7. — Very  restless  during  the 


* Reported  by  Mr.  C.  Henry  Allfrey,  Clinical  Clerk. 


970 


DISEASES  OF  THE  BLOOD. 


night.  Cough  incessant.  Sputa  less  abundant  but  more  tenacious,  and  of  dirty  red- 
dish  color.  The  whole  of  the  mouth  and  fauces  covered  with  a dirty  slough,  emitting 
an  oflensive  odor.  Face  more  swollen,  covered  with  brown  crusts  from  the  dried 
confluent  pustules ; the  intervening  skin  of  a dusky  red  color,  in  some  places  livid. 
Lips  and  teeth  black  from  collection  of  sordes.  Can  still  swallow  beef-tea  and  wine 
readily.  Urine  still  coagulable.  Pulse  100,  weak.  To  have  half  a teacupful  of  heef- 
tea  with  a dessertspoonful  of  wine  every  half  hour.  Nov.  23c?. — Pulse  stronger. 
Pustules  somewhat  enlarged,  though  still  very  small  over  trunk  and  limbs  ; in  many 
places  confluent.  Face  covered  with  a uniform  brown  crust,  excoriated  below  the  eye- 
lids, which  are  much  swollen  and  closed.  Skin  generally  of  a dusky  red,  in  some  places 
livid.  Deglutition,  though  difficult,  still  performed.  Dyspnoea  commencing.  A table- 
spoonful  of  brandy  every  hoar.  Continue  nutrients.  Nov.  2^th. — Died  at  6 p.m. 

Sectio  Cadaveris. — Forty-two  hours  after  death. 

The  surface  of  the  body  presented  a copious  variolar  eruption,  consisting  of  small, 
flat,  imperfectly-filled  pustules.  The  skin  of  the  face  was  covered  with  a brownish 
sanguiuolent  crust. 

Throat  and  Thorax. — The  tongue  was  enveloped  with  a dirty  blackish-brown 
soft  crust.  The  whole  mucous  membrane  of  the  velum  palati,  tonsils,  fauces,  and 
pharynx,  was  covered  with  a dirty  grayish  exudation,  in  some  places  of  a broAvn  tint, 
which  on  being  scraped  off  exhibited  a mahogany  red  and  softened  mucous  texture 
below.  The  epiglottis  was  very  vascular,  and  partially  coated  with  the  same  mem- 
brane, which  extended  half  down  the  oesophagus,  throughout  the  larynx  and  trachea, 
and  could  be  traced  to  the  end  of  the  large  divisions  of  the  right  and  left  bronchi. 
The  right  pleurae  were  united  by  chronic  adhesions.  The  lower  third  of  right  lung 
posteriorly  was  infiltrated  and  indurated  with  extravasated  blood,  presenting  on  sec- 
tion a smooth,  dark  purplish-red  color.  Various  other  patches  of  coagulated  blood, 
varying  in  size  from  a hazel-nut  to  a walnut,  were  scattered  throughout  both  lungs. 
The  bronchi  throughout  were  loaded  with  a dh’ty  purulent  fluid.  The  heart  and  peri- 
cardium were  normal.  The  clots  of  blood  everywhere  very  soft. 

Abdomen. — Abdominal  organs  healthy.  Spleen  firm. 

Commentary, — The  two  cases  here  recorded  are  examples,  in  dilferent 
degrees,  of  an  affection  which,  though  previously  known  in  most  coun- 
tries under  the  name  of  sloughing  or  putrid  sore  throat,  angina  maligna, 
etc.,  was  first  called  diphtheritis  (Brettoneau),  and  now  diphtheria,  from 
the  parchment-like  membrane  which  covers  the  mucous  passages  of  the 
fauces  and  throat  As  it  occurs  epidemically,  is  frequently 

rapid  in  its  progress,  appears  to  be  infectious,  and  causes  profound 
alteration  of  the  system,  it  is  generally  considered  as  a blood  disease. 
On  commencing,  it  is  not  to  be  separated  from  tonsillitis  or  ordinary  sore 
throat.  But  when  it  occurs  generally  among  communities,  and  espe- 
cially in  schools,  its  presence,  if  a sloughing  tendency  be  manifested, 
may  be  suspected.  In  severe  cases  a dirty  gray  or  tough  purulent  layer 
of  matter  spreads  rapidly  over  the  tonsils,  uvula,  and  pharynx,  not 
unfrequently  over  the  internal  surface  of  the  mouth,  and  occasionally  of 
the  larynx  and  trachea.  It  may  or  may  not  be  accompanied  with  fever, 
but  sooner  or  later  causes  exhaustion  from  the  difficulty  it  creates  to  the  re- 
ception of  nourishment.  Mr.  Wade,  of  Birmingham,  pointed  out  the  very 
frequent  presence  of  albuminuria  as  a concomitant.  The  disease  is  very 
rare  in  the  Boyal  Infirmary,  where  I have  only  seen  one  other  case  of 
it  in  addition  to  those  above  reported,  in  which  also  it  was  associated 
with  small-pox.  In  private  practice  in  Edinburgh,  however,  it  is  more 
common.  I have  never  seen  the  membrane  to  contain  a fungus  such  as 
has  been  described  by  some  authors,  although  I am  quite  familiar  with 
it  in  the  muguet,  so  common  in  the  infants  of  foundling  hospitals 
abroad — a disease  which  bears  a close  analogy  to  diphtheria  (see  Fig.  53). 


SYPHILIS. 


971 


With  regard  to  treatment,  I Have  not  found  the  application  of  caustic, 
either  solid  or  in  solution,  to  the  diseased  part,  of  any  benefit.  On  the 
contrary,  I think  iced  water  in  the  incipient  stage,  and  subsequently 
inhalations  of  steam,  relieve  more.  Poultices  externally,  and  diuretics 
internally,  when  albuminuria  is  present,  are  directly  indicated  (see 
p.  826).  Above  all,  supporting  the  strength  with  nutrients  and  resto- 
ratives, so  as  to  gain  time  and  enable  the  disease  to  run  through  its 
natural  progress,  is  the  chief  point  to  be  attended  to.  In  case  CCLXVII. 
I believe  life  was  preserved  by  maintaining  the  patient  for  a week  on 
nutritive  enemata.  Case  CCLXVIII,  was  one  of  the  most  frightful  I 
ever  witnessed,  and  its  extent,  not  to  speak  of  the  complicated  variola  and 
pulmonavy  disease,  stamped  it  as  fatal  from  the  commencement.  I have 
seen  diphtheria  associated  with  scarlatina.  When  the  larynx  is  diseased 
and  respiration  affected,  laryngotomy  should  be  tried,  which,  in  the  prac- 
tice of  l)r.  Jenner,  of  Dr.  M’Leod  of  Glasgow,  and  others,  has  saved 
several  lives ; otherwise  a fatal  result  may  occur  in  a few  days,  and  is 
seldom  prolonged  above  a week.  On  the  other  hand,  diphtheria,  with 
only  reual  complication,  may  go  on  till  the  fourteenth  day.  For  important 
information  on  this  subject  you  may  consult  the  reports  of  Drs.  Green- 
how  and  Sanderson,  Public  Health  Reports,  1860  ; the  translation  of 
Trousseau  on  Diphtheria,  by  Dr.  Semple,  and  the  excellent  little  mono- 
graph by  Dr.  Jenner — “ Diphtheria,  its  Symptoms  and  Treatment,”  1861. 

SYPHILIS  AND  MERCURIAL  POISONING. 

Case  CCLXIX."^ — Syphilitic  Ulceration  of  the  Face. 

Anne  Bruce,  aet.  24 — admitted  January  10th,  1852.  Her  face  presented  a most 
frightful  appearance,  being  covered,  as  well  as  the  neck  and  upper  part  of  the  chest, 
with  circular  masses  of  pustular  scabs.  These  varied  in  size  from  a fourpenny-piece 
to  half-a-crown,  several  being  in  some  places  crowded  together.  Some  of  the  prom- 
inent scabs  were  dry,  others  soft,  with  foetid  pus  oozing  from  their  bases.  In  a few 
places  they  had  fallen  off,  exposing  circular,  unhealthy-looking  ulcers.  Wherever 
the  skin  could  be  seen,  it  was  of  a fiery-red  color,  and  puckered  with  old  cicatrices. 
The  lower  lip  was  swollen  and  dragged  downwards,  and  the  left  lower  eyelid  was 
ulcerated  and  everted.  The  metacarpal  bones  of  the  left  hand  were  enlarged,  and 
the  skin  covering  them  red  and  painful.  No  ulceration  of  the  throat  or  other  com- 
plaints, with  the  exception  of  weakness.  External  appearance  highly  cachectic. 

The  history  she  gave  of  her  case  is  as  follows : About  five  years  ago  she  con- 
tracted primary  sores  from  her  husband,  who  had  suffered  from  a very  malignant 
form  of  them  in  the  West  Indies.  Shortly  after,  she  was  attacked  with  a minute 
pustular  eruption  of  the  skin.  This  shortly  disappeared,  but  was  succeeded  by 
occasional  blotches  on  the  skin,  which  sometimes  broke,  but  always  went  away 
slowly.  Eighteen  months  after  the  commencement  of  the  disease,  one  of  these 
appeared  on  her  chin,  when,  being  alarmed,  she  came  to  Edinburgh.  The  prac- 
titioner she  consulted  placed  her  under  a mercurial  course,  and  she  was  salivated 
for  six  weeks.  The  disease  in  the  face,  instead  of  healing  slowly  as  formerly,  now 
ulcerated  and  began  to  spread.  Six  months  afterwards,  she  was  again  salivated  for 
four  weeks,  but  the  whole  of  the  lower  half  of  the  face  was  now  involved,  and  she 
entered  the  clinical  ward  of  the  Royal  Infirmary.  She  was  confident  that  these  are 
the  only  occasions  on  which  she  has  taken  mercury.  She  remained  in  the  house 
upwards  of  a month,  and  went  out  with  the  face  nearly  well,  from  the  use  of  topical 
emollient  applications,  and  the  internal  use  of  small  doses  of  iodide  of  potassium. 
Six  weeks  afterwards,  however,  she  was  exposed  to  cold  and  wet,  when  the  blotches, 
scabs,  and  ulcers  returned  in  the  face,  and  gradually  spread  to  the  neck  and  chest, 
as  formerly  described. 

* Reported  by  Mr.  G.  A.  Douglas,  Clinical  Clerk. 


972 


DISEASES  OF  THE  BLOOD. 


She  was  ordered  four  grain  doses  of  Iodide  of  Potassium  in  a mixture  containing 
^ i of  tincture  of  Cardamoms^  and  § vij  of  compound  infusion  of  Gentian.  The  face 
was  dressed  first  with  a zinc  lotion,  afterwards  with  one  of  chloride  of  lime,  and 
subsequently  with  an  ointment  of  iodide  of  lead.  Gradually  the  further  ulceration 
was  checked,  and  the  ulcers  healed,  and  on  the  19th  of  February  she  was  so  much 
relieved  that  she  insisted  on  going  out.  I saw  her  in  the  following  June,  with  the 
face  cicatrised  all  over,  but  quite  well. 

Commentary. — It  is  very  rarely  that  we  have  an  opportunity  of 
seeing  so  frightful  a case  of  mercurial  syphilis  as  the  one  just  noticed ; 
it  fully  equalled  many  of  the  horrible  representations  I now  show  you 
in  the  work  of  Divergie.  You  will  have  observed  from  the  history  of 
this  patient,  that  previous  to  the  exhibition  of  mercury  she  was  subject 
to  the  slow  formation  of  boils,  which,  however,  spontaneously  disappeared. 
The  moment  her  system  was  saturated  with  that  drug  the  boils  and 
ulcers  first  became  stationary,  and  then  commenced  spreading  over  the 
integument.  This  is  an  important  fact  too  little  attended  to  by  those 
who  practise  the  mercurial  treatment. 

Case  COLXX.* — Syphilitic  Laryngitis. 

Margaret  Dickie,  a staymaker,  aBt.  25 — admitted  September  9th,  1851,  laboring 
under  occasional  vomiting,  frequent  cough,  with  haemoptysis,  and  copious  purulent 
expectoration.  There  was  considerable  sweating  at  night,  and  her  general  health, 
owing  to  want  of  sleep  and  the  harassing  cough,  was  much  broken  down.  At  the 
commencement  of  the  winter  session  in  November  I found  her  taking  an  acid 
mixture  to  relieve  the  sweating,  a cough  mixture  to  diminish  the  cough,  together 
with  cod-liver  oil.  The  chest  had  also  been  blistered.  Careful  percussion  and 
auscultation  convinced  me  that  the  thoracic  physical  signs  were  perfectly  normal. 
I then  examined  the  fauces,  which  were  covered  with  purulent  mucus,  but  present- 
ing here  and  there  red  and  prominent  follicles.  The  cough  was  also  ascertained  to 
be  convulsive,  the  voice  hoarse  and  broken,  and,  on  placing  the  stethoscope  over 
the  larynx,  a loud  ringing  sound  accompanied  the  inspiration.  From  these  facts  I 
had  no  difficulty  in  diagnosing  laryngitis  ; and  on  ascertaining  that  the  woman  was 
a prostitute  and  addicted  to  drink,  there  could  be  little  doubt  that  it  was  of  syphi- 
litic origin.  The  fauces  were  freely  touched  with  a solution  of  nitrate  of  silver  ( 3 ss 
to  J j of  water).  This  was  repeated  on  the  following  day,  and  on  the  next  the  upper 
part  of  the  glottis  was  touched,  causing  severe  convulsive  cough.  I subsequently 
passed  the  sponge,  saturated  with  the  solution,  into  the  larynx  every  second  or  third 
day  during  the  month  of  November,  which  at  first  caused  very  severe  and  prolonged 
convulsive  cough,  that  gradually  became  somewhat  diminished.  On  the  whole, 
however,  no  great  amendment  was  produced,  although  the  expectoration  and  cough 
during  the  intervals  vere  lessened.  The  local  applications  were  then  suspended, 
but  it  soon  appeared  that  they  had  been  beneficial  in  checking  the  symptoms,  from 
their  severity  again  increasing,  especially  the  amount  of  expectoration  streaked  with 
blood,  and  the  want  of  sleep  at  night  owing  to  the  severity  of  the  cough.  In  the 
second  week  of  December,  therefore,  the  topical  applications  were  resumed,  together 
with  occasional  blisters  to  the  larynx,  and  once  more  a certain  amount  of  benefit  was 
obtained.  But  as  this  treatment,  combined  with  the  internal  administration  of 
iodide  of  potassium  and  bitter  infusions,  for  a period  of  four  weeks,  seemed  to  produce 
no  further  improvement,  she  was  dismissed  on  January  7th,  1852. 

Commentary. — Syphilitic  disease  of  the  larynx  is  one  of  the  most 
common  of  the  secondary  forms  of  the  disease,  a fact  indicated  by  the 
hoarse  and  broken  voices  so  frequently  noticed  among  women  of 
abandoned  character.  The  topical  treatment  with  the  sponge,  and  a 
solution  of  nitrate  of  silver,  does  not  seem  to  be  so  useful  as  in  simple 
laryngitis  ; but  even  here  its  effects  on  the  mucous  membrane  are 
evidently  beneficial. 

* Reported  by  Mr,  C.  D.  F.  Phillips,  Clinical  Clerk. 


SYPHILIS. 


973 


Case  CCLXXI.* — Syphilitic  Rupia^  followed  hy  Keloid  Growths  on  the 
Cicatrices — Syphilitic  Psoriasis. 

History. — John  Young,  set.  24,  boiler-maker,  native  of  New  Monklaud — admitted 
November  29,  1858.  The  patient  states  that,  until  eighteen  months  ago,  he  was  per- 
fectly healthy,  but  at  that  time,  while  residing  at  Kilmarnock,  he  contracted  a chancre 
upon  the  prepuce.  This  was  treated  by  the  external  application  of  blackwash  ; and 
he  took  what  he  believes  to  have  been  mercurial  pills  internally.  The  sore  under  this 
treatment  healed  in  a week.  He  then  went  to  Leith,  and  after  remaining  there  a fort- 1 
night,  discovered  that  an  ulcer  had  spontaneously  formed  exactly  where  the  previous  i 
one  had  existed.  He  at  this  time  (July  31st,  1857)  entered  the  surgical  wards  of  the 
Edinburgh  Infirmary,  and  there  took  pills  which  produced  soreness  of  the  mouth  and 
gums,  and  increased  salivation  lasting  for  about  three  weeks.  The  ulceration  of  the 
throat,  from  which  he  then  also  suffered,  was  frequently  cauterized,  and  black-wash  was 
applied  to  the  preputial  sore.  This  plan  of  treatment  was  followed  by  a course  of 
iodide  of  potassium.  During  his  residence  in  hospital  an  eruption  made  its  appearance, 
which  was  evidently  rupia,  as  proved  by  the  numerous  large  cicatrices  which  are  at 
present  visible  all  over  the  surface  of  the  body.  He  gradually  got  much  better,  and 
was  dismissed  after  six  weeks’  residence.  At  the  time  of  his  dismission,  however, 
there  were,  according  to  his  own  account,  numbers  of  adherent  crusts  of  rupia  scattered 
over  the  greater  part  of  his  body.  After  he  left  the  Infirmary  he  went  to  Motherwell, 
where  his  throat  again  became  sore ; fresh  pustules  of  rupia  formed,  many  of  the  old 
crusts  and  sores  enlarged,  and  deafness  supervened,  which  continued  for  eight  or  ten 
days.  He  applied  to  a medical  man,  who  syringed  his  ears  with  warm  milk  and  water, 
and  gave  him  some  liquid  to  take  internally,  which  he  says  benefited  him  while  he 
continued  to  use  it.  Fifteen  weeks  after  this  time  he  went  to  Cumbernauld,  and  there 
purchased  a quack’s  book  containing  a prescription  for  sarsparilla  and  iodide  of 
potassium,  which  he  has  continued  to  take  from  time  to  time  until  the  present  date. 
The  medicine  did  not  cure  the  disease,  but  kept  it,  he  believes,  from  “ turning  worse.” 
Six  months  ago  patches  of  psoriasis  commenced  to  appear  on  the  neck  and  shoulders, 
which  were  soon  followed  by  a similar  eruption  over  other  parts  of  the  body.  Twelve 
weeks  ago  a medical  man  made  three  attempts  to  inoculate  him  with  syphilitic  virus, 
repeated  at  intervals  of  eight  days,  but  without  success.  The  operation  was  performed 
by  scraping  some  of  the  matter  off  a glass  upon  which  it  had  been  dried,  and  inserting 
it  under  the  skin  by  means  of  a lancet. 

Symptoms  on  Admission. — The  entire  surface  is  scattered  over  with  round  and 
oval  cicatrices  of  rupia,  which  are  closest  on  the  thighs,  are  not  so  common  on  the 
breast  and  abdomen,  but  pretty  general  on  the  back.  In  the  centre  of  some  of  the 
cicatrices  on  the  upper  extremities  and  back  are  a few  flesh-colored  solid  elevations, 
some  occupying  only  a portion,  others  the  entire  surface  of  these  cicatrices.  In  the 
latter  case  they  constitute  nodular  swellings  or  tumors  of  a flesh  or  pinkish  color; 
smooth  on  the  surface  and  elevated  above  the  level  of  the  skin  from  one-eighth  to  one- 
quarter  of  an  inch ; they  are  indurated  and  tough  to  the  feel,  oval  or  round  in  form, 
and  vary  from  one-eighth  of  an  inch  to  one  inch  and  a half  in  diameter.  The  largest 
of  them  is  situated  over  the  left  shoulder,  and  about  a dozen  are  scattered  over  the 
neck,  back,  and  superior  extremities  ; there  are  none  over  the  chest,  abdomen,  or 
lower  extremities.  In  addition  to  these  there  are  irregularly-shaped  patches  of  psoriasis 
scattered  over  the  head,  neck,  abdomen,  arms,  legs,  and  back.  On  two  of  the  largest 
patches  irregular  ulcers  have  formed,  which  are  about  ha  f an  inch  in  diameter  and  are 
at  the  present  time  covered  with  elevated  brown  crusts.  There  are  numerous  small 
pustules,  resembling  those  of  acne,  over  the  shoulders,  back,  breast,  and  face,  some  of 
which  are  advancing  towards  suppuration.  Other  systems  normal.  He  was  ordered 
to  take  five  grains  of  the  iodide  of  potassium  three  times  a day,  and  to  apply  pitch- 
ointment  to  the  patches  of  psoriasis  morning  and  night. 

Progress  of  the  Case.  The  treatment  just  stated  was  continued  for  two  months. 
The  patches  of  psoriasis  gradually  lost  their  scaly  character,  and  assumed  the  appearance 
of  copper-colored  blotches,  and  the  intervening  portions  of  the  skin,  owing  to  occa- 
sional baths,  became  much  clearer,  and  freed  from  the  acne. 

On  resuming  my  duties.  May  1st,  I found  this  man  still  in  the  house.  In  the  inter- 
val he  had  taken  Pot.  Iodide,  Liq.  Arsenic.,  and  Liq.  Hydrar.  Bichl.,  for  various  periods 
internally,  and  several  of  the  patches  and  ulcerations  had  been  treated  externally  with 


* Reported  by  Dr.  T.  A.  Carter,  Clinical  Physician. 


974 


DISEASES  OF  THE  BLOOD. 


nitrate  of  silver,  and  solution  of  cupri  sulph.  In  May  he  was  in  no  respect  better,  the 
patches  of  psoriasis  had  now  assumed  the  character  of  elevated  warts  of  papilloma,  of 
a bi»»wnish-red  color,  and  were  so  evidently  chronic  that  by  his  own  wish  he  was 
dismissed  May  11th. 

Commentary. — This  case  offers  a good  example  of  the  inutility  of 
mercury,  and  perhaps  even  of  the  evils  it  produces  on  the  economy,  for 
no  one  can  say  how  much  of  the  pustular  and  scaly  disease  might  not 
have  been  owing  to  the  effects  of  that  drug.  The  keloid  growths  were 
evidently  fibro-vascular  tumors,  occurring  in  the  cicatrices,  and  gave 
him  no  inconvenience  whatever.  It  is  seldom  I have  seen  the  skin  of 
a young  man  so  disfigured,  presenting,  as  it  did,  circular  and  oval  marks 
of  the  former  rupia,  the  pink  swellings,  and  the  large  copper-colored 
blotches  here  and  there. 

The  literature  of  syphilis  is  exceedingly  rich.  The  origin  of  the 
word,  the  source  of  the  disease,  the  time  of  its  appearance,  its  subsequent 
course,  and  the  identity  of  its  different  forms  at  various  times,  have  all 
been  keenly  disputed.  Even  at  the  present  day,  its  exact  nature  and 
mode  of  treatment  excite  lively  discussion;  for  such  are  the  discordant 
facts  reported  and  such  are  the  prejudices  resulting  from  education  and 
ex  parte  statements,  that  it  is  extremely  difficult  to  form  an  unbiassed, 
not  to  speak  of  a correct  opinion.  All,  then,  that  I shall  venture  upon 
here  is  to  communicate  some  of  my  own  reflections  and  observations  on 
this  subject. 

The  venereal  disease  presents  a great  variety  of  symptoms,  which  are 
generally  considered  as  primary  and  secondary.  They  may,  with  more 
propriety  perhaps,  be  divided  into  primary,  secondary,  and  tertiary,  as 
follows  • — 

Primary  symptoms — 

1.  Balanitis. 

n rK  ( Simple  or  ulcerative. 

2.  Gonorrhoea,-  | ^ 

3.  Chancre, 

4.  Granular  disease  of  os  uteri. 

i TesteSy  Prostate.,  Rectum., 

5.  Irritation  in  other  organs, — -<  Schneiderian  Membrane, 

( Conjunctiva,  etc. 

Secondary  symptoms,  affecting  the — 

1.  Lymphatic  glands, — Bubo. 

2.  Mucous  membrane, — Vicerations. 

3.  Skin, — Ulcerations  or  eruptions. 

4.  Eye, — Iritis,  etc. 

Tertiary  Symptoms — 

5.  Disease  of  bone, — Exostosis,  Caries,  Necrosis. 

The  forms  of  syphilitic  disease  which  commonly  fall  under  our  notice, 
in  the  medical  clinical  wards,  are  such  as  affect  the  skin,  fauces,  and 
larynx.  They  all  require  the  same  constitutional  treatment,  but  the 
two  latter  demand  also  local  applications,  some  of  which  have  been  refer- 
red to  when  speaking  of  laryngitis; 


SYPHILIS. 


975 


All  the  different  kinds  of  skin  disease  formerly  described  may  occur 
in  an  individual  affected  with  syphilis.  They  then  become  modified  in 
their  general  appearance,  course,  and  seats  of  predilection.  Thus  it  has 
been  observed  that  the  ordinary  red  color  of  skin  diseases  assumes,  in 
those  affected  with  syphilis,  a darker  or  coppery  tint.  This  is  especially 
observed  in  the  scaly  eruptions,  the  patches  of  which  are  also  smaller, 
while  the  scales  are  thin,  and  of  a gray  color,  often  approaching  black. 
The  pustular  scabs  are  hard  and  thick,  of  a dark  greenish  or  black  color, 
furrowed  on  the  surface,  and  deep  in  the  skin.  The  ulcers  are  deep, 
circular,  with  hard  and  callous  edges.  The  cicatrices  are  unequal,  round, 
or  spiral,  white  and  depressed.  These  eruptions  may  occur  all  over  the 
surface,  but  are  most  common  on  the  forehead,  face,  nose,  back,  and 
shoulders.  In  children  they  generally  assume  the  form  of  maculae  or  of 
ulcerations  ; in  adults,  of  tubercular  and  scaly  disorders,  although  ulcers 
are  also  very  frequent. 

Diagnosis  of  Syphilis. 

' It  has  been  said  by  some  persons  that  they  can  readily  detect  a 
syphilitic  from  all  other  skin  eruptions.  But  I have  known  errors 
made  in  this  respect  by  the  most  experienced  and  eminent  dermatolo- 
gists, one  of  which  I may  relate. 

A young  gentleman,  on  rising  one  morning,  found  himself  covered 
with  an  exanthematous  eruption.  He  had  dined  out  the  previous  day, 
and  indulged  in  eating  more  than  usual.  He  applied  to  an  English 
physician  practising  in  Paris,  who  pronounced  it  to  be  urticaria,  recom- 
mended a dose  of  salts,  and  assured  him  that  it  would  disappear  in  a 
couple  of  days.  Some  friends,  however,  advised  him  to  consult  M.  Biett, 
at  that  time  chief  physician  to  the  Hdpital  St,  Louis,  and  certainly  one 
of  the  most  experienced  dermatologists  in  Paris.  He  did  so,  and  the 
eruption  was  stated  at  once  to  be  syphilitic,  and  a course  of  mercury 
recommended.  It  was  with  the  utmost  difficulty  that  his  English 
medical  adviser  could  prevail  upon  him  to  wait  two  days  before  com- 
mencing the  mercurial  treatment,  when,  however,  he  had  the  pleasure  of 
seeing  his  diagnosis  justified  by  the  disappearance  of  the  eruption. 
Now,  I need  not  say,  that  if  such  an  error  could  occur  to  one  so  expe- 
rienced as  M.  Biett,  how  much  more  readily  may  it  happen  to  a practi- 
tioner comparatively  unacquainted  with  such  disorders. 

The  same  difficulty  occurs  with  primary  and  secondary  syphilitic 
ulcers.  The  question  here  is,  Is  there  anything  in  the  aspect  of  the 
sore  itself  which  will  enable  us  to  determine  its  nature  ? Here,  also,  I 
have  seen  the  greatest  mistakes  made  by  the  most  experienced  surgeons. 
M.  Bicord  was  so  doubtful,  after  long  practice,  of  the  characters  of  a 
common  chancre,  that  he  commenced  a series  of  inoculations  in  1837-38 
to  determine  which  was,  and  which  was  not,  a true  venereal  sore.  So 
late  as  1857  his  views  on  this  subject  have  undergone  a complete  revo- 
lution. I am  satisfied  also,  that  individuals  whose  systems  have  been 
impregnated  with  mercury  frequently  have  ulcers  which  are  constantly 
mistaken  for  venereal  ones,  although  really  the  results  of  a poison  with 
which  the  body  is  impregnated.  The  following  case,  which  I observed 


976 


DISEASES  or  THE  BLOOD. 


twenty-two  years  ago,  was  the  first  which  strongly  impressed  my  mind 
with  this  truth. 

A girl,  seven  years  of  age  entered  the  surgical  hospital  in  1836. 
She  had  a round  ulcer  over  the  tibia,  about  the  middle  of  the  left  leg. 
It  presented  all  the  characters  of  a venereal  ulcer,  as  described  by  Hun- 
ter. On  inquiry,  it  appeared  that  her  bowels  having  been  somewhat  de- 
ranged, the  mother  had  gone  to  a druggist’s  shop  and  asked  for  some 
opening  powders.  She  received  twelve,  which  contained  a white,  finely 
powdered  substance.  One  was  given  morning  and  night.  In  four  days 
profuse  salivation  came  on.  The  whole  dozen  powders  were  given,  how- 
ever, and  a cachectic  state  was  induced.  Owing  to  some  accident,  she 
received  a violent  blow  on  the  leg,  and  the  ulcer  mentioned  made  its 
appearance.  There  had  never  been  a venereal  taint  in  the  family,  and 
the  parents  were  perfectly  healthy.  The  clinical  professor  declared 
publicly,  that  had  the  girl  been  seventeen  instead  of  seven  years  old,  no 
asseverations  on  her  part  could  have  persuaded  him  that  the  sore  was  not 
syphilitic. 

Thus,  then,  it  is  only  when  the  symptoms  arise  in  a certain  order  that 
we  can  positively  declare  syphilis  to  be  present.  If  an  individual  has 
chancre,  which  is  followed  by  bubo  or  ulcerated  throat,  and  this  is 
accompanied  by,  or  precedes,  eruptions  on  the  skin,  then  we  may  feel 
pretty  confident.  Again,  when  deep-seated  pains  in  the  bones  follow 
the  previous  symptoms,  we  may  consider  them  to  be  syphilitic.  The 
circumstance  of  an  osseous  disease  more  frequently  affecting  the  shaft 
than  the  extremities  of  a long  bone  will  serve  to  distinguish  syphilitic 
from  scrofulous  disease  and  the  existence  of  caries  in  conjunction  with 
the  peculiar  ulcerations  formerly  alluded  to,  will  confirm  our  suspicions. 
You  should  remember,  however,  that  great  caution  is  always  required. 
The  common  idea  that  the  gonorrhoea  and  excoriations  in  men,  which 
often  follow  impure  connection,  are  a proof  of  disease  in  the  female,  has 
led  to  great  error ; as  it  is  now  ascertained  that  they  may  occasionally 
arise  from  the  presence  of  the  menses,  some  unusually  acrid  discharge,  or 
other  non-venereal  cause.  A hasty  opinion  given  to  the  effect  that  this 
or  that  eruption  is  syphilitic  has  introduced  discord  into  families,  and 
produced  incalculable  mischief.  The  tertiary  syphilitic  symptoms  also 
have  frequently  been  confounded  with  the  deep-seated  pains  of  rheumatism, 
neuralgia,  malacosteon,  etc.  Moreover,  if  such  opinion  leads  to  the  en- 
tering upon  a mercurial  course,  the  original  disorder  is  often  replaced  by 
an  artificial  one,  not  unfrequently  more  destructive  in  character,  which 
is  again  confounded  with  syphilis ; and  so  the  error  is  perpetuated. 

Propagation  of  Syphilis. 

Actual  contact  from  impure  connection  is  the  most  common  mode  by 
which  syphilitic  sores  are  communicated.  A gonorrhoeal  discharge  also 
applied  incautiously  to  the  conjunctiva  or  other  mucous  membranes  will 
excite  inflammation  in  them.  The  secondary  forms  of  the  disease  are 
always  the  result  of  inoculation ; but  this  may  arise  not  only  from  the 
poison  being  absorbed  directly  from  a primary  sore,  but  may  be  communi- 
cated by  the  mother  to  the  foetus  in  utero, — by  the  infant  to  the  nurse, 


SYPHILIS. 


977 


— ^and  again  by  the  nurse  to  the  infant.  The  following  case,  which  was 
most  carefully  investigated,  and  was  the  subject  of  legal  proceedings, 
illustrates  how  nurses  may  be  affected  by  sypliilitic  infants. 

In  1842  the  late  Dr.  W.  Campbell  brought  to  me  a woman  with  a 
child  in  her  arms,  to  obtain  my  opinion  whether  a skin  eruption  on  the 
latter  was  or  was  not  syphilitic.  I pronounced  that  it  was,  and  that  the 
woman  should  cease  to  nurse  it,  although  her  nipples  at  that  time  were 
in  no  way  affected.  The  child  was  the  offspring  of  respectable  parents, 
and  had  been  sent  to  her  to  nurse.  In  consequence  of  my  opinion,  the 
infant  was  returned  to  the  friends,  whose  medical  attendant  maintained 
the  eruption  to  be  non-syphilitic.  The  woman  who  applied  to  me  (nurse 
1)  was  received  as  a wet-nurse  into  another  family,  and  the  child  was 
sent  to  another  nurse  (nurse  2).  In  a week  the  child  died,  and  a few 
days  afterwards  nurse  2 was  attacked  with  sore  nipples.  Nurse  1, 
shortly  after  entering  her  new  situation,  also  perceived  sores  round  her 
nipples  ; and  the  medical  attendant  of  the  family,  after  consultation  with 
me,  caused  her  to  be  discharged.  She,  in  consequence,  brought  an 
action  against  the  medical  man  who  had  caused  the  syphilitic  infant  to 
be  sent  to  her,  and  had  mistaken  the  disease.  The  lawyer  she  employed 
then  took  me  to  visit  nurse  2,  whose  whole  body  was  covered  with  a 
syphilitic  tubercular  eruption.  Both  nurses  ultimately  succeeded  in  ob- 
taining compensation  from  the  medical  attendant. 

Pathology  of  Syphilis, 

Syphilis  is  caused  by  a poisonous  virus  which,  mixing  with  the 
blood,  taints  the  constitution,  and  predisposes  it  to  those  forms  of 
secondary  and  tertiary  disorders  formerly  alluded  to.  The  nature  of  this 
virus  is  involved  in  the  same  mystery  as  that  of  other  animal  poisons. 
All  that  we  know  of  it  is  from  observation  of  its  effects.  Sir  A.  Crich- 
ton, adopting  Liebig’s  view  of  a catalytic  action  produced  in  the  blood, 
pointed  out,  in  1842,  that  this  catalytic  action  was  soon  destroyed  in 
cases  of  scarlatina,  small-pox,  and  similar  acute  diseases.  Here  “ the  fever, 
which  de.stroys  both  the  desire  for  food  and  the  process  of  chymification, 
and  consequently  the  supply  of  new  elements  for  the  further  formation 
of  new  virus,  is  cut  off.  But  in  syphilis  and  yaws,  which  do  not  affect 
the  brain  or  vital  functions  for  a long  time,  the  patient,  by  daily  taking 
food  in  abundance,  supplies  every  day  new  elements  for  the  production 
of  fresh  quantities  of  poison,  and  consequently  the  disease  goes  on  and  is 
protracted  indefinitely.  ” This  theory  is  supported  by  the  comparatively 
mild  character  of  the  syphilis  in  warm  climates,  where  the  natives  live 
chiefly  on  vegetable  food,  and  is  abundantly  proved  by  the  good  effects 
of  a low  diet  and  the  mast  simple  m.eans,  when  contrasted  with  the 
effjcts  of  so-called  specifics. 

OpinioQs  in  the  French  and  German  schools  have  greatly  varied  in 
recent  times,  and  at  the  present  moment  are  most  conflicting.  Bicord, 
having  nearly  all  his  life  supported  the  views  of  Hunter,  in  1857  an- 
nounced his  adhesion  to  the  view  that  there  were  two  venereal  contagions, 
— one  connected  with  the  soft,  and  the  other  with  the  indurated  chancre. 
The  views  of  Sigmund  of  Vienna,  of  Von  Baerinsprung  of  Berlin,  of 
' 62 


978 


DISEASES  OF  THE  BLOOD. 


Rollet  and  Diday  of  Lyons,  of  Michaelis,  and  various  others,  all  founded 
on  extensive  observation,  with  numerous  inoculations  and  experiments, 
are  most  contradictory.  Whether  there  be  one  or  two  poisons  is  unsettled, 
and  whether  they  are  always  distinct  or  capable  of  blending  and  producing 
mixed  sores,  equally  uncertain.  I would  refer  you  to  an  excellent  sum- 
mary of  recent  continental  opinions  by  Mr.  Hill  (British  Medical  Journal, 
vol.  ii.,  for  1862).  See  also  the  works  of  H.  Lee  and  Thompson.  In  the 
present  state  of  the  question  too  much  caution  cannot  be  exercised  in 
forming  conclusions  regarding  it. 

A few  years  ago  my  attention  was  directed  to  the  skeleton  of  a dog 
in  the  museum  of  this  University,  which  presented  ail  the  aspects  of 


Fig.  535, 

tertiary  syphilis.  Its  history  is  as  follows  : — The  dog  lived  in  the  shop 
of  Mr.  Ballantyne,  eighteen  years  ago,  in  Carrubber’s  Close.  At  that 
time  the  work  carried  on  consisted  almost  exclusively  in  painting  with 
vermilion  and  lackering  Japan  articles.  The  dog,  who  never  left  the 
premises,  was  frequently  seen  lapping  the  vermilion  oil  paint,  and  there 
can  be  no  doubt  that  in  this  way  there  was  introduced  into  his  system  a 
considerable,  quantity  of  mercury.  After  death  the  dog  was  dissected. 
Numerous  cancerous-like  masses  were  found  in  the  lungs  and  internal 
viscera,  and  his  skeleton  was  preserved.  It  will  be  seen  that  the  shaft 
of  the  long  bones  and  not  their  extremities  were  attacked  (Fig.  535). 
The  disease  closely  resembles  what  may  be  observed  in  many  other 
specimens  of  so-called  syphilitic  disease.  (See  Figs.  536,  537.) 
Yet  in  this  dog  we  have  the  positive  proof  that  it  was  caused  by 
mercury,  as  all  attempts  to  communicate  true  syphilis  to  dogs  by  inocu- 
lation have  failed. 

For  my  own  part,  I believe  that  the  virus  of  syphilis,  if  left  to  itself. 

Fig.  636.  Skeleton  of  a dog  poisoned  by  mercury.  One-fifth  real  size. 


SYPHILIS. 


979 


and  if  the  health  of  the  patient  be  attended  to,  will  generally  wear  itself 
out.  Unfortunately  we  are  only  commencing  to  observe  the  natural  pro- 
gress of  syphilis,  and  consequently  we  are  unable  to  determine  how  long, 
usjder  ordinary  circumstances,  it  takes  to  accomplish  this.  So  far  as  I 
know,  wo  have  no  specific  for  any  kind  of  animal  poison,  for  you  will 
remember  that  Jenner  was  of 
opinion  (and  there  can  be  little 
doubt  that  he  was  correct),  that 
in  giving  vaccination  to  man,  he 
was  merely  giving  him  small- 
pox in  a modified  form.  The 
idea  that  mercury  is  a specific 
for  the  syphilitic  poison,  and 
the  incalculable  mischief  it  has 
occasioned,  will  constitute  a 
curious  episode  in  the  history  of 
medicine  at  some  future  day. 

It  is  now  well  known  that  the 
poison  of  mercury  produces  a 
cachectic  disease  and  secondary 
sores  on  the  body,  which  have 
been  to  a great  extent  mistaken 
for  those  of  syphilis.  It  conse- 
quently has  happened  that  mer- 
cury given  to  cure  primary 
sores  has  produced  a constitu- 
tional disorder  closely  resem- 
bling that  of  syphilis ; more  mer-  ■ -pigr.  536.  Fig.  537. 

cury  has  been  administered,  increasing  the  mischief,  and  so  the  disease  has 
been  perpetuated.  The  real  fact,  however,  is,  that  the  syphilitic  poison 
is  no  exception  to  the  general  rule,  which  informs  us  that  all  contagious 
diseases  of  the  blood  run  a certain  course,  and  that  we  have  not  yet  dis- 
covered a specific  cure  for  one  of  them.  The  great  proof  of  this  is,  that 
the  intensity  of  the  disease  in  modern  times  has  declined  exactly  in  pro- 
portion as  its  treatment  by  mercury  has  diminished  and  the  disorder 
been  left  to  follow  its  natural  course.  When  we  treat  syphilis  on  the 
same  principles  that  we  do  scarlatina  and  small-pox,  it  will  prove  in- 
finitely less  fatal  than  those  disorders. 

I have  previously  referred  to  the  great  caution  which  should  be  exer- 
cised in  adopting  the  opinions  of  some  pathologists  who  ascribe  all  sorts 
of  chronic  indurations,  puckerings,  gummy  exudations,  waxy  degenera- 
tions, etc.  etc.,  to  syphilis,  and  call  them  syphilitic  deposits,  in  the  same 
manner  that  certain  other  lesions  were  formerly  called  typhous  deposits. 
The  general  result  of  such  a pathology  is  to  increase  the  horrors  of 
syphilis,  and  make  it  even  more  dreadful  than  it  was  rendered  by  the 
imaginative  writings  of  Paracelsus  and  his  followers.  I believe  these 
views  to  be  founded  in  error  (see  p.  503). 


Fig.  536.  Exostosis  of  dog’s  femur. 
Fig.  537.  Internal  view. 


One-half  real  size. 


980 


DISEASES  OF  THE  BLOOD. 


Treatment  of  Syphilis. 

The  treatment  of  syphilis  may  be  said  to  be  of  two  kinds,  namely, 
the  simple  and  mercurial.  The  profession  are  rapidly  deciding  in  favor 
of  the  first,  although  some  of  its  members  still  give  mercury  in  inveterate 
cases.  Many  of  the  cases  we  meet  with,  therefore,^  have  taken  the  drug, 
and  we  have  to  eradicate  the  eflects  of  the  mineral  poison  as  well  as  of 
the  original  disease. 

The  Simple  Treatment  is  divided  into  internal  or  medical,  and  external 
or  surgical.  The  first  consists  in  the  observation  of  certain  hygienic 
rules,  and  the  employment  of  general  therapeutic  means.  The  diet 
must  be  light  and  mild — meat  and  all  stimulating  viands  retarding  the 
cure  ; even  with  the  lightest  diet,  the  hunger  should  never  be  quite  ap- 
peased. The  regimen  must  be  the  more  diminished  and  rigid  in  propor- 
tion to  the  youth  and  vigor  of  the  patient.  Diluent  beverages,  decoctions 
of  barley,  liquorice,  and  linseed,  alone  or  mixed  with  milk,  should  be 
taken  freely,  to  the  amount  indeed  of  several  pints  a day.  Perfect 
repose  must  be  secured  by  confinement  to  bed.  Constipation  must  be 
obviated  by  the  use  of  emollient  clysters  or  mild  laxatives.  The  air 
should  be  maintained  at  the  same  temperature  : this  is  an  indispensable 
precaution  in  chronic,  consecutive,  and  mercurial  aftections.  Exercise  is 
only  useful  in  the  convalescent  stage.  In  chronic  syphilis,  however,  it 
may  often  be  carried  to  fatigue  with  advantage.  Tepid  baths,  repeated 
three  or  four  times  a day,  are  always  attended  with  advantage. 

In  the  external  or  surgical  treatment,  strict  attention  to  cleanliness 
and  the  position  of  the  diseased  parts  should  never  be  lost  sight  of. 
Emollient  decoctions  or  fomentations,  or  dressings  of  simple  cerate,  are 
the  best  applications,  and  the  dressings  should  not  be  too  frequently  re- 
newed. The  greatest  benefit  is  derived  from  the  external  use  of  a con- 
centrated solution  of  opium  (in  the  proportion  of  about  3 ij  to  J j of 
water)  ; it  soothes  excessive  irritability  in  all  cases.  When  the  suppura- 
tion is  moderated  and  the  surface  of  the  ulcer  cleansed,  stimulating 
dressings,  consisting  of  solutions  of  the  sulphates  of  alum  and  copper,  the 
nitrate  of  silver,  and  sub-acetate  of  lead,  favor  cicatrisation. 

In  inveterate  cases,  more  especially  those  laboring  under  tertiary 
symptoms,  the  iodide  of  potassium,  which  was  introduced  by  Dr.  Wallace 
of  Dublin,  and  used  by  him  with  considerable  success,  may  be  employed. 
I have  myself  given  it  in  numerous  cases  with  benefit,  in  doses  of  5 gr. 
three  times  a-day,  conjoined  with  emollient  applications  to  the  affected 
parts. 

The  Mercurial  Treatment  used  to  consist  in  keeping  up  slight  salivation 
by  means  of  the  internal  administration  of  blue  pills  or  some  other  form 
of  mercury,  sometimes  conjoined  with  mercurial  frictions  or  fumigations, 
at  least  for  the  space  of  a month.  More  recently  much  smaller  doses,  so 
as  to  produce  scarcely  sensible  effects  have  been  given  for  a longer  or 
shorter  time.  The  physiological  action  of  the  drug  may  be  produced  by 
administering  any  of  its  preparations  continuously  in  small  doses.  If 
combined  with  opium,  they  act  less  on  the  bowels,  and  more  on  the  sys- 
tem generally. 

It  is  necessary  during  decided  salivation  that  the  patient  do  not  ex- 


SYPHILIS. 


981 


pose  himself  to  cold.  A certain  irritability  is  produced,  and  the  con- 
stant soreness  of  the  gums,  the  metallic  taste  in  the  mouth,  not  to  speak 
of  the  inconveniences  of  profuse  salivation,  which  occasionally  occurs, 
render  this  species  of  treatment  anything  but  agreeable  to  the  patient. 

Both  kinds  of  treatment  have  now  been  extensively  tested.  In  the 
year  1822  the  Boyal  Council  of  Health  in  Sweden,  having  been  charged 
by  the  king  to  conduct  a series  of  experiments  upon  the  different  modes 
of  treating  venereal  diseases,  reports  from  all  the  civil  and  military  hos- 
pitals were  ordered  to  be  drawn  up  annually.  These  reports  establish 
the  inconveniences  of  the  mercurial  system,  and  the  superior  advantages 
of  the  simple  treatment.  In  the  various  hospitals  of  Sweden  40,000 
cases  had  been  under  treatment,  one-half  by  the  simple  method,  the  re- 
maining half  by  mercury ; the  proportion  of  relapses  had  been,  in  the 
first  class,  seven  and  a half,  in  the  second  thirteen  and  two-thirds,  in  one 
hundred.  Dr.  Fricke’s  experiments  in  the  Hamburg  general  hospital 
were  first  made  public  in  1828.  In  four  years,  out  of  1649  patients  of 
both  sexes,  582  were  treated  by  a mild  mercurial  course,  and  1067 
without  mercury ; the  mean  duration  of  the  latter  method  was  51  days, 
and  that  by  mercury  85.  He  found  that  relapses  were  more  frequent, 
and  secondary  syphilis  more  severe,  when  mercury  had  been  given. 
When  the  non-mercurial  treatment  was  followed,  they  rarely  occurred, 
and  were  more  simple  and  mild  when  met  with.  He  tells  us  that  he  has 
treated  more  than  5000  patients  without  mercury,  and  has  still  to  seek 
cases  in  which  that  remedy  may  be  advantageously  employed.  He  has 
never  observed  caries,  loss  of  the  hair,  or  pains  in  the  bones  following  his 
treatment,  and  in  all  cases  which  have  come  under  his  care,  much  mer- 
cury had  been  given. 

In  1833  the  French  Consul  of  Health  published  the  reports  sent  in 
by  the  physicians  and  surgeons  attached  to  regiments  and  military  hos- 
pitals in  various  parts  of  France.  Some  of  the  reports  are  in  favor  of  a 
mild  mercurial  course,  others  - in  favor  of  simple  treatment.  They  all 
agree  in  stating  the  cure  by  mercury  to  be  one-third  longer  than  by  the 
other  treatment.  At  Strasburg,  mercury  was  only  given  to  very  obsti- 
nate cases.  Between  1831  and  1834,  5271  patients  had  been  thus 
treated,  and  the  number  of  relapses  and  secondary  affections  calling  for 
the  employment  of  mercury  was  very  small.  No  case  of  caries,  and  only 
one  or  two  instances  of  exostosis,  had  been  observed.  Full  reliance  may 
be  placed  on  these  facts,  as  regiments  remain  in  garrison  at  Strasburg 
for  five  or  six  years. 

In  the  various  reports  now  published  more  than  80,000  eases  have 
been  submitted  to  experiment,  by  means  of  which  it  has  been  perfectly 
established  that  syphilis  is  cured  in  a shorter  time,  and  with  less  pro- 
bability of  inducing  secondary  syphilis,  by  the  simple  than  by  the  mer- 
curial treatment. 

These  facts  are  now  very  generally  admitted,  and  malignant  syphilis 
is  gradually  disappearing.  Thirty  years  ago  the  most  frightful  secon- 
dary and  tertiary  cases  were  met  with,  and  the  usual  treatment  was  pro- 
fuse salivation.  At  present  such  cases  are  rare.  Abroad,  owing  to 
wise  police  regulations,  the  disease  is  infinitely  more  innocent  than  it  is 


982 


DISEASES  OF  THE  BLOOD. 


even  at  present  in  Scotland ; and  under  the  salutary  influence  of  a mild 
and  simple  treatment  its  virulence  is  daily  abating. 

In  appreciating  the  value  of  this  important  revolution  in  practice, 
we  should  not  forget  to  eulogise  those  who  had  first  the  boldness  to 
introduce  it.  The  credit  of  this  is  mainly  due,  in  England,  to  Mr. 
Fergusson  and  other  British  army  surgeons,  who  practised  it  during 
the  Peninsular  campaign  (Medico-Chir.  Trans.,  vol.  4) — and  to  Mr. 
Bose  of  the  Coldstream  Guards  (Ibid.,  vol.  8).  In  Scotland  the 
writings  and  lectures  of  the  late  Professor  John  Thomson  of  this  Uni- 
versity were  mainly  instrumental  in  convincing  Scotch  practitioners  of 
the  evils  of  mercury  in  venereal  diseases.  In  England  the  Hunterian 
theory  and  practice  have  been  deeply  rooted,  and  in  Ireland  have  been 
supported  by  the  writings  of  Carmichael  and  Collis.  Mercury  in  con- 
sequence is  still  very  generally  employed  in  those  parts  of  the  kingdom. 
The  gigantic  experiments  made  abroad,  however,  ought  to  convince  the 
most  sceptical — if  not,  let  him  compare  what  syphilis  is  in  Scotland 
with  what  it  was,  and  especially  observe  that  we  never  see  an  instance 
of  the  disease  such  as  those  recorded  (Cases  CCLXIX.  to  CCLXXI.), 
unless  the  patient’s  system  has  been  contaminated  with  mercury. 

For  an  account  of  the  treatment  by  inoculations,  or  what  is  called 
“ syphilisation,”  in  Italy,  France,  and  Norway,  which  was  apparently 
commenced  in  Case  CCLXXI.,  I must  refer  you  to  papers  by  Brs. 
Murchison  and  Lindsay,  in  the  Edinburgh  Monthly  Journal  for  June 
1852,  p.  575,  and  November  1857,  p.  407.  See  also  the  Brit,  and  For. 
Medico-Chir.  Beview,  vol.  45,  p.  118 ; and  Dr.  Boeck’s  pamphlet, 
“ Be  la  Syphilisation  : etat  actuel,  et  statistique  ” 1860.  I have  en- 
deavored to  impress  upon  you  the  great  difficulties  which  exist  in 
forming  a correct  diagnosis  of  syphilis.  Until  this  is  made  more  certain 
nothing  can  positively  be  determined  with  regard  to  the  results  of  ino- 
culation as  a therapeutic  procedure.  Again,  may  not  the  alleged  suc- 
cess which  has  attended  it  be  explained  by  the  disease  going  through 
its  natural  progress,  syphilisation,  according  to  Dr.  Boeck,  acting  best 
when  neither  mercury  nor  other  remedies  have  been  employed  ? 

BHEUMATISM  AND  GOUT. 

General  Fathology  and  Treatment. 

The  present  theory  with  regard  to  these  affections  is,  that  they  are 
both  connected  with  an  increase  of  lithic  acid  in  the  blood.  In  rheu- 
matism, this  is  dependent  on  excess  of  the  secondary,  and  in  gout  on 
excess  of  the  primary  digestion.  In  rheumatism,  however,  there  is  con- 
siderable excretion  of  lactic  acid  by  the  skin  (Todd),  while  in  gout  there 
is  an  excess  of  soda,  which,  uniting  with  the  lithic  acid,  produces  a com- 
pound of  lithate  of  soda,  that  may  be  detected  as  such  in  the  blood 
(Garrod),  while  sometimes  it  exudes  into  the  cellular  tissue  of  the  skin, 
constituting  tophaceous  deposits.  In  both  diseases  there  is  an  undue 
balance  between  the  excess  of  lithic  acid  and  the  power  of  excretion — in 
rheumatism  by  the  skin,  and  in  gout  by  the  kidney.^  This  pathology 
serves  to  explain  the  similitudes  and  differences  existing  between  the 


EHETJMATISM  AND  GOUT. 


983 


two  affections.  In  both  there  is  a certain  constitutional  state,  dependent 
on  deranged  digestion,  during  which  exciting  causes  occasion  local 
effects.  These  exciting  causes  in  rheumatism  are  bad  diet,  hard  work, 
exposure  to  cold  and  wet,  and  its  subjects  generally  are  the  poor  and 
laboring  population.  In  gout  the  causes  are  good  diet,  indolence, 
repletion,  or  indigestion,  and  its  subjects  are  for  the  most  part  the  rich 
and  sedentary.  The  local  manifestations  in  both  are  acute  wandering 
pains,  with  swelling — in  rheumatism  of  the  large,  and  in  gout  of  the 
small  joints,  constituting  the  acute  attack  in  the  one,  and  the  so-called 
regular  attack  in  the  other.  These  are  combined  with  a tendency 
to  various  complications  of  the  internal  viscera,  which  are  more  or  less 
dangerous  to  life.  . 

The  general  indications  of  treatment  are,  in  both  diseases — (1st),  So 
to  regulate  the  nutritive  functions  as  to  ensure  a due  balance  between 
the  amount  of  matters  entering  the  blood  as  the  result  of  digestion, 
primary  or  secondary,  and  the  amount  of  matters  discharged  from  the 
economy  by  the  excretory  organs.  (2),  To  conduct  the  acute  attack  to 
a favorable  termination,  carefully  watching  the  internal  viscera,  and 
being  prepared  to  act  with  vigor  should  these  become  affected.  Hence 
the  treatment  of  these  diseases  resolves  itself  into  what  may  be  called 
curative  and  preventive — the  first  having  reference  to  the  acute  attack, 
the  second  to  the  means  most  likely  to  hinder  its  return ; the  one  must 
be  carried  out  by  remedies  which  act  upon  the  blood  and  excretory 
organs,  the  other  by  the  management  of  diet  and  exercise. 

Although  the  general  pathology  above  mentioned,  which  considers 
rheumatism  as  a blood  disease,  may  be  considered  on  the  whole  as  cor- 
rect, we  are  not  yet  enabled  to  explain  by  it  the  symptoms  of  an  acute 
attack  of  the  disease,  where,  in  addition  to  the  constitutional  disorder, 
we  have  local  pain,  occasional  heat,  redness,  and  swelling,  with  febrile 
symptoms.  Most  practical  men  have  attributed  these  phenomena  to  a 
superinduced  inflammation,  although  it  has  not  been  shown  that  exuda- 
tion occurs,  or  that  it  is  followed  by  the  usual  results  of  that  condition. 
Besides,  its  erratic  character  is  opposed  to  what  we  know  of  the  process 
of  true  inflammation,  and  calling  it  an  unhealthy  inflammation  in  no 
way  clears  up  the  mystery.  The  real  pathology  of  acute  rheumatism, 
therefore,  has  yet  to  be  determined,  and,  as  a preliminary  step,  a careful 
histological  examination  of  the  affected  tissues  is  absolutely  necessary. 
So  far  as  I am  aware,  this  has  never  yet  been  attempted,  if  we  except 
some  observations  by  Hasse  on  the  structure  of  the  bones  in  rheuma- 
tism (see  Monthly  Journal  of  Medical  Science  for  June  1847). 

Our  treatment  of  this  disease,  therefore,  is  purely  empirical,  some- 
times directed  against  the  pain,  at  others  against  the  supposed  inflamma- 
tion ; now  attempting  to  combat  the  pathological  condition  of  the  blood, 
then  striving  to  remedy  its  effects  by  acting  on  the  excretions,  and  not 
unfrequently  giving  specifics,  in  the  hope  that  any  change  in  the  con- 
stitution, however  produced,  may  be  beneficial.  In  no  disorder,  pro- 
bably, has  such  a crowd  of  opposite  remedies  and  plans  of  treatment 
been  extolled,  and  yet  none  of  them  can  be  depended  on ; so  that  it  has 
been  hinted  that  six  weeks’  rest  is  the  most  useffil  prescription  (Warren). 
The  latest  author  on  rheumatism  endeavors  to  explain  the  fact  by  ob- 


084 


DISEASES  OF  THE  BLOOD. 


serving  that  this  need  not  to  be  wondered  at  by  “ those  who  consider 
the  true  nature  of  the  disorder,  and  the  variety  of  circumstances  under 
which  the  physician  may  be  called  upon  to  minister  to  his  patient’s 
relief.  The  bleeding,  which  in  the  young,  plethoric,  and  robust,  may 
be  necessary  to  allay  excessive  vascular  action  and  cause  free  secretion, 
may  in  the  weakly  induce  irritability  of  the  heart,  and  a consequent 
attack  of  cardiac  inflammation.  The  opium,  which  in  one  person  may 
prove  of  the  greatest  service  in  promoting  free  perspiration,  and  in 
allaying  the  general  irritability  of  the  system,  may  in  another  check  the 
biliary  and  other  secretions,  and  thus  prevent  the  elimination  of  the 
rheumatic  poison.  The  continued  use  of  calomel,  and  the  constant 
purging,  which  may  be  beneficial  to  one  patient  by  removing  large 
quantities  of  unhealthy  secretions,  may  unnecessarily  exhaust  the 
strength  of  another,  and  tend  very  greatly  to  impede  recovery.  And 
so  in  regard  to  every  remedy  which  has  been  proposed.  What  is  use- 
ful at  one  time  proves  useless,  or  positively  injurious,  at  another ; and 
the  conclusion  is  forced  upon  us,  that  what  is  wanted  ‘ is  far  less  the 
discovery  of  untried  methods  of  treating  disease,  than  of  discriminative 
canons  for  the  proper  use  of  those  we  possess;  ’ — far  less  the  discovery 
of  any  new  medicines,  than  the  adaptation  of  our  present  remedies  to 
the  exigencies  of  each  case  ” (Fuller  on  Kheumatism,  p.  73).  These 
judicious  observations  may  serve  to  explain  the  cause  of  our  failure  ; but 
until  we  obtain  more  exact  information  regarding  the  special  pathology 
of  rheumatism,  it  is  in  vain  to  hope  for  a rational  treatment. 

Occasionally  I have  tried  the  effects  of  special  remedies  in  this 
disease,  and  watched  a series  of  cases,  all  which  were  treated  in  the 
same  manner.  Thus  I have  tried  aconite,  and  believe  that  alone  it  is 
of  little  service ; colchicum  also  I have  given  frequently,  and  am  of 
opinion  that  in  pure  rheumatism  it  is  of  no  advantage,  although  in  gout 
it  is  invaluable. 

Treatment  of  Acute  Rheumatism  hy  Nitrate  of  Potash. 

During  the  session  1851-52  I made  another  trial  of  this  kind  with 
the  nitrate  of  potash,  a remedy  formerly  recommended  by  Dr.  Brock- 
lesby,  and  which  had  been  given  with  good  effect  by  M.  Gendrin  in  the 
wards  of  La  Pitie  in  Paris,  as  recorded  by  Dr.  Henry  Bennet  (Lancet, 
1844,  vol.  i.  p.  374).  It  has  more  lately  been  pressed  on  our  atten- 
tion by  Dr.  Basham  (Medico-Chir.  Trans.,  vol.  xxxii.),  who  tells  us  that 
from  one  to  three  ounces  of  the  salt,  if  freely  diluted  in  water,  may  be 
taken  by  the  patient  in  the  course  of  twenty-four  hours,  without  any 
injurious  results,  but  with  the  effect  of  relieving  in  a marked  manner 
the  swelling,  heat,  and  pain  in  the  joints.  In  the  following  cases  the 
remedy  was  tried  in  much  smaller  doses,  and  it  appears  to  me  with  more 
than  average  success. 

Case  CCLXXIL* — Mrs.  Anderson,  a?t.  48,  sick  nurse — admitted  December  3d, 
1851.  States  that  previous  to  the  present  attack  she  had  always  enjoyed  pretty  good 
health,  with  the  exception  of  a liability  to  a slight  cough ; had  been  lately  sub- 
jected to  much  fatigue  in  her  occupation  as  a sick  nurse,  and  had  been  exposed  to 


* Reported  by  Mr.  William  Broadbent,  Clinical  Clerk. 


rheumatism:  and  gout. 


985 


cold  from  sitting  up  for  several  nights  in  succession  in  a large  room,  heated  by  a fire, 
and  ventilated  by  keeping  the  windows  open.  Having  no  adequate  protection  from 
the  cold  draught  thus  caused,  she  became  affected  with  sore  throat,  and  had  pain  in 
the  chest.  TMs  occurred  in  the  latter  part  of  October  last,  and  from  that  time  up 
to  November  20th  she  suffered  from  slight  shivering  and  uneasiness  ; transient  pain 
in  different  parts  of  the  body ; nausea  and  vomiting.  About  a fortnight  before 
admission,  she  had  a distinct  rigor,  followed  by  heat  of  skin  and  other  febrile 
symptoms,  with  very  severe  pain  in  the  joints  especially,  much  increased  by  any 
attempt  at  motion.  The  vomiting  also  continued  ; and  last  Week  she  suffered  from 
pain  and  palpitation  in  the  cardiac  region,  and  at  the  same  time  an  aggravation  of 
her  former  symptoms.  At  present  she  cannot  move  without  suffering  excruciating 
agony,  having  severe  pain  apparently  in  every  joint  of  the  body.  Heart’s  sounds, 
impulse,  rhythm,  and  position  normal ; pulse  about  100,  weak.  Irregular  tits  of 
copious  clammy  perspiration,  of  acid  smell ; no  oedema  of  the  joints.  Urine  scanty, 
dark-colored,  deposits  crystals  of  the  triple  phosphates,  with  some  mucus.  Tongue 
loaded ; anorexia ; thirst  ; occasional  vomiting ; no  tenderness  on  pressing  the 
epigastrium ; bowels  confined  ; pulmonary  functions  normal.  Mariatis  Morphia 
semigranum  ; Fulveris  Aromatici  grana  quinque.  M.  Ft.  pulv.  Mittantur  tales  sex. 
One  to  be  taken  every  half  hour.  December  Ath. — She  took  three  of  the  powders 
last  night,  after  which  she  fell  asleep;  and  this  morning  feels  somewhat  better; 
she  has  also  had  the  bowels  emptied  by  an  enema,  and  is  now  using  a diuretic  mix- 
ture. December  hth. — Pains  in  limbs  much  the  same ; gets  no  sleep ; perspiration 
still  copious  ; urine  not  increased  in  quantity  ; vomiting  continues  ; has  been  taking 
diuretics  and  Dover’s  powder.  December  6/A. — Had  an  exacerbation  last  night,  the 
pain  in  the  joints  and  limbs  being  excruciating.  Potassce  Nitratis  semiunciam ; 
Aquae  uncias  sex.  Misce  et  signetur — a table- spoonf  al  every  four  hours.  December 
*lth. — Has  taken  three  doses  of  the  medicine  ; she  perspired  a good  deal  during  the 
night ; urine  not  increased  in  quantity ; pain  is  less  severe.  December  d>th. — Still 
sweats  a good  deal ; pains  much  the  same  as  yesterday.  Adde  misturae  Nitratis 
Potass.  3j-  December  ^th. — Pains  better;  copious  perspiration;  urine  increased  in 
quantity  ; increase  of  the  nausea  and  vomiting  and  of  the  thirst.  December  \0th. — 
Pains  nearly  gone  ; sickness  continues  ; refuses  to  use  her  medicine  ; pulse  80,  weak ; 
much  general  debility.  After  this  date  the  pain  ceased  entirely,  and  she  was  shortly 
afterwards  discharged  cured. 

Commentary. — This  was  a severe  case  of  both  general  muscular  and 
articular  rheumatism,  of  a fortnight’s  standing  when  she  entered  the 
house.  There  was  still,  however,  great  pain  on  the  slightest  movement, 
which,  during  two  days,  in  no  way  yielded  to  morphia,  diaphoretics, 
and  diuretics.  On  the  exhibition  of  the  nitrate  of  potash,  profuse 
diaphoresis  came  on,  which  was  apparently  kept  up  by  the  medicine, 
with  marked  amendment  to  the  rheumatic  pains,  followed  by  rapid 
recovery.  The  improvement  could  not  be  attributed  to  the  occurrence 
of  any  critical  day  in  this  case ; and  the  night  previous  to  the  exhibition 
of  the  remedy  there  had  been  a marked  exacerbation.  Every  one  who 
saw  this  case  felt  persuaded  that  the  good  effects  were  attributable  to  the 
nitrate  of  potash. 

Case  CCLXXIII.*— Jane  Irvine,  set.  lY,  servant,  admitted  19th  December 
1851.  States  that  seven  days  ago,  whilst  engaged  at  her  usual  occupation,  she  was 
suddenly  seized  with  severe  febrile  symptoms,  and  constant  pain  in  the  left  ankle, 
which  was  increased  by  pressure  and  motion ; it  was  red  and  tumefied.  On  the 
following  day  the  right  ankle  became  similarly  affected,  and  then  in  succession  the 
knees,  shoulders,  wrists,  and  fingers ; the  pain  still  continuing,  but  modified  in 
severity  in  the  parts  first  attacked.  She  had  been  undeigoing  treatment  by 
diaphoretics,  without,  however,  having  experienced  any  relief  from  them.  On 
admission  the  pulse  is  100,  full  and  soft.  A soft  bellows  murmur,  synchronous  with 
the  radial  pulse,  accompanies  the  first  sound,  heard  loudest  at  the  base,  and  is  propa- 

* Reported  by  Mr.  J.  L.  Brown,  Clinical  Clerk. 


986 


DISEASES  OF  THE  BLOOD. 


gated  along  the  course  of  the  large  arteries.  Cannot  sleep  from  the  pain,  u hich  is 
general,  and  is  causing  intense  sutfering.  Tongue  moist,  preternaturally  red  at  the 
tip  and  margin ; no  appetite;  thirst,  nausea,  and  vomiting;  the  bowels  are  costive; 
some  tenderness  on  pressure  in  the  epigastrium.  Urine  high  colored,  deposits  a 
slight  sediment  of  lithates.  Skin  moist,  from  copious  perspiration;  knees  and  ankles 
are  swollen  and  painful  on  the  least  pressure.  The  right  wrist,  especially  near  the 
metacarpal  bone  of  the  thumb,  is  at  present  the  seat  of  greatest  suffering,  and  is  red, 
painful,  and  swollen.  Ordered  to  be  bled  to  § xvj,  and  to  have  a -purgative  enema. 
December  ‘■10th. — Is  much  worse  to-day;  the  pains  in  the  wrist  and  hands  are  especially 
aggravated.  Copious  perspiration  still  continues,  Potass.  Nitratis  § ss ; Aquce 
§ vj,  A table-spoonful  every  four  hours.  December  2\st.—  Slept  during  the  night. 
The  sweating  is  still  profuse.  Urine  in  moderate  quantity,  sp,  gr.  1016,  deposits 
lithates.  Pulse  90,  weak  ; cardiac  murmur  very  indistinct.  The  pain  is  considerably 
relieved,  except  in  the  left  lower  extremity.  December  lid. — Still  continues  taking 
the  Potass.  Nit.  ; the  improvement  more  marked,  and  she  can  allow  the  limbs  to  be 
moved  about  to-day,  December  l^d. — She  presents  quite  a cheerful  appearance  to- 
day, and  is  entirely  relieved  from  pain ; all  the  joints  can  be  moved  quite  freely  with- 
out exciting  uneasiness.  Pulse  68  ; skin  cool  ; tongue  clean  ; appetite  returning ; 
bowels  regular  ; urine  natural — some  sediment.  Cardiac  murmur  is  more  distinct  to- 
day.— Convalescence  proceeded  satisfactorily  from  this  date  till  January  6th,  when 
she  was  attacked  by  typhus  fever,  from  which,  however,  she  ultimately  recovered, 
and  was  dismissed  well. 

Commentary. — This  was  also  a very  severe  case  of  general  rheumatism, 
which  was  in  no  degree  benefited  by  diaphoretics,  and  a large  bleeding 
on  the  seventh  day.  On  the  8th  day  she  was  if  anything  worse,  and 
then  nitrate  of  potash  was  given,  producing  marked  relief  on  the  follow- 
ing  day.  On  the  eleventh  day  of  the  disease,  and  third  from  the 
exhibition  of  the  salt,  the  disease  was  subdued  and  she  became  convales- 
cent. Here,  again,  the  period  of  improvement  cannot  be  confounded 
with  critical  days,  and  strictly  corresponds  to  the  administration  of  the 
remedy.  The  bleeding  may  have  assisted  its  efi'ects,  but  certainly  was 
not  followed,  as  is  usually  the  case,  by  any  evident  amelioration.  This 
girl  had  an  endocardial  murmur  on  admission,  which  continued  during 
the  progress  of  the  case,  and  I ascertained  from  the  medical  practitioner 
who  sent  her  into  the  house  that  she  had  labored  under  this  before  the 
attack  of  rheumatism  came  on.  Was  this,  therefore,  an  anemic  murmur 
independent  of  the  general  disease,  or  produced  by  it?  We  may  ask 
another  question — viz..  Are  all  the  endocardial  murmurs  occurring  in 
conjunction  with  rheumatism  caused  by  endocarditis,  and  attributable  to 
the  rheumatic  diathesis  ? These  questions  demand  more  careful  atten- 
tion to  these  murmurs  in  young  women  than  has,  I think,  hitherto  been  paid 
to  them.  For  my  own  part,  I am  satisfied  that  these  anemic  murmurs  in 
young  girls  are  very  common,  and  that  they  have  frequently  been  mis- 
taken for  sounds  dependent  on  endocarditis.  As  the  patient  becomes 
more  robust  these  murmurs  disappear,  and  hence,  probably,  has  arisen 
the  idea  of  the  good  effects  of  mercury  when  given  in  such  cases. 

Case  CCLXXIY.* — Janet  Wright.  This  woman  had  been  admitted  October  22d, 
1851,  laboring  under  the  usual  symptoms  of  acute  rheumatism,  and  had  been 
undergoing  treatment  by  Dover’s  powder,  diuretics,  leeching,  etc.,  up  to  the  6th 
December,  without  any  benefit  whatever,  when  on  that  day  she  was  ordered  1^  Potass. 
Nitratis  3 iij  ; Aq.  3 vj.  Misce.  A table-spoonful  every  three  hours.  December  ^Uh. 
— Has  taken  four  doses  of  the  medicine,  but  without  any  good  effect.  Took  a dose 
of  Dover’s  powder  last  night,  and  slept  well ; pain  in  the  shoulders  very  severe,  and 


Reported  by  Mr.  William  Broadbent,  Clinical  Clerk. 


EHEUMATISM  AND  GOUT. 


987 


also  in  the  knees.  December  8th. — Pain  still  continues.  Adde  miaturce  Potass.  Ni- 
ty'atis  3j.  December  10th. — Has  been  using  the  medicine  regularly;  she  says  it 
makes  her  very  weak,  sleepy,  and  stupid.  She  sweats  a good  deal  at  night,  and  the 
urine  is  increased  in  quantity ; is  very  thirsty,  and  complains  of  bad  taste  in  her 
mouth;  pains  gone  from  knees.  December  18th. — Still  continues  the  medicine.  No 
return  of  pain  in  the  knees  ; greatly  relieved  in  shoulders,  etc. ; the  increased  secre- 
tion from  the  skin  and  kidneys  continues.  The  improvement  continued  up  to  the  16th, 
when  she  was  dismissed  for  disorderly  conduct. 

Commentary. — In  this  case  the  nitrate  of  potash,  after  being  taken 
for  three  days,  had  caused  much  diaphoresis  and  diuresis,  followed  by 
diminution  in  the  rheumatic  pains,  and  rapid  improvement  at  the  time 
she  was  dismissed. 

Case  CCLXXY.* — James  Rough,  aet.  26,  blacksmith,  admitted  December  29,  1851. 
States  that  he  has  suffered  on  two  former  occasions  from  attacks  of  rheumatism. 
During  his  last  attack,  three  years  ago,  he  was  treated  in  this  hospital,  and  it  lasted 
five  weeks.  The  present  attack  came  on  nine  days  ago  with  great  severity,  having 
been  preceded  by  febrile  symptoms,  wliich  appeared  to  have  followed  exposure  to 
cold ; the  pain  was  very  severe  in  all  the  joints,  but  especially  so  in  the  wrists  and 
knees.  He  has  noticed  within  the  last  year  or  two  that  considerable  palpitation 
of  the  heart  ensues  after  much  exertion,  or  indulgence  in  ardent  spirits ; but  in  his  or- 
dinary condition  he  is  not  troubled  with  it.  At  present  the  pain  in  the  joints  is  not 
severe,  unless  on  attempting  motion  ; pressure  on  the  right  shoulder  and  ankle  causes 
considerable  tenderness.  The  cardiac  dulness  measures  a few  lines  more  than  two 
inches  across  ; the  apex  strikes  the  thoracic  parietes  in  the  normal  position.  A very 
distinct  bellows  murmur  accompanies  the  first  sound,  is  heard  loudest  at  the  apex,  and 
is  not  prolonged  along  the  course  of  the  great  vessels  ; the  second  sound  is  more 
sharp  and  abrupt  *than  natural.  The  radial  pulse  is  not  synchronous  with  the  impulse 
of  the  heart,  but  follows  it  after  a very  appreciable  interval.  A few  sibilant  rales 
can  be  heard  here  and  there  over  the  chest.  Tongue  is  slightly  furred ; appetite  is 
impaired ; thirst  not  excessive.  There  is  slight  diarrhoea.  The  urine  is  normal. 
Skin  is  moist,  but  no  excessive  perspiration,  R Potass.  Nitratis  § ss  ; Aq.  | vj. 
M.  A table-spoonful  to  be  taken,  diluted  with  much  water,  three  times  a day.  Decem- 
ber 81st. — Pains  much  easier  to-day.  The  bellows  murmur  is  much  softer  also.  Urine 
deposits  some  lithates.  Is  sweating  a little  to-day.  Pulse  86,  soft  and  regular. 
January  'Id,  1852  (Thirteenth  day). — Has  no  pain  to-day.  Continues  to  perspire  a 
good  deal ; and  the  urine  deposits  a copious  precipitate  of  the  lithate  of  ammonia. 
Pulse  68,  soft  and  regular.  Complains  much  of  weakness.  After  this  date,  the  amend- 
ment continued  uninterruptedly,  although  only  one  bottle  of  the  Nit.  of  Potash  mix- 
ture had  been  used,  and  he  was  dismissed  cured  on  the  12th  January. 

Commentary, — The  employment  of  the  nitrate  of  potash  was  followed 
by  apparently  marked  effects  in  this  case,  producing  diaphoresis  and 
evident  benefit  on  the  twelfth  day,  and  removal  of  pain  on  the  thirteenth 
day  of  the  disease.  As  the  attack  commenced  nine  days  before  admis- 
sion, we  cannot  suppose  that  the  recovery  was  owing  to  the  occurrence 
of  a critical  day.  Besides,  the  good  effects  were  apparent  the  day  after 
the  exhibition  of  the  salt,  and  on  the  following  day  the  pains  had 
disappeared.  The  valvular  murmur  with  the  first  sound  at  the  apex, 
and  the  character  of  the  pulse,  could  leave  little  doubt  as  to  the  mitral 
incompetency ; and  as  he  had  been  previously  subject  to  rheumatism, 
there  is  every  probability  that  the  cardiac  lesion  was  the  result  of  pre- 
vious attacks  of  the  disease. 

In  a large  number  of  cases  which  I have  subsequently  treated  with 
nitrate  of  potash,  I have  satisfied  myself  that  the  disease  is  more  readily 
subdued  by  this  treatment  than  by  any  other. 

* Reported  by  Mr.  William  Calder,  Clinical  Clerk. 


988 


DISEASES  OF  THE  BLOOD. 


Treatment  of  Rheumatism  hy  Lemon-juice. 

Case  CCLXXVI.*—* Abigail  Rankin,  a servant,  aet.  39 — admitted  15tli  Decemlber 
1852.  Had  rigors  on  the  '7th,  followed  by  febrile  symptoms  and  acute  pain  in  all  the 
joints.  On  admission,  pulse  100,  full  and  strong  ; heart  sounds  normal ; considerable 
febrile  symptoms ; acute  pains  and  swelling  in  all  the  joints  increased  on  motion; 
much  sweating  at  night.  Other  functions  healthy.  - Habeat  Succ.  lAmonnm  ^ ij  ter 
indies.  On  the  I'Zth  she  was  ordered  3j  of  Dover’s  powder.  December  20th. — The 
pains  have  continued  as  acute  as  ever  till  to-day,  although  she  has  taken  f vj  of  lemon- 
juice  every  twenty-four  hours.  At  present  she  experiences  somewhat  less  suffering  on 
moving  the  joints.  Habeat  Succ.  Limonum  f iij  ter  indies.  December  22d — There 
was  great  sweating  last  night,  and  to-day  she  is  much  better.  Habeat  Sticc.  Limonum 
§ i ter  indies.  Some  swelling  of  the  left  wrist  joint  remained  until  the  23d,  on  which 
day  all  pain  had  left  her.  Dismissed  well,  January  6th,  1853. 

Case  CCLXXVII.f — Catharine  Rooke,  set.  21,  married— admitted  December  23d, 
1852.  Had  rigors  on  the  14th,  followed  by  febrile  symptoms  and  excessive  pain,  at 
first  in  the  knees  and  ankles,  but  subsequently  in  every  joint  in  the  body.  On  ad- 
mission pulse  84,  of  moderate  strength;  heart’s  sounds  and  impulse  normal ; the  joints 
are  more  or  less  swollen,  painful  on  pressure  and  on  motion  ; skin  bathed  with  perspi- 
ration ; febrile  symptoms,  with  the  exception  of  increased  pulse,  well-marked  ; a con- 
siderable deposit  of  lithates  in  the  urine.  Other  symptoms  noimal.  ^ Pulv.  Doveri 
gr.  X statim  smnend.  ^ Sol.  Mur.  Morph.  3 ss  ; Potasses  Bitart.  § ss  ; Sp.  HEther. 
Nit.  § j ; Aquee  3 j ; Pt.  haust.  kora  somni  sumendus.  On  the  25th,  purgatives  of 
calomel  and  jahip  were  ordered.  Dec.  2Uh. — The  pain  and  swellings  of  the  joints 
have  somewhat  diminished,  but  are  still  very  acute.  Habeat  Succ.  Limon.  §j  ter 
indies.  Jan.  2,  1853. — The  pains  have  slowly  subsided  since  last  report,  but  there  is 
still  considerable  soreness  and  stiffness  of  the  knees.  The  arthritic  swellings  have 
everywhei’e  disappeared.  Jan.  47A. — Acute  pain  has  returned  in  the  right  arm, 
which  she  cannot  move.  Jan.  ^th. — Acute  pain  has  extended  to  the  right  arm  and 
back.  Omittatur  Succ.  Limonum.  Potasses  Nitratis  ^ ss ; Agues  '^\v.  M. 

Sumat  ex  agues  | iv  ter  indies.  Jan.  0th. — The  pains  have  now  disappeared ; 
marked  improvement.  No  critical  discharge.  Dismissed  well,  January  7th. 

Case  CCLXXVIII.f — Thomas  Aitken,  aet.  30,  blacksmith — admitted  December 
25th,  1852.  Fourteen  days  ago,  after  exposure  to  cold,  he  was  attacked  by  rigors, 
followed  by  febrile  symptoms  and  pain  in  his  joints,  which  have  continued  up  to  this 
date.  On  admission,  pulse  74,  rather  weak.  A blowing  murmur  wdth  the  first 
sound,  loudest  at  the  apex,  which  it  seems  resulted  from  a previous  attack  twelve 
months  ago.  Slight  swelling  only  in  his  right  hand  and  wrist,  but  there  is  pain  in  all 
the  joints,  more  or  less  of  an  erratic  character.  Febrile  symptoms  very  slight.  Slight 
bronchitis.  Habeat  Succ.  Limonum  3 ss  ter  indies.  On  the  28th,  the  dose  of  lemon- 
juice  w^as  increased  to  |j.  On  Jan.  'id  he  was  much  better;  but  on  the  4th  the 
pains  returned,  but  not  so  violently.  On  the  12th,  he  was  free  from  pain,  having  had 
some  diarrhoea,  and  taken  a two-scruple  dose  of  Dover’s  powder.  On  the  22d  the  pains 
returned,  but  again  subsiding  on  the  24th,  he  was  dismissed. 

Case  CCLXXIX.f — James  Ollason,  set.  20,  clerk — admitted  January  4th,  1853, 
with  organic  disease  of  the  heart  of  old  standing,  and  chronic  rheumatism  of  an  erratic 
character,  sometimes  violently  attacking  one  joint  and  sometimes  another,  accom- 
panied with  swelling  and  tenderness.  Lemon-juice  in  | j doses  was  tried  three  times 
a day,  for  four  days ; but,  being  evidently  of  little  benefit,  was  then  abandoned  for 
opiates  and  sedatives. 

Commentary. — In  no  one  of  these  four  cases  in  which  lemon -juice 
was  given,  although  in  two  six  ounces  and  in  one  nine  ounces  were 
taken  daily,  did  it  appear  to  me  that  the  disease  was  in  any  way  con- 
trolled or  alleviated  by  the  remedy.  In  Case  CCLXXVI.  six  ounces 
were  taken  daily  without  any  effect,  and  then  the  quantity  was  increased 
to  nine  ounces  daily,  until  the  21st  day  of  the  disease,  when  sweating 
and  resolution  of  the  symptoms  followed,  more  from  natural  crisis,  per- 

* Reported  by  Mr.  F.  M.  Russell,  Clinical  Clerk. 

f Reported  by  Mr.  Alexander  J.  Macarthur,  Clinical  Clerk. 


RHEUMATISM  AND  GOUT. 


989 


haps,  than  from  the  effects  of  the  juice.  In  case  CCLXXVTI.  the 
remedy  was  continued  for  ten  days,  and  until  the  21st  day  of  the  disorder 
was  fairly  passed.  The  nitrate  of  potash  was  given  with  the  immediate 
effect  of  relieving  the  symptoms — although  here  also  it  is  not  improbable 
that  a natural  crisis  of  the  disease  was  then  established.  In  any  case  the 
inefficiency  of  the  lemon-juice  appeared  manifest.  Cases  CCLXXVIII. 
and  OCLXXIX.  were  cases  of  sub-acute  and  erratic  rheumatism,  which 
also  resisted  the  lemon-juice;  the  first  for  a month,  the  second  for  four 
days.  On  the  whole,  this  trial  of  the  remedy  was  in  no  way  favorable, 
and  is  strongly  contrasted  with  the  good  effects  of  nitrate  of  potash, 
which  I formerly  brought  before  you. 

Case  CCLXXX.* — Diaphragmatic  Rheumatism. 

History. — John  Robinson,  a bookbinder,  set,  24 — admitted  February  5th,  1858. 
He  says  that  on  Sunday  last,  January  31st,  he  caught  cold  when  at  a funeral,  and 
experienced  some  pain  across  the  back  and  chest,  especially  on  the  right  side.  He 
felt  extremely  weak,  and  experienced  great  difficulty  in  breathing.  On  the  following 
day  he  noticed  an  eruption  on  the  extensor  surfaces  of  both  legs.  Beyond  a blister 
which  was  applied  to  the  painful  side,  he  has  been  subjected  to  no  treatment. 

Symptoms  on  Admission. — Pain  on  inspiration  over  right  side,  laterally  and  pos- 
teriorly, Slight  cough  with  scanty  expectoration.  Percussion  good  and  ecjual  on 
both  sides.  On  auscultation  slight  harshness  of  inspiratory  murmur ; pulmonary 
sounds  otherwise  normal.  Pulse  110,  soft.  Tongue  furred,  but  moist ; bowels  open; 
skin  hot ; perspires  abundantly.  The  extensor  surfaces  of  both  legs  are  covered  with 
urticaria.  Other  systems  normal.  To  have  scruple  doses  of  nitrate  of  potash  in  half 
a tumblerful  of  water  three  times  a day. 

Progress  op  the  Case. — Feb.  ^th. — Perspired  profusely  yesterday,  and  to-day 
there  is  a copious  sediment  of  urates  in  the  urine.  The  pain  is  greatly  relieved. 
The  urticaria  is  nearly  gone,  but  there  is  an  erythematous  spot  over  each  patella. 
Feb.  \hth. — Has  now  no  pain,  and  complains  of  weakness  only.  R Quince  Sulph. 
gr.  i. ; Acid.  Nitric,  m.  x. ; Aquae  ^ j ; M.  Ft.  haustus  ter  in  die  sumendus.  Dis- 
missed well,  March  10th. 

Commentary. — Deep-seated  rheumatic  pains  in  the  chest  are  very 
apt  to  be  mistaken  for  pleural  or  pulmonary  diseases.  In  the  present 
case  I found  most  of  the  clinical  clerks  disposed  to  consider  the  disease 
a pleuro-pneumonia,  and  they  had  framed  a report  which  gave  con- 
siderable color  to  their  opinion.  A careful  examination  of  the  chest, 
however,  convinced  me  that  the  lungs  were  sound,  whilst  the  febrile 
symptoms,  the  pain  on  inspiration  and  its  seat,  satisfied  me  we  had  to 
do  with  diaphragmatic  rheumatism.  The  treatment,  therefore,  was 
governed  by  this  view  of  the  case,  and  we  saw  the  usual  phenomena  of 
critical  discharge  by  urine  and  skin  on  the  seventh  day  of  the  disorder. 
He  was  of  weak  constitution,  however,  and  lingered  in  the  house  some 
time  longer.  In  the  same  manner  intercostal  rheumatism  is  very  likely 
to  be  mistaken  by  inexperienced  persons  for  pleurisy,  especially  if  they 
are  not  sure  of  the  non-existence  of  friction  or  other  physical  sign  in 
the  chest,  which  their  pre-conceptions  have  suggested  to  them  exists 
there.  But  if  they  carefully  compress  and  rub  the  muscles  between  the 
ribs,  while  the  chest  is  at  rest,  pain  will  be  elicited,  even  to  a greater 
extent  than  occurs  during  inspiration ; a symptom  which  is  diagnostic. 
Such  cases  formerly  must  have  frequently  been  mistaken  for  pleurisy,  and 
bled  of  course  with  the  effect  of  ultimately  causing  a cure.  In  agricultural 

* Reported  by  Mr.  Adolphe  Baraud,  Clinical  Clerk. 


990 


DISEASES  OF  THE  BLOOD. 


districts,  slight  intercostal  or  diaphragmatic  rheumatism  is  most  common 
at  certain  seasons  of  the  year  among  laborers,  who  used  consequently  to 
be  bled  on  a Saturday  afternoon,  rest  all  Sunday,  and  return  to  their 
work  quite  well  on  the  following  Monday.  In  such  persons  the  vene- 
section was  supposed  by  both  practitioner  and  patient  to  have  cut  short 
an  incipient  pleurisy. 

Case  CCLXXXI.* — Rheumatic  Iritis^  following  Acute  Rheumatism — 

Recovery. 

History. — John  Duffy,  ast.  25,  Ordnance  surveyor — admitted  April  6th,  185Y. 
Three  weeks  before  admission,  when  in  the  pursuit  of  his  occupation,  he  got  wet,  and 
a day  or  two  afterwards  was  seized  with  rigors,  followed  by  febrile  symptoms,  pains  in 
all  his  joints,  and  swelling  of  both  knees,  and  of  the  left  elbow.  After  being  in  bed  a 
fortnight  and  treated  medically,  he  entered  the  Infirmary,  where  he  took  Pulv.  Dover! 
and  Tr,  Colchici  internally,  and  had  Tr.  lodini  applied  locally.  On  taking  charge  of 
the  case  in  May  I first  administered  Nitrate  of  Potash ; subsequently  he  was  ordered 
warm  baths,  and  then  quinine  and  wine  with  generous  diet,  under  which  treatment  he 
became  much  better.  * Chronic  pains,  however,  still  continuing  to  linger  about  the 
joints,  and  especially  the  knees,  cod-liver  oil  was  ordered  on  the  25th  of  May,  both 
internally  and  externally,  and  the  quinine  was  discontinued. 

Occurrence  of  Iritis  and  Progress  of  the  Case. — June  ^th.—  For  three  days 
has  had  slight  redness  of  the  conjunctivae,  with  watering  of  both  eyes,  for  which  he 
was  ordered  a zinc  lotion.  June  9th. — Conjunctivitis  on  the  right  side  increased,  and 
a small  blister  was  applied  over  the  right  temple.  June  10th. — Frontal  headache. 
The  conjunctiva,  immediately  around  the  cornea,  is  surrounded  by  a zone  of  straight 
vessels,  radiating  outwards.  Inferior  half  of  conjunctiva  of  uniform  red  color.  To 
be  cupped  over  right  temple,  and  § v of  blood  extracted.  Extract  of  belladonna 
to  be  applied  externally  round  the  eye.  June  11th. — The  whole  of  right  conjunctiva 
of  a deep  uniform  vermilion,  and  zone  of  vessels  round  the  cornea  of  a darker  shade. 
Atropine  to  be  dropped  into  the  eye  to  ensure  dilation  of  the  pupil.  To  wear  a large 
shade.  Jime  IZth. — Yesterday  a weak  lotion  of  Alum  (gr.  iij  to  | j of  water)  was 
applied,  but  has  caused  much  irritation.  Inner  margin  of  iris  thickened  and  irregular, 
pupil  dilated.  Discontinue  lotion,  apply  belladonna  externally,  and  a warm  poultice 
over  the  eye  at  night.  June  14:th. — To-day  iritis  and  conjunctivitis  have  appeared 
ill  the  left  eye.  Much  pain  in  head,  and  restlessness  during  the  night.  Appetite 
bad ; tongue  coated ; pulse  7 6,  moderate  strength.  To  have  Quince  Sulph.  gr.  iij 
three  times  a day.  To  go  into  the  side  room,  and  the  window  to  be  obscured.  June 
l^th.  Left  conjunctiva  now  of  as  uniform  redness  as  the  right,  and  iritis  well 
developed ; pupil,  however,  more  dilated.  Belladonna  has  been  applied  round  both 
eyes.  Last  night  had  § j of  Castor-oil,  which  not  having  operated,  was  ordered  to-day, 
01.  Croton,  gutt.  unam  et  Ext.  Colocynth.  Co.  gr.  x.  June  20^A.— Both  irides,  which 
naturally  are  of  a light-blue  color,  present  a dark,  dirty  green  color.  The  pupillary 
margins  are  thick,  and  that  of  the  right  side  irregular,  especially  at  one  place  where 
an  adhesion  has  formed.  Both  conjunctivae  are  of  a uniform  dense  vermilion  color. 
There  is  considerable  pain  in  the  head  ; photophobia  and  lachrymation.  Discontinue 
quinine.  ^ Pulv.  Cinchon.  Ruhr,  et  Pulv.  Sodce  Bicarb,  aa  gr.  v.  Ft.  pulv.  to  he 
taken  three  times  a day.  July  ^ith. — To-day  the  right  eye  is  much  improved,  redness 
of  conjunctivae  diminished,  adhesion  of  pupillary  margin  disappeared,  and  vision 
perfect.  Left  eye  the  same  as  before,  but  an  adhesion  has  formed,  which  has 
rendered  the  pupil  irregular  for  some  days.  Cephalalgia  has  been  sometimes  better, 
sometimes  worse.  Belladonna  has  been  constantly  applied.  Applicent.  hirudines  iij 
tempor.  sinist.  July  14th. — The  right  eye  is  now  quite  well.  Left  eye  appears  if 
anything  worse.  The  pupil  is  dim,  greatly  contracted,  and  its  margin  much  thick- 
ened. Vision  also  is  nearly  gone ; he  sees  as  if  through  a thick  cloud.  Applicent. 
hirudines  ij  tempor.  sinist.  July  22c?. — The  leeches,  he  says,  relieve  the  frontal  pain, 
and  they  were  again  applied  yesterday.  To-day  conjunctivitis  less,  and  evident 
improvement ; pupil  larger ; vision  clearer.  July  28?A. — Since  last  report  the  morbid 
appearances  in  the  eye  have  gradually  disappeared.  Two  leeches  have  again  been 
applied,  and  a blister  to  the  neck.  General  health  much  improved,  although  still 

^ Reported  by  Mr.  Stewart  Lockie,  Clinical  Clerk. 


EHEUMATISM  AND  GOUT. 


991 


weak.  AuguH  \0th. — Has  been  quite  well  for  some  days;  vision  in  left  eye  is  still 
slightly  dim,  but  is  getting  clearer  daily.  Dismissed. 

Commentary. — This  case  of  double  rheumatic  iritis,  with  conjuncti- 
vitis, was  of  the  most  severe  description.  So  much,  however,  has  been 
said  about  the  danger  of  allowing  such  cases  to  run  their  natural  course, 
and  of  the  necessity  of  treating  them  with  specifics,  more  especially  with 
colchicuin  and  mercury,  that  I resolved  to  treat  this  case  without  them. 
It  was  watched  on  this  account  with  great  interest  by  the  clinical  class, 
especially  as  it  was  seen  from  time  to  time  by  my  friend,  the  ophthalmic 
surgeon  to  the  Infirmary,  who  predicted  the  worst  consequences.  Yet 
notwithstanding  the  weakened  condition  of  the  patient  when  iritis  came 
on,  the  severity  of  the  disease  in  both  eyes,  and  the  apparent  closure 
which  was  about  to  take  place  in  one  pupil,  I persevered,  and  the  result 
in  perfect  recovery  justified  my  expectations.  It  may  be  argued,  how- 
ever, that  the  case  would  have  got  well  much  sooner  if  mercurials  had 
been  given.  It  is  very  difficult  to  determine  this  point,  because  few 
oculists  have  informed  us  what  is  the  ordinary  course  of  a severe  rheu- 
matic iritis  with  conjunctivitis.  According  to  Wharton  Jones,*  if  taken 
in  time  before  much  exudation  has  occurred,  and  properly  treated,  it 
may  be  cured  in  three  or  four  weeks.  What  are  called  active  remedies 
were  not  applicable  in  this  case,  even  according  to  the  principles  of 
those  who  use  them,  and  the  amount  of  exudation  was  considerable. 
The  complete  recovery  of  the  right  eye,  therefore,  in  five  weeks,  and  of 
the  left  eye  in  six  weeks,  seems  to  me  to  have  baen  on  the  whole  a short 
period,  considering  all  the  circumstances,  although  on  this  point  further 
observations  are  required.  In  the  meantime,  the  case  demonstrates  that 
the  most  severe  attacks  of  rheumatic  iritis  may  get  well,  altogether  inde- 
pendent of  mercurials  and  active  antiphlogistics.  A similar  conclusion 
had  been  previously  arrived  at  by  Dr.  Williams  of  Boston,  U.  S.,  from  a 
pretty  extensive  field  for  observation.  (See  p.  318.)  1 have  now 

treated  four  other  cases  of  rheumatic  iritis  in  the  Infirmary  without 
mercury,  and  they  have  all  recovered. 

Case  CCLXXXII.f — Chrojiic  Gout  with  Tophaceous  Deposits  m all  the 

Joints. 

History. — Thomas  Burns,  a tobacco-pipe  maker — admitted  November  4th,  1857. 
Says  he  first  became  ill  in  Glasgow  about  ten  years  and  a half  ago,  with  pain  and 
swelling  in  both  his  big  toes.  Soon  afterwards  the  ankles  and  knees  became  affected. 
He  was  confined  for  a month,  being  unable  to  walk,  or  even  to  put  on  his  shoes. 
Since  then  he  has  had  on  an  average  three  such  attacks  every  year,  spring  and  autumn 
being  the  worst  seasons;  but  he  has  rarely  been  confined  by  them  more  than  a week. 
The  attacks  have  generally  commenced  with  rigors,  followed  by  more  or  less  fever  and 
swelling  in  one  or  other  of  the  joints.  Almost  every  joint  in  his  body  has  suffered  in 
this  way  at  one  time  or  another.  At  the  first  attack,  he  says,  chalk  stones  formed  in 
his  toes,  and  since  then  they  have  appeared  in  his  feet,  knees,  elbows,  and  hands. 
The  right  hand  especially  has  been  much  deformed  by  them.  He  is  in  the  habit  of 
cutting  down  upon,  and  extracting  them,  whenever  they  approach  the  surface  and  are 
unusually  painful.  He  has  been  twice  in  the  Infirmary,  and  on  both  occasions  dis- 
missed relieved.  The  present  illness  commenced  suddenly  six  weeks  ago,  and  has 
more  especially  affected  the  ankles.  He  has  undergone  a great  amount  of  treatment, 
having  been  bled  and  cupped,  and  having  taken  much  medicine.  He  had  been  accus- 
tomed to  drink  a good  deal  of  porter,  as  well  as  of  spirits,  until  three  weeks  before 
his  first  admission,  in  June,  1856,  since  which  time  he  has  been  more  temperate. 

^ Ophthalmic  Medicine  and  Surgery,  p.  150. 

f Reported  by  Mr.  Wilkes,  Clinical  Clerk. 


992 


DISEASES  OF  THE  BLOOD. 


Symptoms  on  Admission. — He  complains  of  pain  in  the  left  wrist  and  both  ankle 
joints,  which  latter  are  swollen,  and  pit  on  pressure.  The  joints  of  the  fingers  are 
nodulated  and  crooked,  especially  those  of  the  right  hand,  hard  to  the  feel,  with 
numerous  tophaceous  deposits  visible  through  the  shining  and  stretched  integument, 
about  the  size  of  millet  seeds.  The  elbow  and  knee  joints  are  similarly  affected,  with 
several  deposits  over  the  olecranon  and  patella  of  each  limb.  The  toes  are  not  so 
distorted  as  the  hands.  There  is  pain  on  pressure  over  the  right  lumbar  region,  with 
a slight  trace  of  albumen  in  the  urine.  Other  functions  normal.  Foiassce  Acet. 
3 iiss  ; Sp.  uEther.  Nit.  3 ss  ; Tr.  Colchici  3 j ; Mist.  Camph.  ad  | viij.  M.  § j be 
takoi  three  times  a-day. 

Progress  of  the  Case. — November  25^A. — Small  abscesses  have  appeared  over 
the  patella  and  heel,  to  which  poultices  have  been  applied.  The  mixture  has  been 
apparently  of  no  service  and  is  to  be  discontinued.  Dec.  18th. — Last  night  was 
seized  with  severe  lumbar  pain,  and  general  febrile  symptoms,  and  on  examining  the 
urine  it  was  found  to  be  highly  albuminous.  The  sediment  contained  numerous  epi- 
thelial cells  from  the  kidney,  with  granular  and  desquamative  casts  of  the  tubes.  § v 
of  blood  to  be  extracted  from  the  loins  by  cupping^  and  to  have  at  night  Pulv.  Doveri 
gr.  X.  Dec.  21sL — Is  much  better.  Albumen  in  the  urine  diminished.  3 Ammon. 
Phosphat.  li\Tr.Gent.  Co.  §j;  Inf.  Gent.  Co.  § v.  M.  A fourth  part  to  be  taken 
in  half  a tumblerful  of  water  three  times  a day.  Jan.  6^/q  1868. — Since  last  report 
has  been  comparatively  free  from  pain  and  doing  well,  but  last  night  was  again  seized 
with  severe  febrile  symptoms,  accompanied  by  painful  sensations  throughout  his  body. 
To-day  the  joints  of  the  extremities,  especially  those  of  the  hands,  are  very  painful. 
The  hands  to  be  poulticed.  To  have  Sol.  Acet.  Ammon.  3 j every  hour.  Jan.  9>th. — 
He  has  been  perspiring  much,  and  is  better,  although  pains  in  joints  are  still  very 
severe.  The  poultices  have  brought  away  several  fragments  of  the  tophi  near  the 
surface.  They  are  of  a pale  yellow  color,  friable,  and  when  examined  under  the  micro- 
scope present  a mass  of  needle-shaped  crystals  of  urate  of  soda.  1^  Ammon.  Phos- 
phatis  3 ss;  Tr.  Colchici  3 j ; Aquee  ^ vj  M.  A third  part  to  be  taken  three  times  a 
day.  Jan.  22d. — The  pains  in  the  joints  have  now  been  absent  for  ten  days,  and  he  was 
dismissed. 

Commentary. — The  above  is  only  the  third  case  of  gout  I have  seen 
in  the  wards  of  the  Royal  Infirmary,  and  it  is  a matter  of  general  obser- 
vation that  the  disease  is  one  from  which  the  people  of  Scotland  are  re- 
markably free.  This  has  generally  been  attributed  to  their  frugal  habits, 
but  more  especially  to  the  drinking  of  whisky,  instead  of  malt  liquors 
and  wines.  Dr.  William  Budd  has  described  gout  to  be  common  among 
a class  of  workmen  on  the  Thames,  whose  occupation  it  is  to  raise  ballast 
from  the  bottom  of  the  river.  “ Those  men,”  he  says,  “ drink  from  two 
to  three  gallons  of  porter  daily,  and  generally  a considerable  quantity  of 
spirits  besides.”  * Now,  it  is  curious  that  this  is  what  the  man,  whose 
case  is  before  us,  seems  to  have  done,  and  to  this  habit,  therefore,  we 
may  fairly  ascribe  the  occurrence  of  the  disease.  He  admitted  that  for 
some  years  he  was  accustomed  to  drink  upwards  of  half  a gallon  of 
porter,  besides  from  four  to  eight  ounces  of  whisky  daily.  There  was  no 
hereditary  tendency.  The  numerous  local  attacks  frequently  gave  rise 
to  excretion  of  the  morbid  products  by  the  kidneys,  with  all  the  symptoms 
of  Bright’s  disease,  including  albuminous  urine,  and  desquamation 
of  cells  with  casts  of  the  tubuli.  In  a week  or  so,  however,  they  disap- 
peared, and  he  enjoyed  a temporary  immunity  from  uneasiness.  As  to 
treatment,  nothing  seems  to  have  been  of  permanent  benefit,  the  topha- 
ceous deposits  apparently  keeping  up  more  or  less  irritation  and  tendency 
to  local  attacks,  which  in  their  turn  excited  constitutional  ones,  more 
especially  the  fever  and  urinary  symptoms. 


* Library  of  Medicine,  vol.  v.,  p.  219. 


SCORBUTUS. 


993 


SCORBUTUS. 

Case  CCLXXXIIT.* — James  Dermot,  set.  21,  railway  laborer — admitted  May  2Yth 
1847.  Has  been  working  on  the  Caledonian  line  of  railway  for  nine  months,  and 
enjoyed  good  health  till  three  months  ago,  when  he  received  a blow  on  the  right  tibia. 
This  produced  a sore,  and  an  ulcer  formed.  His  diet  consisted  of  bread,  coffee,  ham, 
butter,  and  sugar ; but  no  milk  or  fresh  vegetables.  On  admission,  an  elliptical-shaped 
ulcer,  about  two  inches  in  length,  is  seated  over  the  middle  of  the  tibia,  covered  with 
irregular  livid  granulations,  and  surrounded  by  a raised  purple  edge.  Another  ulcer, 
the  size  of  a shilling,  is  seated  below  this,  and  a third  similar  one  on  the  outside  of  the 
leg.  Eighteen  months  ago  his  left  leg  was  burnt,  and  over  the  seat  of  the  old  cicatrix 
a number  of  ulcers,  similar  to  those  on  the  opposite  leg,  exist.  One  of  these,  towards 
the  lower  part  of  the  leg,  is  the  size  of  half-a-crown,  and  more  livid  than  the  others, 
which  are  smaller.  The  gums  are  swollen  and  fleshy,  but  not  livid.  Pulse  74,  soft. 
Bowels  constipated.  To  have  full  diet.  B Aluininis  3 i ; Aquce  ^ viij.  Solve.  Ft. 
Gargarisma.  B linionis  3 iij  ; Sacchari  §iss;  Aquae  § iss.  M.  Sumat  pro 

potu  ex  aqua  indies.  June  ‘Id. — Ulcers  looking  more  healthy.  Their  surface  to  he 
touched  with  nitrate  of  silver.  July  Tlth. — Has  slowly  got  well  since  last  report,  and 
is  now  discharged. 

Case  CCLXXXIV.* — John  M‘Kenzie,  aet.  26,  railway  laborer — admitted  July  7th, 
1847.  During  the  last  two  months  his  diet  has  consisted  chiefly  of  coffee  or  tea,  with 
bread,  butter,  and  sugar,  but  no  milk.  Two  weeks  ago  pain  and  swelling  came  on  in 
his  left  leg.  Soon  afterwards  the  right  leg  was  also  affbcted,  and  both  became  dis- 
colored. Epistaxis  now  occurred,  and  has  continued  at  intervals  ever  since,  and  has 
been  so  severe  during  the  last  two  days  that  his  nostrils  have  been  plugged.  On 
admission,  the  left  leg  is  much  swollen,  and  of  a purple  color  chiefly  on  its  anterior 
and  inner  aspect.  The  right  leg  is  similarly  affected,  but  to  a less  degree.  H«  com- 
plains of  pain  and  stiffness  in  both  limbs,  especially  about  the  ankles.  The  gums  are 
slightly  swollen,  and  livid  at  the  edges,  but  do  not  bleed  on  masticating  food.  Pulse 
80,  soft.  Tongue  clean.  Bowels  regular.  To  have  full  diet.  July  ‘2.0th. — Since  ad- 
mission the  symptoms  have  gradually  disappeared,  and  to-day  he  was  dismissed  cured. 

Commentary. — During  the  year  from  October  1846  to  October  1847 
no  less  than  231  cases  of  Scorbutus  entered  the  Royal  Infirmary,  of 
whom  30  also  labored  under  continued  fever.  Of  the  entire  number, 
nine  were  females,  and  seven  died.  In  the  previous  year  only  one  case 
entered  the  Infirmary,  and  in  the  following  one  only  six.  I myself 
treated  between  seventy  and  eighty  of  these  patients,  having  succeeded 
Dr.  Christison  in  the  charge  of  a long  shed  which  contained  a large 
number  of  them,  besides  seeing  others  who  came  into  my  other  wards. 
At  the  same  period,  there  existed  a most  extensive  epidemic  of  typhoia 
or  typhus  fever.  Yet  it  is  singular  that  the  causes  which  produced 
scurvy,  mostly  in  the  able-bodied  population,  and  especially  among  the 
class  of  laborers  or  “ navvies  ” then  working  on  our  railways,  were  of  a 
kind  distinctly  different  from  those  usually  giving  rise  to  continued 
fever  ; the  potato  crop  had  failed  for  two  successive  seasons,  and  caused 
among  the  poorer  population  the  consumption  of  a diet,  not  only  deficient 
in  vegetables,  but  of  milk  and  fresh  meat  also.  Among  the  railway 
laborers,  the  truck  system,  and  establishment  of  local  stores  where  provi- 
sions of  inferior  quality  were  given  on  a ruinous  system  of  credit  or  ex- 
change, greatly  assisted  the  absence  of  vegetables  in  causing  the  disease. 
The  previous  winter  had  been  severe  and  protracted;  so  that  whilst  food 
of  all  kinds  was  high  priced,  the  work  and  exposure  of  the  laboring  popu- 
lation were  unusually  severe.  But  scanty  and  improper  diet,  and 

* Reported  by  Mr.  J.  Robertson,  Clinical  Clerk. 


63 


994 


DISEASES  OP  THE  BLOOD. 


especially  such  a kind  as  was  deficient  in  fresh  meat,  milk,  or  vegetables, 
could  in  almost  every  case  be  ascertained  to  be  the  cause  of  its  occurrence. 
Accordingly  in  a large  proportion  of  the  cases  it  was  found  suificient  to 
give  the  full  diet  of  the  house  (Case  CCLXXXIII.),  to  which  in  unusu- 
ally severe  cases,  two  or  three  ounces  of  lemon-juice  with  wine  were 
added  (Case  CCLXXXIV.)  This  if  the  individual  was  not  too  prostrated 
before  admission,  produced  a cure  in  a period  varying,  according  to  tlie 
intensity  of  the  disease,  from  three  to  six  weeks.  Most  of  the  cases 
entered  the  house  between  the  months  of  January  and  August. 

Dr.  Christison,  who  has  given  a most  able  history  of  the  epidemic  as 
it  was  observed  in  Edinburgh  and  in  the  Perth  Penitentiary,^  conclu- 
sively shows  that  to  the  absence  of  milk,  or  its  equivalent  nitrogenous 
constituents,  much  of  the  disease  was  owing.  In  the  Perth  Penitentiary 
treacle  water  had  been  given  instead  of  it,  and  on  restoring  the  milk  no 
fresh  cases  occurred.  Dr.  Lonsdale  again  showed  that  in  the  agricultu- 
ral valleys  of  Cumberland  milk  was  abunclant,f  and  that  the  absence  of 
potatoes  and  fresh  vegetables  was  the  evident  cause.  The  probably  cor- 
rect conclusion  is,  that  health  demands  a varied  diet,  and  that  a too  rigid 
abstinence  from  milk  and  fresh  meat  as  well  as  from  vegetables  may  oc- 
casion the  disorder.  The  observations  of  Dr.  Christison  unquestionably 
prove  the  anti-scorbutic  properties  of  milk,  and  of  the  full  diet  of  the 
Edinburgh  Infirmary,  as  these  very  frequently  constituted  the  only  treat- 
ment of  individuals  who  recovered  rapidly. 

The  following  table  shows  the  nutritive  proximate  principles  in  ounces 


I.  HEALTHY. 

Non-Nitrogenoxjs. 

Nitrogenous. 

Totfll. 

Siarch. 

Sugar. 

Fat. 

Gl  ten. 

Legum. 

Album. 

Casein. 

Mus.  fin 

Total. 

1.  Scott.  Prison  standard 

25-2 

17-8 

1-32 

0-11 

3-96 

0-13 

0-03 

1-36 

0-55 

6*03 

2.  Glasgow  Pris’n,  3d  rate 

25.0 

18-2 

0-82 

0-16 

4-07 

0-13 

0-04 

1-36 

0-23 

5-83 

3.  Edinburgh  Prison,  do. 

24-3 

17-8 

1-56 

0T3 

3-89 

0-25 

0-04 

0-38 

0-23 

4-79 

4.  Millbank  Prison,  1821 

25-0 

19-4 

. . 

0-55 

3-01 

0-47 

0-36 

1-21 

5-05 

5.  Do.  Convicts,  1840  . 

23-1 

17-9 

0*57 

3-06 

0-23 

0-40 

0-99 

4-74 

6.  Dublin  Bridewell,  1847 

19-5 

13-4 

0 03 

0-60 

2-93 

T57 

0-94 

5-49 

II.  CONVALESCENT. 

7.  Edin.  Inf.  full  diet  . 

194 

11-6 

1-10 

1-26 

2-33 

, . 

0-01 

1-50 

1-65 

5-52 

8.  Fever  conval.  diet  . 

20-1 

11-1 

1-50 

3-88 

1-82 

•• 

0-49 

0-03 

2T6 

4*40  I 

,III.  SCORBUTIC. 

1 

1 

9.'  General  Prison,  1846 

24*2 

17-8 

1-56 

1-11 

3-96 

0-13 

0-03 

0-07 

0-55 

4-40  1 

10.  Millbank  Prison,  1823 

20-9 

16-6 

. . 

0-20 

3-80 

.. 

0-30 

3-98 

11.  Do.  Soldiers,  1840-41 

12.  Do.  do.  improved,  1841 

18-9 

15-3 

, , 

0-38 

2-97 

0-23 

, . 

0-78 

3-78 

19-2 

15-0 

• • 

0-38 

3-04 

0-21 

0’04 

• * 

0-64 

3-89 

Note.— 1,  2,  3.  The  standard  third-rate  diet  of  the  Scotch  prisons,  as  used  in  the  General 
Prison  at  Perth,  in  healthy  years.  4.  Diet  of  Millbank  Penitentiary,  London,  before  being 
changed  to  No.  10.  5.  Millbank  diet  of  civil  convicts,  who  remained  free  of  scuiA’y,  while  the 
military  prisoners  were  attacked  under  the  diet.  No.  11.  The  data  given  by  Dr.  Baly,  physi- 
cian to ‘the  prison.  6.  The  present  diet  of  the  Dublin  Prison,  where  male  convicts  are  kept  for 
long  terms.  7.  Edinburgh  Boyal  Infirmary  full  diet,  under  which  scorbutics  promptly  re- 
covered. 8.  Convalescent  diet  of  a fever  patient  of  the  wealthy  ranks,  rapidly  recovering  j 
fiesh  and  strength.  9.  Diet  of  the  General  Prison  before  the  scurvy  broke  out.  10.  Ditto 
before  the  Millbank  epidemic  at  London  in  1823.  11.  Ditto  before  the  military  prisoners  in 
Millbank  Penitentiary  were  attacked  with  scurvy  in  1840-41.  12.  Improved  diet  on  that  occa- 
sion, but  found  ineffectual.  _ , , 

The  individuals  subjected  to  the  dietaries  in  the  I.  and  III.  Divisions  were  all  m confine- 
ment for  long  terms.— ( Christison.)  j 

* Monthly  Journal  of  Medical  Science,  June  and  July  184'7.  See  also  Dr.  Ritchie 
on  Scorbutics,  as  it  appeared  in  Glasgow  at  the  same  time.  July  and  August  1847. 
f Op.  t itat.,  August  1847. 


POLYDIPSIA, 


995 


avoirdupois  of  the  various  dietaries,  healthy,  convalescent,  and  scorbu- 
tic. 

Dr.  G-arrod,'^  from  an  examination  of  the  composition  of  food,  under 
the  use  of  which  scurvy  was  capable  of  occurring,  as  well  as  of  such 
substances  as  had  been  proved  beyond  doubt  to  be  anti-scorbutic,  was 
led  to  the  conclusion  that  the  absence  of  potash  was  the  cause  of  scurvy. 
In  this  way  he  shows — 1st,  That  potash  is  deficient  in  scorbutic  diet; 
2d,  That  all  bodies  proved  to  be  anti-scorbutic,  including  fresh  meat  and 
vegetables,  milk,  lemon-juice,  etc.,  contain  a large  amount  of  potash; 
3d,  That  in  scurvy  the  blood  is  deficient  in  potash,  and  the  amount  of 
that  substance  thrown  out  by  the  kidneys  is  less  than  what  takes  place 
in  health ; 4th,  That  scorbutic  patients,  when  kept  under  a diet  which 
gave  rise  to  the  disease,  recover  wlmn  a few  grains  of  potash  are  added 
to  their  food.  The  salts  of  potash,  such  as  the  nitrate,  oxalate,  and  bi- 
tartrate,  are  well-known  anti-scorbutics,  but  the  efficacy  has  always  be«n 
ascribed  to  the  acid  rather  than  to  the  alkali ; 5th,  That  deficiency  of 
potash  in  the  system  seems  capable  of  explaining  some  of  its  symptoms, 
especially  muscular  weakness,  as  potash  is  a necessary  constituent  of  the 
muscular  system.  These  views  undoubtedly  merit  attention,  and  it  is 
much  to  be  regretted  that  they  were  not  made  known  until  the  epidemic 
which  had  called  them  forth  had  disappeared. 

POLYDIPSIA. 

Ca.se  CCLXXXV.f — Sudden  Polydipsia — Incur alle. 

History. — Margaret  Shearer,  a French  polisher,  set.  34 — admitted  May  31st,  1854. 
States  that  a year  and  a half  ago  she  went  to  work  at  six  o’clock,  a.m.,  in  her  usual 
state  of  good  health,  and  at  eight  o’clock,  two  hours  afterwards,  was  suddenly  seized 
with  great  thirst,  which  has  continued  ever  since,  accompanied  by  excessive  discharge 
of  urine.  About  three  months  afterwards  she  was  obliged  to  give  up  work  on  account 
of  a pain  in  the  loins.  At  various  times  she  has  experienced  loss  of  appetite,  nausea, 
fulness  of  the  abdomen,  palpitations,  constipation,  or  diarrhoea.  Thinking  that  her 
strength  had  diminished  of  late,  she  entered  the  Infirmary. 

Symptoms  on  Admission. — On  admission,  the  amount  of  urine  passed  in  twenty- 
four  hours  was  424  ounces — pale  in  color — of  sp.  gr.  1005,  not  coagulable  by  heat  or 
nitric  acid,  and  containing  no  sugar,  as  determined  by  Trommer’s  test.  She  is  a stout 
able-bodied  woman,  and  speaks  of  occasional  slight  complaints.  She  has  a pale  coun- 
tenance, furred  tongue,  and  dry  skin  ; but  in  every  other  respect  is  quite  healthy.  Dr. 
Alison,  who  first  treated  her,  ordered  warm  baths  and  astringents,  and  afterwards 
galvanic  shocks  to  be  passed  through  the  epigastric  region.  On  taking  charge  of  the 
case  in  the  middle  of  June  I ordered  bitter  tonics,  and  the  diet  was  carefully  arranged, 
and  the  amount  of  water  drank  limited,  and  mixed  with  milk  and  a little  magnesia. 
No  change,  however,  occurred,  and  she  confessed  that  she  could  not  admit  of  restraint 
with  regard  to  the  amount  of  drink.  During  the  whole  month  of  July  she  was 
weighed  daily,  and  the  amount  of  water  drank  and  emitted  from  the  kidneys  carefully 
measured.  Her  average  weight  was  eight  stone,  which  underwent  little  valuation. 
The  amount  of  water  drank  varied  from  370  to  520  ounces,  the  average  being  440 
ounces.  The  amount  passed  varied  from  350  to  500  ounces ; and  it  was  observable 
that  it  was  always  from  20  to  50  ounces  less  than  the  quantity  drank.  The  sp.  gr. 
varied  from  1001  to  1005,  and  was  frequently  tested  for  sugar,  with  the  uniform  result 
of  its  never  being  detected  The  bowels  were  generally  open  every  other  day,  and  the 
Btool  was  of  normal  consistence  and  healthy  appearance. 

Progress  of  the  Case. — From  the  9th  to  the  14th  of  July  I tried  the  influence  of 
narcotics,  and  she  took  three  grains  of  opium  daily,  with  3 iss  and  then  3 ij  of  solu- 
tion of  morphia.  Under  this  treatment  she  frequently  appeared  drowsy  and  stupid, 

* Montlily  Journal  of  Medical  Science,  January  1848. 
f Reported  by  Mr.  James  Thorbum,  Clinical  Clerk. 


996 


DISEASES  OF  THE  BLOOD. 


but  sound  sleep  was  never  prolonged,  and  no  diminution  of  the  thirst  and  diuresis  wai 
perceptible.  She  then  took  large  doses  of  gallic  acid,  and  subsequently,  at  her  own 
request,  cod-liver  oil,  under  the  use  of  which  she  became  stouter,  stronger,  and 
the  appetite  improved.  August.  22c?. — All  other  treatment  was  suspended,  and  she 
was  ordered  to  take  ten  minims  of  the  liq.  iodinei  comp.,  which  was  continued  to  the 
14th  of  September  without  any  effect.  On  the  16th  she  was  ordered  1^  Mass.  jnl. 
aloes  et  myrrhce  ; Ferri.  sulph.  3ij. ; Ext.  liyoscyam.  3ij.  Ft.  massa  in  xij 
dividenda.  Two  pills  to  be  taken  twice  daily.  On  the  26th  there  was  diarrhoea,  when 
the  pills  were  discontinued,  and  an  astringent  mixture  ordered.  The  report  on  the 
1st  of  October  was — “ general  health  good,”  and  from  an  observation  made  for  the 
first  seven  days  of  this  month,  it  appears  that  the  thirst  and  diuresis  had  somewhat 
diminished,  the  amount  of  urine  varying  from  280  to  350  ounces.  There  was  no 
further  change  up  to  October  10,  when  she  left  the  house. 

Commentary. — -I  prefer  calling  this  case  polydipsia  to  diabetes  insi- 
pidus, as  frequent  careful  inquiry  established  the  fact  that  it  commenced 
with  thirst,  and  that  the  increased  flow  of  urine  was  a simple  result  of 
the  quantity  of  water  drank.  In  the  present  state  of  science  no  reason- 
able theory  can  be  conceived  explanatory  of  the  fact,  that  a woman, 
apparently  in  good  health,  is  suddenly  seized  with  great  thirst,  and 
thereupon  drinks  two  or  three  gallons  of  water  daily,  passes  a corre- 
sponding quantity  of  urine,  and  that  this  continues  for  nearly  two  years 
without  any  marked  change  in  her  health.  Where  there  is  no  scientific 
indication,  the  treatment  is  wholly  empirical,  and  even  the  results  of 
experience  are  wholly  negative  and  useless.  Astringents,  diaphoretics, 
galvanic  shocks,  narcotism  by  means  of  opium,  cod-liver  oil,  iodine,  and 
purgatives,  all  failed.  The  latter,  by  increasing  the  alvine  discharges, 
diminished  somewhat  the  excretion  of  urine,  but  we  could  not  flatter 
ourselves  that  she  was  in  any  way  benefited  by  her  four  months’  treat- 
ment in  the  Infirmary. 

Case  CCLXXXVI."^ — T oly dip ma  during  the  last  two  months  of  Preg- 
nancy— Disappearing  after  Delivery. 

History. — Mary  M‘Donald,  set.  34,  married — admitted  November  26th,  1860.  She 
is  nowin  the  seventh  month  of  pregnancy,  and  two  months  ago  her  attention  was  di- 
rected to  a strong  craving  she  experienced  for  drinking  water.  She  frequently  took 
two  or  three  tumblers  full  at  a time,  and  during  the  twenty-four  hours  swallowed  half 
a pitcher  full,  or  about  200  oz.  This  has  continued  ever  since,  and  latterly  she  has 
been  troubled  with  cough  and  expectoration. 

Symptoms  on  Admission. — Her  digestive  system  is  in  every  respect  healthy,  with 
the  exception  of  inordinate  thirst,  which  is  greatest  in  the  morning,  and  after  every 
meal,  even  when  for  the  most  part  fluid,  as  tea.  Before  she  drinks  there  is  expe- 
rienced a sensation  of  dryness  in  the  mouth,  tongue,  and  fauces,  and  a feeling  of  dis- 
comfort arises  if  prevented  from  gratifying  her  desire.  Three  or  four  tumblers  full  of 
water  generally  cause  satisfaction  and  a feeling  of  satiety.  She  passes  a large  quantity 
of  urine,  which  is  voided  frequently.  The  desire  to  micturate  comes  on  immediately 
after  drinking  a large  quantity  of  water,  and  the  fluid  is  passed  in  a full  and  prolonged 
stream,  over  which  she  has  no  control.  Percussion  over  the  chest  is  everywhere 
resonant,  but  on  auscultation,  loud  sibilating  and  sonorous  rales  are  heard  with  expira- 
tion, on  both  sides  over  the  upper  two-thirds  of  both  lungs.  Cough  severe  and 
paroxysmal.  Sputum  copious  and  watery.  Pulse  104,  weak.  Skin  dry.  Other 
functions  normal.  ^ Sp.  EEther.  Sulph.  3 ij  ; Chlorodyne  3 j ; Mist.  Scillce  c.  § yj 
M.  Ft.  3Iist.  A tahle-spoonfxd  to  he  taken  when  the  cough  is  troublesome. 

Progress  of  the  Case. — During  November  and  December  the  bronchitis  gra- 
dually got  better,  and  had  disappeared  on  the  20th  of  the  last-named  month.  She 
drank,  in  addition  to  a certain  amount  of  fluid  taken  at  meals,  from  90  to  130  oz.  of 


Reported  by  Mr.  Kenneth  M‘Leod,  Clinical  Clerk. 


POLYSAECIA  OK  OBESITY. 


997 


water  daily,  and  passed  from  130  to  250  oz.  of  urine,  clear  and  watery-looking,  sp.  gr. 
1003.  December  '•21th. — She  was  delivered  of  a healthy  boy,  the  labor  being  natural 
and  quick.  December  2d>th. — Her  thirst  and  dryness  of  mouth  have  greatly  dimiu- 
ishtid,  December  2^ih. — Has  no  thirst ; urine  only  60  oz.  She  recovered  rapidly. 
The  polydipsia  has  disappeared,  and  she  passed  from  40  to  VO  oz.  of  urine  daily  up  to 
3d  of  January,  when  she,  with  her  infant,  was  dismissed  quite  well. 

Commentary. — In  this  case  the  same  condition  existed  as  in  the  last, 
but  not  to  the  same  extent.  Her  pregnancy  forbade  all  active  remedies, 
and  no  curative  trial  was  made.  She  informed  us  that  during  the  latter 
period  of  her  previous  pregnancy  the  same  excessive  thirst  had  occurred 
which  immediately  disappeared  after  delivery,  I therefore  merely  treated 
the  bronchitis,  and  we  saw  the  polydipsia  cease  on  the  birth  of  her  child. 


POLYSARCIA  OR  OBESITY. 

Case  CCLXXXVII.* — Great  Obesity — Fatty  Degeneration  of  Heart 
and  Muscular  System  generally — of  Liver  and  Kidneys — Hyper- 
trophy  and  Dilatation  of  Heart. 

History. — Anne  Gilchrist,  aet.  42,  a cook — admitted  June  IVth,  185V.  With  the 
exception  of  an  attack  of  rheumatism  when  13  years  of  age,  she  has  enjoyed  good 
health  until  three  years  ago,  when  she  ruptured  a blood-vessel  in  the  lung  from  over- 
exertion. Last  March  she  caught  a cold,  and  shortly  afterwards  observed  a swelling 
of  the  feet,  gradually  extending  up  the  exti-emities.  Since  then  she  has  suffered  much 
from  dyspnoea.  She  has  been  of  a full  habit  of  body  since  the  age  of  thirteen ; has 
indulged  largely  in  eating  and  drinking;  besides  spirits,  having  drank  at  least  a bottle 
of  porter  daily.  She  has  always  been  exposed  to  large  fires  in  the  kitchen,  and  in  con- 
sequence  of  corpulence,  has  taken  little  exercise. 

Symptoms  on  Admission. — The  woman  is  of  an  unwieldy  size  from  corpulence. 
The  circumference  of  the  body  at  the  umbilicus  is  61  inches,  of  the  calf  of  the  leg  20 
inches,  and  of  the  ankle  13  inches.  She  can  lie  on  either  side,  but  is  very  uneasy  on 
the  back.  Slight  exertion  produces  dyspnma.  The  sounds  of  the  lungs  and  heart  are 
normal.  Percussion  of  the  latter  organ  is  unsatisfactory,  in  consequence  of  the  un- 
common size  of  the  left  mamma,  and  accumulation  of  fat.  Pulse  82,  regular  and  of 
good  strength.  Tongue  covered  with  a thick  fur.  Appetite  good.  Urine  scanty  and 
turbid,  sp.  gr.  1015,  albuminous  on  being  heated.  The  skin  over  the  abdomen  and 
lower  extremities  is  indurated  and  coarse.  The  scales  of  the  house  will  only  weigh 
25  stone,  and  she  is  much  heavier  than  this.  To  have  a scruple  dose  of  Bitartrate  of 
Potash  three  times  a-day.  Full  diet  and  4 oz.  of  wine  daily. 

Progress  op  the  Case. — June  21s;;. — Since  admission  pulse  better,  and  passes 
more  urine — yesterday  voided  30  oz.  July  2th. — Has  passed  from  20  to  30  oz.  of 
urine  daily,  and  the  legs  have  ceased  to  be  oedematous.  Complains  of  loss  of  appetite. 
Pulse  80,  weak.  To  have  3 vj.  of  wine  daily.  July  10i!/i. — Urine  again  scanty,  only 
passed  10  oz.  yesterday.  To  have  a squill  and  digitalis  pill  three  times  daily^  in  auui- 
tion  to  the  powders.  July  \lth. — At  the  visit  to-day  found  lying  on  the  right  side,  too 
w'eak  to  raise  her  head,  and  breathing  with  ditficulty,  the  respirations  being  short  and 
labored.  The  urine  was  again  deficient  in  quantity,  and  there  was  constipation.  A 
drachm  of  the  compound  Jalap  powder  was  ordered  to  be  taken  immediately.  In  the 
afternoon,  before  the  powder  had  operated,  she  suddenly  grew  livid  in  the  face,  a 
tracheal  rattle  was  heard,  and  in  two  minutes  she  expired. 

Sectio  Cadaveris. — Forty-four  hours  after  death. 

External  Appearances. — Body  of  enormous  size,  owing  to  excessive  development  ’ 
of  adipose  tissue.  The  head  appeared  to  emerge  without  any  neck  from  the  trunk. 
Mammie  enlarged,  each  above  the  size  of  an  adult’s  head.  The  following  measure- 
ments were  taken : — 

* Keported  by  Dr.  John  Glen,  Kesident  Physician. 


998 


DISEASES  OF  THE  BLOOD. 


Height  ..... 

65^ 

inches. 

Circumference  of  chest  below  nipple 

64 

Breadth  from  shoulder  to  shoulder 

36 

Circumference  of  abdomen 

69 

„ mammae  at  base 

36 

>> 

„ upper  arm 

19 

„ lower  arm 

16 

„ thigh  . 

28 

„ leg  below  the  knee 

20| 

„ ankle 

13 

Thickness  of  integument  over  sternum 

2 

5) 

,,  „ abdomen 

6 

Thorax. — Heart  much  enlarged ; it  weighed  22  oz.  All  the  cavities  were  dilated, 
the  walls  retaining  their  normal  thickness.  The  valves  were  healthy.  The  muscular 
tissue  of  the  heart  was  pale  and  soft.  The  lungs  were  healthy.  The  osseous  walls 
of  the  thorax  were  not  larger  than  usual,  the  breadth  internally  being  1 1^  inches. 

Ardomen. — There  were  two  ounces  of  serum  in  the  peritoneal  cavity.  The  liver 
was  much  enlarged,  weighed  7 lb.  10  oz.,  and  was  of  a pale  fawn  color.  The  two 
kidneys  weighed  13|  oz.  They  were  of  soft  consistence  and  pale  color.  The  spleen 
weighed  13^  oz. ; it  was  softer  than  natural.  The  intestines  were  healthy,  and  with 
the  exception  of  a few  cysts  in  each  ovary,  the  other  viscera  were  normal. 

Microscopic  Examination.  — The  muscular  tissue  of  the  heart  was  seen  to  be  in 
an  advanced  stage  of  fatty  degeneration.  The  cells  of  the  liver  were  crowded  with 
large  drops  of  oil,  and  the  nuclei  of  many  of  them  were  absent.  The  cells  of  the  kid- 
ney were  also  very  fatty. 

Commentary . — The  circumstances  in  wliich  this  poor  woman  was 
placed  were  exactly  those  most  favorable  to  the  production  of  obesity. 
As  cook  in  several  noblemen’s  families,  there  had  been  no  necessity  for 
her  undertaking  much  personal  exertion,  and  having  a good  appetite  and 
sound  digestive  organs,  she  indulged  largely  in  eating  and  drinking, 
whilst  always  more  or  less  in  a heated  atmosphere.  It  is  much  to  be  re- 
gretted that  her  exact  weiglit  was  not  ascertained.  When  standing  on 
the  Infirmary  scale,  which  only  allowed  us  to  weigh  to  the  extent  of  25 
stone,  it  seemed  as  if  she  was  at  least  5 stone  more.  In  a table  of  obese 
persons  given  by  Dr.  T.  K.  Chambers,*  one  man  is  said  to  have  weighed 
36  stone,  but  he  was  6 feet  1 inch  high  ; two  others,  a man  and  a woman, 
weighed  28,  and  another  woman  26  stone.  In  the  case  before  us  the 
increase  of  fat  had  certainly  arrived  at  an  extent  seldom  witnessed  in  the 
human  subject,  and  with  the  result  of  gradually  causing  fatty  degenera- 
tion of  internal  organs  essential  to  life.  Latterly,  from  fatty  degenera- 
tion of  the  kidneys,  albuminuria  made  its  appearance,  with  cedematous 
limbs.  From  this,  however,  she  might  have  recovered,  had  not  the  ad- 
vanced fatty  degeneration  of  the  heart  and  liver  so  enfeebled  the  circu- 
lation as  to  render  fatal  syncope  at  no  distant  period  certain.  It  is 
probable  that  the  change  of  diet  and  absence  of  her  accustomed  stimuli 
contributed  to  the  result,  although  every  care  was  taken  to  counteract 
such  causes  of  exhaustion  as  much  as  possible. 

Mr.  Banting,  in  a pamphlet  on  Corpulence,  London,  1864,  tells  us, 
that  acting  by  the  advice  of  his  medical  attendant,  he  reduced  his  weight 
in  twelve  months  from  202  lbs.  to  156  lbs.,  by  abstaining  from  bread, 
butter,  milk,  sugar,  beer,  and  potatoes.  Though  this  plan  of  diet  un- 
questionably diminishes  obesity,  care  should  be  taken  to  adapt  it  to  the 
exigencies  of  particular  cases.  The  not  following  this  precaution  has 
already  led  to  injurious  effects  in  many  persons  (see  p.  322). 

* On  Corpulence.  1850.  P.  139. 


CONCLUSION* 

The  Ethics  of  Medicine. 

Gentlemen, — After  a lengthened  period  of  study,  and  a series  of 
examinations,  intended  to  test  the  amount  of  your  knowledge,  you  have 
received  the  degree  of  Doctor  in  Medicine,  the  highest  academic  honor 
it  is  in  the  power  of  any  University  to  confer.  The  direct  connection 
which  has  hitherto  existed  between  you  and  your  teachers  here  termi- 
nates, and  all  those  restraints  which  public  opinion  and  legal  forms  have 
imposed  upon  the  uneducated  are  removed.  The  energies  which  you 
have  hitherto  employed  in  acquiring  the  necessary  preparatory  informa- 
tion you  may  now  dedicate  to  the  practical  affairs  of  life.  In  short, 
gentlemen,  you  this  day  obtain  a high  status  in  society,  and  without,  1 
hope,  ceasing  to  be  students,  you  become  members  of  a liberal  and 
highly  honorable  profession.  Such  an  event  constitutes  an  important 
epoch  in  the  life  of  every  man,  and  is  well  calculated  to  excite  not  only 
deep  feelings  of  reflection  in  yourselves,  but  those  of  lively  emotion  in 
all  who  are  concerned  (and  who  is  not  ?)  in  the  progress  of  that  art 
which  is  directed  to  the  prolongation  of  life  and  the  cure  of  diseases. 
It  will  not,  then,  be  considered  superfluous  if,  in  obedience  to  established 
usage,  before  you  leave  this  institution,  a member  of  the  medical  faculty 
seizes  the  opportunity  of  offering  to  you  a few  words  of  advice,  of  point- 
ing out  the  importance  of  your  future  profession,  and  describing  to  you 
the  spirit  in  which  it  ought  to  be  practised. 

I.  The  first  piece  of  advice  that  I shall  take  the  liberty  of  offering  is, 
always  to  cherish  a feeling  of  deep  responsibility . A medical  man  is  the 
earthly  arbiter  of  life  and  death.  He  is  the  guardian  of  our  race  through 
the  dangers  of  birth  and  the  perils  of  infancy.  He  is  called  upon  to 
treat  the  different  maladies  which  can  afflict  the  human  frame,  under 
every  circumstance  of  climate,  age,  sex,  or  condition  ; and  lastly,  when 
all  means  fail  to  prolong  life,  it  is  his  duty,  if  possible,  to  alleviate  those 
pangs  and  diminish  those  sufferings  which  accompany  the  separation  of 
the  soul  from  its  present  dwelling-place.  If,  then,  we  regard  him  as  the 
soother  alike  of  the  entrance  and  the  exit  of  this  life,  as  the  first  and  the 
last  friend  of  frail  humanity,  and  if  we  further  consider  him,  in  the  social 
scale,  as  the  superintendent  of  all  public  and  private  institutions  for  the 
sick  and  the  insane,  as  the  adviser  of  legal  tribunals  in  the  administra- 
tion of  justice,  and  as  the  regulator  of  the  sanitary  conditions  of  armies, 
fleets,  and,  indeed,  of  nations,  it  is  scarcely  possible  to  conceive  a voca- 
tion in  which  every  feeling  of  duty  and  honor  ought  to  incite  to  activity 

* An  address  delivered  as  Promoter  of  the  Medical  Faculty  to  the  graduates  in 
medicine.  August  1,  1849. 


1000 


CONCLFSION. 


and  usefulness ; to  the  cultivation  of  his  intellectual  powers  and  resources ; 
to  a life  of  beneficence  and  integrity,  and  above  all,  to  a sense  of  the 
deepest  responsibility.  This  feeling  is  one  which  the  most  experienced 
and  able  practitioner  can  scarcely  shake  otiF,  and  which  ought  to  press, 
with  enormous  force,  upon  those  who  are  newly  called  upon  to  decide 
concerning  the  awful  affairs  of  life  and  death.  A fellow-creature  having 
received  some  violent  accident,  or  being  attacked  by  acute  disease,  calls 
upon  you  for  assistance.  There  may  be  no  more  experienced  practitioner 
near;  there  is  none  to  consult  with;  the  danger  is  imminent,  and  you 
feel  conscious  that  not  only  something  must  be  done  immediately,  but 
that  what  is  done  may  save  or  destroy.  Then  there  rushes  upon  your 
mind  a peculiar  feeling  of  dread  and  anxiety,  rendered  more  embarrass- 
ing, perhaps,  by  the  conviction  that  your  future  prospects  may  be  in- 
fluenced by  the  manner  in  which  you  conduct  the  case  before  you.  Such 
a circumstance  as  I have  supposed  may  happen  to  any  of  you  at  the  com- 
mencement of  your  career,  and  it  is  then  you  will  perceive,  that  the  only 
true  support  to  be  depended  on  is  a consciousness  that  you  are  enabled 
to  put  in  practice  all  those  means  which  the  present  condition  of  the 
science  and  the  art  of  medicine  have  recognised  as  being  correct.  At 
such  moments  there  will  be  impressed  upon  you  the  conviction  that  the 
good  of  your  patients,  and  your  own  mental  tranquillity,  are  intimately 
united ; you  will  see  the  advantage  of  having  studied  your  profession, 
not  merely  as  an  object  of  gain,  but  from  a love  of  its  intrinsic  excellence 
— not  because  it  brings  you  consideration  and  respect,  but  because  it  en- 
ables you  to  do  good  and  to  relieve  suffering — not  with  a vain  effort  at 
exhibiting  your  superior  knowledge,  but  with  that  humility  which  is  the 
necessary  result  of  true  wisdom. 

The  object  of  medicine  is  to  preserve  health,  prolong  life,  cure  diseases, 
and  thereby  to  forward  the  happiness  of  mankind ; and  it  is  evidently 
the  duty  of  those  who  practise  it  to  lose  no  opportunity,  and  to  adopt 
every  means  of  prosecuting  that  object  to  its  fullest  extent  and  in  its  widest 
signification.  With  this  view,  gentlemen,  your  past  studies  have  been 
directed  to  the  acquirement  of  various  kinds  of  knowledge,  the  purpose 
of  which  has  been  not  merely  the  obtaining  of  professional  rules,  but  en- 
larging the  mind  and  cultivating  the  reasoning  powers.  The  time  has 
now  arrived  when  you  must  concentrate  the  miscellaneous  information 
you  have  gathered  together,  in  order  better  to  carry  out  that  particular 
kind  of  practice  which  you  in  future  intend  to  pursue.  Any  of  the  so- 
called  accessory  sciences  may  (should  your  tastes  allow)  be  still  further 
prosecuted,  but  not  to  the  exclusion  of  more  important  matters.  Your 
duty  is  to  cure  the  sick  and  relieve  suffering,  and  not  to  be  distinguished 
as  a chemist,  a botanist,  or  a naturalist.  Neither  is  it  expected  that  you 
should  have  all  the  knowledge  which  each  of  your  teachers  possesses  in 
his  especial  department,  but  that  from  the  whole  you  should  have  obtained 
such  a sum  of  learning,  and  such  an  available  kind  of  information,  that 
you  may  undertake  the  serious  duties  of  a medical  practitioner  with 
credit  to  yourselves  and  advantage  to  the  public.  Such  an  amount  of 
knowledge  is  within  the  reach  of  all;  and  should  there  have  been  any 
deficiencies  or  omissions  in  your  past  career,  you  are  imperatively  called 
upon  to  remedy  them  at  once.  Perhaps  it  is  unnecessary  for  me  to  say 


THE  ETHICS  OF  MEDICINE. 


1001 


your  education  is  not  complete ; indeed,  in  one  sense,  it  may  be  said  to 
be  only  beginning.  Hitherto,  you  have  depended  on  others,  now  you 
must  advance  by  yourselves — the  information  of  collegiate  life  must  be 
perfected  and  elaborated,  in  order  to  meet  the  exigencies  of  every-day 
affairs.  You  must  prune  away  those  imaginings  in  which  the  student 
loves  to  indulge,  and  direct  your  thoughts  to  the  stern  realities  before 
you.  For  this  purpose,  you  should  seize  the  interval  which  may  elapse 
between  your  retirement  from  the  schools  and  the  commencement  of 
actual  practice,  in  arranging  your  past  acquirements  for  ready  use,  and  in 
extending,  by  every  possible  means,  your  experience  in  the  observation 
and  treatment  of  disease.  By  so  doing,  I consider  you  will  be  best 
qualified  to  meet  the  serious  responsibility  you  have  to  undertake,  and 
will  thereby  attain  that  comfort  of  mind  and  true  respectability  which 
the  proper  and  enlightened  exercise  of  our  noble  profession  can  alone 
secure. 

II.  This  leads,  me,  in  the  second  place,  to  impress  upon  you  the 
importance  of  practising  the  art  and  cultivating  the  science  of  medicine 
in  a spirit  of  sincerity  and  of  truth — li  is  a well-known  fact,  that  whilst 
the  public  can  judge  with  tolerable  correctness  of  merit  in  any  other 
profession,  it  is  wholly  incapable  of  forming  an  estimate  of  ability  in 
medicine.  The  structure  of  the  human  body,  the  functions  it  performs, 
the  laws  which  regulate  it,  and  the  derangements  which  affect  it,  are  to 
mankind  in  general  completely  unknown.  All  that  your  patients  will 
concern  themselves  with  are  results — but  so  ignorant  are  they  of  the 
means  by  which  results  are  obtained,  so  little  do  they  know  of  the  opera- 
tions of  nature  as  distinguished  from  those  of  art,  that  they  are  especially 
liable  to  be  led  into  erroneous  conclusions.  In  consequence,  unprincipled 
persons,  from  time  immemorial,  have  successfully  practised  on  public 
credulity,  and  some  specious  but  shallow  theory,  some  vaunted  nostrum, 
some  peculiar  accomplishment,  or  some  singularity  of  manner,  have  each 
in  turn  been  made  the  means  of  imposition.  It  is  expected  of  you, 
gentlemen,  that  you  are  so  well  grounded  in  the  facts  and  principles  of 
medicine  as  to  be  enabled,  on  all  proper  occasions,  to  put  down  ignorant 
presumption,  refute  false  doctrines,  and  expose  artful  knavery.  You  will 
remember  that  medicine  is  a progressive  science,  and  that  whilst  the  wise 
and  learned  who  have  cultivated  it  have  done  much,  more  remains  to  be 
accomplished.  You  will  therefore  readily  acknowledge  its  imperfections 
where  such  truly  exist,  and  prefer  a frank  avowal  of  ignorance  to  a false 
assumption  of  knowledge. 

There  is  one  great  difficulty  you  will  have  to  encounter,  viz.,  that 
the  rules  and  principles  which  guide  the  profession  in  the  course  of 
time  undergo  a considerable  variation.  The  arts  and  luxuries  of  life, 
the  physical  changes  of  the  globe,  and  the  differences  of  education  and 
civilisation,  to  a certain  extent  modify  the  constitution  of  man  and  the 
diseases  to  which  he  is  subject.  Maladies  described  as  existing  in 
former  times  are  now  unknown,  whilst  others  are  altogether  of  modern 
origin.  It  is  of  the  utmost  consequence,  therefore,  that  the  medical 
practitioner  should  be  alive  to  the  importance  of  following  the  progress 
of  h*ls  art,  and  not  imagine  that  at  any  time  he  has  learnt  all  that  is 


1002 


CONCLUSIOJT. 


useful,  or  that  he  can  ever  reach  that  point  at  which  improvement  is  not 
to  be  gained.  At  the  same  time,  he  must  learn,  amidst  the  multitude 
of  suggestions,  the  number  of  theories,  and  the  opposing  statements 
which  will  perplex  him,  to  reject  what  is  worthless,  and  only  adopt 
what  is  truly  useful.  In  all  such  cases,  the  best  rule  is  to  be  on  your 
guard  against  loose  and  confident  plausibilities,  especially  where  such 
are  advanced,  not  in  their  true  character  as  hypotheses,  but  as  estab- 
lished laws  which  are  to  regulate  your  practice  at  the  bed-side.  It 
is  sometimes  allowable  to  give  a certain  rein  to  the  imagination,  and 
cultivate  that  power  of  generalisation  which  has  led  to  the  most  im- 
portant and  brilliant  results  in  science ; but  if  this  be  not  controlled 
within  its  proper  limits,  nothing  can  be  more  mischievous,  especially 
when  the  errors  may  affect  the  lives  of  mankind.  Strive,  then,  so  to 
improve  your  intellectual  resources  and  observing  powers,  that  you 
may  be  enabled  to  shun  error  and  admit  truth,  especially  avoiding  all 
those  easy  and  fallacious  paths  to  knowledge  into  which  the  interested 
endeavor  to  entrap  the  unwary. 

A desire  to  practise  your  profession  in  sincerity  and  truth  will  also 
lead  you,  in  cases  which  you  have  not  particularly  studied,  or  which 
demand  special  kinds  of  treatment,  to  require  the  assistance  of  some 
brother  practitioner.  No  two  persons  prosecute  their  study  in  exactly 
the  same  direction;  and  the  subject  of  medicine  is  so  extensive,  so 
complicated,  and  requires  so  much  application,  that  it  is  almost  im- 
possible for  a single  individual  to  become  master  of  the  whole.  Vanity 
and-  self-conceit,  it  is  true,  have  led  some  men  to  maintain  the  con- 
trary; but  where  is  the  individual  who  is  at  the  same  time  a good 
physician,  a good  surgeon,  and  a good  obstetrician  ? There  are  many, 
doubtless,  who  practise  very  usefully  in  all  these  branches,  and  you 
may  be  so  circumstanced  hereafter  as  to  do  the  same.  If  so,  you  will 
necessarily  be  often  consulted  in  cases  where  you  must  feel  internally 
convinced  that  you  cannot  do  full  justice  to  your  patient,  and  then  it 
will  be  right  to  bear  in  mind  that,  if  you  possess  a greater  share  of 
information  in  some  respects  than  others,  they  in  certain  particulars 
know  more  than  you.  Do  not,  then,  be  deterred  by  a false  feeling  of 
shame,  or  a desire  for  gain,  from  consulting  your  medical  brethren; 
reciprocal  services  beget  mutual  kindness,  and  it  is  at  all  times  better 
to  resign  the  treatment  of  a case  you  do  not  understand,  than  subject 
yourselves,  by  undertaking  it,  to  a perpetual  series  of  mortifications 
and  disappointments.  By  exercising  your  profession,  then,  in  a spirit 
of  sincerity  and  truth,  you  will  be  animated  by  a proud  desire  to  advance 
its  claim  to  public  confidence,  rather  than  your  own  immediate  interests; 
you  will  despise  the  miserable  vanity  of  announcing  what  is  new,  with- 
out a scrupulous  regard  to  its  being  correct.  You  will,  while  retaining 
the  right  of  thinking  boldly  for  yourselves,  not  forget  that  observation 
is  difficult,  theory  imperfect,  and  experience  frequently  fallacious.  You 
will  not,  therefore,  rashly  substitute  your  own  authority  for  that  of 
those  whose  knowledge  is  more  extensive,  or  commit  yourselves  to  the 
ephemeral  doctrines  of  the  day,  by  which  a few  otherwise  respectable 
men  have  lost  their  professional  reputation.  You  will  remember  that 
the  conclusions  of  youth  are  almost  always  modified  by  the  experience 


THE  ETHICS  OF  MEDICINE. 


1003 


of  age , and  that  the  wisest  and  most  eminent  men  of  science  have 
given  the  best  proofs  of  a solid  understanding  by  the  readiness  with 
which  they  have  acknowledged  their  own  ignorance. 

III.  The  third  and  last  point  to  which  I shall  direct  your  atten- 
tion is,  that  you  ought  to  le  strongly  imbued  with  a sense  of  duty  and  of 
moral  obligation.  No  profession  demands  that  its  members  should  be 
governed  in  their  practice  by  purer  principles  of  honor  than  our  own. 
The  medical  man  is  received  into  the  bosom  of  private  families,  where 
he  is  intrusted  with  matters  of  such  a nature  that,  if  they  were  dis- 
closed, they  would  be  attended  with  the  greatest  distress,  and  would 
plunge  parents  or  children  into  the  most  bitter  and  poignant  agony. 
It  is  your  office  not  only  to  regulate  the  corporeal,  but,  in  many  cases, 
the  mental  derangements  and  irritability  of  your  patients ; but  who  can 
govern  the  minds  of  others  if  he  is  incapable  of  commanding  his 
own  ? Prudence,  sobriety,  kindness,  and  delicacy  of  feeling,  are  there- 
fore especially  enjoined  upon  those  who  treat  the  sick.  It  is  true,  you 
will  labor  among  scenes  ot  woe,  and  have  to  watch  incurable  diseases 
and  loathsome  maladies  ; but  he  whose  sensibility  is  thereby  blunted, 
and  who  can  look  with  indifference  on  the  agonies  of  a fellow-creature, 
will  seldom  feel  that  anxiety,  or  experience  that  watchfulness,  which 
is  so  necessary  for  detecting  the  true  condition  of  his  patient.  Self- 
interest  is  the  worst  of  all  models  for  a medical  practitioner,  and  is  a 
vice  which  our  profession  may  proudly  claim  exemption  from.  You,  I 
trust,  will  never  experience  it,  but  rather  those  pleasurable  emotions 
which  result  from  lessening  human  suffering,  without  thought  of  profit, 
and  from  exercising  friendly  offices  with  that  politeness  and  delicacy  of 
sentiment  which  distinguish  every  man  of  a gentlemanly  and  refined 
mind  Mixed,  as  you  occasionally  will  be,  with  every  branch  of 
society,  you  must  expect  sometimes  to  meet  with  ingratitude,  and  be 
ignorantly  and  undeservedly  charged  with  committing  errors.  All  men 
are  liable  to  misrepresentation ; and  although  I do  not,  at  such  periods, 
advise  you  quietly  to  submit  to  insult,  I strongly  recommend  great  cir- 
cumspection in  manifesting  resentment.  “ Unjust  suspicions  may  attach 
to  an  innocent  man ; the  general  consistency  and  integrity  of  his  life 
will  wipe  them  away ; the  imprudences  of  youth  may  be  repaired  by 
the  circumspection  of  middle  age  ; but  if  you  once  lose  your  reputation 
for  professional  prudence  and  honor,  you  will  find,  whatever  be  your  at- 
tainments, that  your  influence  is  gone,  and  that  you  are,  in  all  respects, 
lost  and  ruined  men.” 

In  addition  to  the  duties  which  you  discharge  to  the  public  at 
large,  there  are  others  of  no  less  importance  which  you  owe  to  your- 
selves. Opportunities  will  frequently  occur  where  you  may,  by  looks 
or  words,  seriously  injure  the  reputation  of  some  brother  practitioner, 
when  in  reality  he  does  not  deserve  it.  The  period  of  the  disease,  or  the 
circumstances  which  have  occurred,  may  enable  you  to  do  what  your  pre- 
decessor could  not.  Every  good  feeling  demands  that  under  such  circum- 
stances you  should  explain  the  cause  of  your  success  to  the  patient,  and 
not  allow  him  to  suppose  his  previous  attendant  was  in  fault.  Besides,  the 
most  scientific  and  experienced  physician  may  sometimes  err  unavoidably. 


1004 


CONCLUSION. 


and  you  must  never  attempt  to  aggravate  the  consequences  of  his 
failure  by  adding  to  the  patient’s  dissatisfaction.  Conduct  of  this  kind 
will  cause  the  offender  to  be  shunned,  and  sooner  or  later  to  feel  that  no 
success,  and  no  wealth,  can  compensate  for  the  absence  of  self-esteem  or 
the  good  opinion  of  the  enlightened  and  honorable  men  of  his  own  pro- 
fession. 

Gentlemen,  habitually  engaged  as  you  will  be  at  the  bed-side  of  the 
sick  and  the  dying,  you  will  have  abundant  opportunities  of  rightly  esti- 
mating the  insufl&ciency  of  mere  worldly  considerations.  I think  you 
will  find,  notwithstanding  what  is  said  to  the  contrary,  that  there  is  no 
class  of  society  in  which  the  true  spirit  of  religion  is  more  extensively 
diffused  than  among  members  of  the  medical  profession.  True,  they 
shrink  from  an  officious  and  public  manifestation  of  it,  and  their  habits 
of  thought  teach  them  to  distinguish  between  trifling  forms  and  essen- 
tial truths ; but  I know  of  no  calling  more  practically  engaged  in  acts 
of  charity,  in  an  abnegation  of  self,  a desire  to  do  to  others  what  we 
wish  others  should  do  to  us,  and  an  endeavor,  if  occasion  require  it,  to 
afford  all  those  consolations  which  a pure  Christianity  can  alone  impart. 
This  has  ever  been  the  conduct  by  which  all  the  brightest  and  most 
eminent  characters  in  our  profession  have  been  distinguished,  and  I ear- 
nestly pray  that  such  may  be  yours. 

And  now,  gentlemen,  I and  my  colleagues  bid  you  farewell,  trusting 
that  whatever  part  you  are  destined  to  fulfil  in  the  affairs  of  life  as 
medical  practitioners,  you  will  ever  labor  under  a deep  sense  of  respon- 
sibility, that  you  will  always  act  in  sincerity  and  truth,  and  ever  be 
governed  by  a high  feeling  of  duty  and  of  moral  obligation  Let  us  hope 
that  you  will  regard  your  past  teachers  as  your  future  friends,  and 
that  in  whatever  part  of  the  world,  however  distant,  your  lot  may  be 
cast,  we  shall  still  be  united  by  a chain  of  good  feeling  and  mutual  es- 
teem, which,  however  it  may  be  lengthened,  can  never  be  cut  across.  We 
desire  that  you  will  consider  the  reputation  of  this  University  as  in 
some  degree  identified  with  your  own,  and  whilst  on  the  one  hand  you 
take  care  never  to  sully  the  degree  she  has  this  day  conferred,  on  the 
other  you  will,  by  constant  good  conduct,  and  by  well-directed  endeavor, 
add  fresh  lustre  to  the  reputation  she  holds  among  the  academic  institu 
tions  of  this  great  country. 


TABLE  OF  CASES 


DISEASES  OF  THE  NERVOUS  SYSTEM. 

OX8B  PaOI 

I.  Acute  hydrocephalus — Recovery  .....  36C 

II.  Acute  hydrocephalus  in  a scrofulous  child — Recovery  . 861 

III.  Acute  hydrocephalus — Phthisis  pulmonalis— Death — Effusion  into 

the  lateral  ventricles— Non-inflammatory  softening  of  the  cen- 
tral parts  of  the  brain — Meningitis  at  the  base  of  cranium — 
General  tuberculosis  ......  362 

IV.  General  acute  meningitis  supervening  on  pleuro-pneumonia  . 867 

V.  Acute  meningitis  at  the  base  of  brain — Serous  effusion  into  the 

venti  icles,  with  white  softening  of  cerebral  substance — Phthisis  868 

VI.  Acute  meningitis  at  the  base  of  the  brain — Effusion  of  serum  into 
the  lateral  ventricles— Effete  tubercle  in  the  pons  varolii  and 
lungs  . . . . . . _ . . 869 

VII.  Chronic  meningitis — Serous  effusion  into  the  ventricles — Tuber- 
cular mass  in  the  left  lobe  of  the  cerebellum — Cretaceous  tuber- 
cle in  the  lungs,  with  fibrous  cicatrix  ....  373 

VIII.  Chronic  cerebral  meningitis — Induration  surrounded  by  softening 

of  a portion  of  the  left  cerebral  hemisphere  . . . 374 

IX.  Acute  cerebritis — Abscesses  in  the  brain — Old  tubercle  in  various 

organs — Chronic  peritonitis  . . . * . 376 

X.  Acute  cerebritis — Abscesses  in  the  brain — Pulmonary  tubercle — 

Abscess  in  the  kidney  ......  377 

*XI.  Chronic  cerebritis — ^Epileptiform  convulsions — Hemiplegia  of  the 
right  side — Loss  of  smell- -Blindness  of  the  left  eye — Amyloid 
bodies  in  the  brain  .......  380 

XII.  Chronic  meningo-cerebritis— Sudden  convulsions — Hemiplegia  of 
left  side — Softening  of  anterior  lobe  of  right  cerebral  hemisphere 
— Adhesions  of  arachnoid  ......  382 

XIII.  Chronic  cerebritis  of  the  right  hemisphere — Cancerous  ulcer  of  the 

oesophagus  and  neighboring  glands — Fatty  heart  . , 384 

XIV.  Paralysis  of  the  abducens  occuli  and  auditory  nerves— Exophthalmia 

— Tumor  at  the  base  of  the  cranium — Partial  recovery  . . 386 

XV.  Paralysis  rapidly  becoming  general — Old  apoplectic  cyst  in  right 
corpus  striatum — Softening  of  pons  varolii — Clot  obstructing 
basilar  artery — Pneumonia  of  left  lung  ....  390 

XVI.  Apoplexy — Hemiplegia  of  left  side — Convulsive  attacks — Cardiac 
and  renal  disease — Old  clot  in  the  right  cerebral  hemisphere, 
with  surrounding  softening  .....  392 

XVII.  Two  sudden  attacks  of  Apoplexy — Hemiplegia— Cardiac  disease — 
Persistent  albuminuria — Enlarged  and  diseased  spleen — Cere- 
bral softening — Anasarca — Atheroma  of  arteries — Obstruction 
of  middle  cerebral  artery  ......  395 

XVIII.  Apoplexy,  followed  by  hemiplegia  of  left  side — Recovery  . . 400 

XIX.  Apoplexy,  followed  by  hemiplegia  of  left  side — Recovery  . . 400 

XX.  Palsy — Hemiplegia  of  the  left  side — Recovery  . . . 401 

XXL  Sudden  Paralysis  of  face  and  left  arm — Pneumonia — Bright’s  dis- 

ea^se — Recovery  .......  402 

XXII.  Apoplexy — Extravasation  of  blood  into  the  left  corpus  striatum — 

Pneumonia — Arrested  tubercle  of  lung  ....  408 

XXIII.  Apoplexy — Hemiplegia  of  left  side— Hemorrhage  into  right  cere- 
bral hemisphere — Diseased  heart— Pneumonia  . . . 404 

XXIV.  Apoplexy — Hemorrhage  at  the  base  of  the  brain  in  a boy  aged 

14  years  ........  405 

XXV.  Apoplexy,  followed  by  delirium,  and  proving  fatal  in  eight  hours 

— Hemorrhage  into  the  meninges  of  the  brain  . , . 406 


1006 


TABLE  OF  CASES. 


Case 

XXVI.  Hemorrhage  into  the  right  crus  cerebri — Meningitis  at  the  base 
of  the  encephalon — Serous  effusion  into  the  lateral  ventricles — 
Chionic  phthisis — Vertigo — Paralysis — Spasms  of  the  jaw— 
Delirium  and  coma  ...... 

XXVII.  Apoplexy — Hemorrhage  into  right  optic  thalamus,  causing  hemi- 
plegia on  left  side — Progressive  recovery — Two  months  after- 
wards, hemorrhage  into  pons  varolii  and  membranes  on  right 
side — Death  in  seven  hours  ..... 

XXVIII.  Five  years  before  admission,  hemiplegia,  followed  by  recovery — 
Four  months  before  admission,  apoplexy,  with  convulsions  and 
partial  recovery — Pulmonary  disease — Death  by  asphyxia — 
Chronic  softening  of  right  corpus  striatum — More  recent  hem- 
orrhage into  the  pons  varolii— Cardiac  hypertrophy,  with  mitral 
constriction — Hemorrhage  into  the  lungs 

XXIX.  Three  attacks  of  apoplexy — The  first  dependent  on  hemorrhage  into 
the  right  corpus  striatum,  in  May  1861 ; the  second  on  hemor- 
rhage into  the  left  cerebral  lobe  and  right  optic  thalamus,  No- 
vember 1861 ; and  the  third  on  hemorrhage  into  the  arachnoid 
cavity,  March  1862 — Atheroma  of  the  blood-vessels — Hyper- 
trophy of  heart — Chronic  disease  of  lungs,  liver,  and  kidneys  . 

XXX.  Cancer  of  the  brain,  spinal  cord,  liver,  and  bones  . 

XXXI.  Chronic  hydrocephalus — Paracentesis  capitis — No  benefit  . 

XXXII.  Otorrhoea  — Sudden  lumbar  and  cervical  pains  — Convulsions — 
Spinal  meningitis  ....... 

XXXIII.  Acute  myelitis  in  the  cervical  portion  of  the  cord — General  pains 
resembling  those  of  rheumatism — Fugitive  paralysis  in  the  arms 
and  legs — Engorgement  of  the  lungs — Death 

XXXIV.  Slight  paraplegia — Recovery  ...... 

XXXV.  Paraplegia — Partial  recovery  ...... 

XXXVI.  Paraplegia — Incurable  ....... 

XXXVII.  Paraplegia — Chronic  myelitis  ...... 

XXXVIII.  Paraplegia — Tubercular  caries  of  dorsal  vertebrae — Myelitis — Pul- 
monary tubercle  ....... 

XXXIX.  Paraplegia — Cancer  of  vertebral  bones  — Softenkrg  of  the  cord 
from  pressure — Cancer  of  lung,  liver,  and  lumbar  glands — 
Ulceration  of  urinary  bladder  ..... 

XL.  Neuralgia  of  the  suborbital  nerve  and  subsequent  irritation  and 
paralysis  of  various  nerves  at  the  base  of  the  cranium,  fi-om 
cancerous  disease  of  the  bones — Catarrhal  pneumonia  . 

XLI.  Partial  amaurosis  — Spectral  illusions — Perversions  of  hearing, 
smell,  and  touch — Spinal  irritation  .... 

XLII.  Delirium  tremens — Recovery  ...... 

XLIIl.  Delirium  tremens  with  ocular  spectra — Recovery 

XLIV.  Delirium  tremens  with  convulsion  and  coma — Recovery 

XLV.  Coma  and  death  from  excessive  drinking — Opacity  of  arachnoid — 
Subarachnoid  effusion — Fluid  blood  .... 

XLVI.  Poisoning  by  opium — Recovery  ..... 

XLVII.  Poisoning  by  opium — Recovery  ..... 

XLVIII.  Poisoning  by  hemlock — Death  ..... 

XLIX.  Poisoning  by  lead  — Painter’s  colic — Lead  paralysis — Partial  re- 
covery ........ 


Pag» 


408 

411 


412 


414 

421 

424 

427 


428 

430 

431 

431 

432 

434 


438 


441 

445 

455 

455 

456 

456 

458 

459 
459 

464, 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


L.  Tonsillitis  .......  . 466 

LI.  Follicular  pharyngitis  .......  467 

LII.  Stricture  of  the  oesophagus  from  epithelioma  . - . 467 

LIII.  Epitlieliomatous  ulceration  of  the  oesophagus,  communicating  with 

the  lung— Pneumonia  terminating  in  gangrene  . . . 468 

LIV.  Carcinomatous  stricture  of  oesophagus — Cancer  of  the  liver — Pul 

inonary  emphysema  and  tubercle — Pneumonia  . . , 470 

liV.  Dyspepsia  .......  472 

LVI.  Dyspepsia — Oxaluria  .......  473 

LVII.  Dyspepsia — Hypochondriasis — Oxaluria  ....  474 

LVIII.  Dyspepsia — Vomiting  of  fermented  matter  containing  sarcime  . 479 

LIX.  Dyspepsia — Vomiting  of  fermented  matter  containing  sarcinae  . 481 

LX.  Chronic  ulcer  of  the  stomach — Recovery  ....  481 


TABLE  OF  CASES. 


1007 


Case 

LXI. 

LXIL 


LXIII. 

LXIV. 

LXV. 
LXVL 
LXVII. 
LXV  I II. 
LX  IX 
LXX. 
LXXI. 


LXXII. 

LXXIII. 


LXXIV. 


LXXV. 

LXXVI. 

LXXVIL 

LXXVIII. 


LXXIX. 


LXXX. 

LXXXI. 
LXXXII. 
LXXXIII. 
LXXXI  V. 
LXXXV. 

LXXXVI. 

LXXXYIL 

LXXXVIII. 

LXXXIX. 

XC. 

XCL 

XCIT. 

XCIIL 

XCIV. 


XCV. 

XCVI. 


Chronic  ulcer  of  the  stomach — Cure  ..... 

Chronic  ulceration  and  perforation  of  the  stomach — Peritonitis — 
Limited  pneumonia  with  gangrene — Abdominal  abscess,  simu- 
lating pleurisy — Death  ...... 

Chronic  ulceratlbn  in  the  stomach — Perforation  occasioned  by  a 
fall  (?) — Recovery  ....... 

Cancer  of  stomach,  pancreas,  and  mesenteric  glands  — Cystic 
atrophy  of  right  kidney  ...... 

Colloid  cancer  with  perforating  ulcer  of  stomach — Peritonitis 
Poisoning  by  o::jalic  acid — Recovery  ..... 

Poisoning  by  sulphuric  acid — Recovery  .... 

Poisoning  by  corrosive  sublimate— Recovery 

A-cute  congestion  of  the  liver — Hepatitis — Recovery 

Acute  jaundice — Albuminuria — Recovery  .... 

Abscess  of  the  liver,  bursting  into  the  right  thoracic  cavity,  and 
into  the  retro-peritoneal  cellular  tissue — Pneumonia  and  gan- 
grene of  right  lung — Pneumo-thorax  .... 

Impaction  of  a gall-stone  in  common  bile-duct — Atrophy  of  the 
substance  of  the  liver — Jaundice — Death 
Jaundice — Compression  of  the  ductus  communis  choledochus  from 
a cancerous  tumor,  composed  of  epigastric  and  lumbar  glands 
-—Occlusion  of  cystic  duct — Enlargement  of  gall-bladder — Can- 
cer of  the  pancreas — Biliary  congestion  of  the  liver — Cancerous 
exudation  into  various  organs — Slight  leucocythemia 
Jaundice  — Cancerous  tumor  of  the  pancreas,  comprising  the 
ductus  communis  choledochus — Dilatation  of  the  gall-bladder, 
and  passage  of  gall-stones  into  the  gall-bladder — Cancer  of  the 
liver  and  kidneys  ....... 

Enlargement  of  the  liver — Ascites — Albuminuria — Recovery 
Fatty  enlargement  of  the  liver  ..... 

Cirrhosis  with  atrophy  of  the  liver — Ascites 

Cirrhosis  with  enlargement  of  liver — Hypertrophy  of  spleen — 
Slight  leucocythemia  — Jaundice  — Constriction  of  arch  and 
descending  aort^a  ....... 

Cancerous  exudation  into  the  liver — Cancerous  ulceration  of  oeso- 
phagus— Simple  stricture  of  pylorus — Profuse  haematemesis — 
Aneurism  of  thoracic  aorta,  bursting  into  the  left  pleura 
Hydatid  cyst  of  the  liver  diagnosed  by  means  of  the  microscope — 
Its  puncture — Discharge  of  Echinococci — Recovery 
Diarrhoea — Recovery  ...... 

Diarrhoea — Recovery  ...... 

Acute  dysentery — Recovery  ...... 

Sub-acute  dysentery — Recovery  ..... 

Chronic  dysentery — Ascites  and  oedema  of  the  legs — Leucocythemia 
— Cirrhosis  of  the  liver — Cancer  of  the  lung 
Obstruction  of  the  large  intestine — -Cancer  of  stomach,  liver,  peri- 
toneum generally,  and  mesenteric  glands  . . ’ . 

Strangulation  of  the  small  intestine  from  inguinal  hernia — Gan- 
grene, ulceration,  and  perforation  of  the  intestine— Peritonitis  . 
Tape-worm  treated  by  the  ethereal  extract  of  the  male  shield  fern 
Tape-worm  expelled  by  the  ethereal  extract  of  the  male  shield 
fern  ......... 

Tape-worm  expelled  by  the  same  remedy  .... 

Tape-worm  expelled  by  kamala— Return  of  the  parasite — Ultimate 
cure  by  means  of  the  male  shield  fern  .... 

Acute  peritonitis — Recovery  ...... 

Acute  peritonitis  from  bursting  of  Graafian  vesicles  into  the  peri- 
toneum— Pleurisy — Interlobular  pneumonia 
Tubercular  peritonitis  with  great  deposit  in  parietal  layer — 
Tubercle  and  hepatisation  of  lungs— Pleuritis — Adherent  peri- 
cardium— Commencing  fatty  degeneration  of  heart — Biliary 
congestion  and  fatty  degeneration  of  liver — Slight  leucocy- 
themia . . . . . 

Cancer  of  various  abdominal  organs  and  of  the  lungs,  producing 
symptoms  of  peritonitis  ...... 

Cancerous  peritonitis  — Ascites  and  hydrothorax  — Paracentesis 
abdominis — Arrested  phthisis  pulmonalis 


Page 

482 


483 

487 

489 

491 

495 

496 

496 

497 

498 


501 

504 


506 


509 

510 

511 
514 


514 


518 

522 

524 

524 

526 

527 

527 

534 

535 

542 

543 
543 


544 

545 

546 


549 

551 

554 


1008 


TABLE  OF  CASES. 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Case 

XCVII.  Acute  pericarditis — Recovery  ..... 
XCVIIL  Pericarditis  and  endocarditis— Hydropericardium 
XCIX.  Acute  pericarditis  followed  by  acute  double  pneumonia — Reco- 
very— Aortic  incompetence — Subsequent  articular  rheumatism 
— Sudden  death — Adherent  pericardium — Fatty  enlarged  heart 
— Thickening  of  aortic  valves  . . . . 

C.  Acute  pericarditis  supervening  on  phthisis 

CL  Ascites — Anasarca — Adherent  pericardium  with  fatty  atrophied 
heart — Congested  liver  ...... 

CII.  Rheumatic  pericarditis  ...... 

cm.  Rupture  of  aortic  valves  ...... 

CIV.  Incampetency  of  aortic  valves — Dilated  hypertrophy  of  left  ven- 
tricle— Dilatation  of  ascending  portion  of  aortic  arch — Chronic 
arteritis  with  aneurismal  pouches  .... 

CV.  Incompetencj^  of  aortic  valves — Hypertrophy  of  left  ventricle  and 
auricle — Obstruction  and  incompetency  of  mitral  valve — 
pneumonia  ....... 

CVI.  Incompetency  of  mitral  valve  ..... 

evil.  Incompetency  of  mitral  valve — Pulmonary  hemorrhage — Hydro- 
thorax ........ 

CVIII.  Mitral  incompetency — Hypertrophy  of  left  ventricle — ‘Attack  of 
acute  rheumatism,  followed  by  aortic  incompetency  . 

CIX.  Mitral  incompetency — Hypertrophy  of  left  ventricle — Aortic 
incompetency  and  obstruction — Angina  . . 

CX.  Incompetency  of  the  aortic  valves  with  musical  murmur — Hy- 
pertrophy with  dilatation  of  left  ventricle — Pneumonia — Pul- 
monary hemorrhage  ...... 

CXI.  Mitral  incompetency — Hypertrophy  of  left  ventricle — Dilatation 
and  disease  of  arch  of  aorta — Aortic  incompetency 
CXII.  Great  constriction  of  mitral  orifice — Dyspnoea,  palpitation, 
cough,  and  haemoptysis — Loud  prae-systolic  (or  diastolic-mitral) 
murmur — Death  following  abortion — Enlargement  of  the  two 
auricles  and  right  ventricle — Atrophy  of  left  ventricular  walls 
CXIII.  Constriction  of  mitral  and  tricuspid  orifices — Aortic  incom- 
petency— Anasarca  — Hydrothorax — Collapse  of  left  lung — 
Bright’s  disease  of  kidney  . . . . . 

CXIV.  Constriction  of  mitral  and  tricuspid  orifices — (mdema — Hemor- 
rhage into  the  lungs  . . . . • . 

CXV.  Soft' adherent  polypus,  causing  incompetency  of  the  mitral  orifice 
— Anasarca  ....... 

CXVI.  Enlarged  foramen  ovale — Phthisis  .... 

CXVII.  Aneurism  of  aortic  valve,  coincident  with  a systolic  murmur  at 
the  base  of  the  heart — Pneumonia-meningitis  . 

CXVIII.  Aneurism  of  the  ascending  arch  of  the  aorta — Incompetency  of 
aortic  valves — Hypertrophy  of  left  ventricle 
CXIX.  Aneurism  of  ascending  aorta  immediately  above  the  aortic  valves 
— Incompetency  of  aortic  and  mitral  valves — Hypertrophy  of 
left  ventricle — Waxy  kidneys — Pulmonary  hemorrhage — Ana- 
sarca ........ 

CXX.  Aneurism  of  ascending  arch  of  aorta — Chronic  pericarditis — Dis- 
ease of  aortic  valves — Great  hypertrophy  of  heart — Anasarca 
CXXI.  Large  aneurism  of  the  ascending  arch  of  the  aorta,  causing  ab- 
sorption of  a portion  of  the  third  rib,  and  bursting  into  the 
pericardium — Chronic  pericarditis — Incompetency  of  aortic 
valves — Hypertrophy  of  left  ventricle  . . . _ . 

CXXII.  Varicose  aneurism  of  the  ascending  aorta  communicating  with 
the  pulmonary  artery — Jaundice  and  nutmeg  liver 
CXXIII.  Aneurism  of  the  arteria  innominata 

eXXIV.  Aneurism  of  transverse  aortic  arch — Chronic  pericarditis  with 
effusion — Tubercular  lungs — Anasarca — Former  popliteal  an- 
eurism cured  by  compression  ..... 
eXXV.  Aneurism  of  lower  portion  of  the  thoracic  aorta,  pressing  on  the 
thoracic  duct — aneurism  of  abdominal  aorta — Chronic  ulcer  of 
stomach — Chronic  tubercular  abscesses  of  liver  and  right  kid- 
ney— Liver  and  left  kidney  waxy — Leucocythemia 
eXXVI.  Aneurism  of  the  superior  mesenteric  artery  and  aorta — Obscure 
aneurism  of  descending  thoracic  aorta — Treatment  by  the 
method  of  Valsalva — Pleuritis — Caries  of  the  vertebrae,  soft- 


Page 

5.59 

560 


561 

564 

566 

568 

576 

577 

577 

579 

579 

580 

581 

588 

584 

585 

587 

588 

590 

592 

601 

602 

603 

605 

606 

608 

613 

616 

618 


TABLE  OF  CASES. 


CjUB  Page 

ening  of  spinal  cord  and  paraplegia — Sudden  death  by  poison- 
ing with  the  tincture  of  aconite  .....  620 

CXXVII.  Phlebitis  of  the  left  iliac  vein,  supervening  on  cancer  of  the  sto- 
mach and  oesophagus  ......  634 

CXXVIII.  Angio-leucitis,  supervening  on  rupia— Recovery  . . . 635 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


CXXIX.  Acute  laryngitis — Treated  by  topical  applications — Recovery  , 638 

CXXX.  Chronic  laryngitis— Topical  applications — Recovery  . . 639 

CXXXI.  Acute  oedema  of  the  glottis— Chronic  pharyngitis  and  laryngitis — 

Sudden  death  . . . . . . . 642 

CXXXII.  Acute  laryngitis  supervening  on  ascites,  and  cirrhosis  of  liver — Sud- 
den death  from  asphyxia  ......  644 

CXXXIII.  Chronic  laryngitis  and  pharyngitis — Tracheotomy — Recovery  . 646 

CXXXIV.  Pertussis — Violent  paroxysms — Bronchitis — Collapse  of  the  lungs 

— Recovery  ..*.....  649 

CXXXV.  Acute  bronchitis  .......  651 

CXXXVI.  Chronic  bronchitis — Acute  peritonitis — Collapse  of  the  lung  . 653 

CXXXVII.  Chronic  bronchitis — Emphysema — Acute  laryngitis  . • . 654 

CXXXVill.  Chronic  bronchitis — Emphysema — Injection  of  the  bronchi  with  a 

solution  of  the  nitrate  of  silver  .....  657 

CXXXIX.  Acute  pleurisy — Recovery  ......  660 

CXL.  Acute  pleurisy  without  functional  symptoms — Rapid  recovery  . 661 

CXLI.  Chronic  pleurisy  on  both  sides— Bronchitis  ....  663 

CXLII.  Empyema,  with  fistulous  openings  between  the  lung  and  pleural 

cavity,  and  between  the  pleural  cavity  and  external  surface  ^ . 667 

CXLIII.  Chronic  pleuritis  and  pneumo-thorax,  without  symptoms— Articu- 
lar rheumatism— Pericarditis — Recovery  . . 669 

CXLIV.  Empyema,  follovving  chronic  phthisis  — Paracentesis  thoracis — 
Pneumo-thorax — Singular  mode  of  death  from  enormous  dis- 
tention of  the  stomach  and  emphysema  of  its  coats — Tubercular 
pleuritis — Adherent  pericardium — Waxy  spleen — Tubercle  in 
the  kidneys  ...  ....  671 

CXLV.  Chronic  pleurisy,  with  fluid  in  the  left  chest,  forcing  the  heart  into 

the  right  thoracic  cavity — Recovery  ....  677 

CXLVI.  A similar  case — No  improvement  . _ . . . . 677 

CXLVII.  Pneumonia  on  right  side  and  slight  pleuritis — Recovery  . . 678 

CXLVIII.  Double  pneumonia,  with  urgent  symptoms,  and  full  strong  pulse 

— Pleuritis  on  left  side — Recovery  in  nine  days  . . 679 

CXLIX.  Double  pneumonia — Great  dyspnoea— No  bleeding — Local  warmth 

and  stimulants — Rapid  recovery  .....  681 

CL.  Pneumonia  on  the  right  side — Early  bleeding — Slow  recovery  . 682 

CLI.  Double  pneumonia — Treatment  by  mercuiy,  which  caused  profuse 

salivation  before  admission — Prolonged  recovery  . . 684 

CLII.  Pneumonia — ushered  in  by  violent  vomiting  and  gastric  pain — Re- 
covery in  five  days  .......  685 

CLIII.  Bronchitis  and  pulmonary  congestion,  from  morbus  cordis,  resem- 
bling pneumonia,  but  no  absence  of  chlorides  in  the  urine  . 688 

CLIV.  Chronic  pneumonia  of  upper  thiid  of  right  lung  — Gangrenous 

abscess — Recovery  . . . . . . .713 

CLV.  Chronic  pneumonia  of  both  lungs,  with  ulceration — Death — Great 
condensation,  with  cavities  and  pignientary  deposits  in  the  lungs 
— Chronic  tubercle  in  various  organs  — Disease  of  both  supra- 
renal capsules,  without  bronzing  of  the  skin  . . . 714 

CLVI.  Gangrene  of  the  lungs — Dysentery  .....  716 

CLVII.  Gangrenous  abscess  of  the  right  lung,  caused  by  swallowing  a 

piece  of  chicken  bone  four  and  a half  years  previously  . . 718 

CLYIII.  Phthisis  pulmonalis  in  its  last  stage,  with  incompetency  of  the 

aortic  valves — Cod  liver  oil  and  nutrients — Complete  recovery  . 722 

CLIX.  Phthisis  pulmonalis — Amendment  from  treatment  and  disappear- 
ance of  symptoms — Their  subsequent  return — Death  . . 725 

CLX.  Phthisis  pulmonalis — Large  vomica  on  left  side — Cirrhosis  ot  lung 

— Canes  of  left  wrist-joint — Scrofulous  nephritis  . 727 

CLXI.  Chronic  phthisis — Enlarged  liver  — Albuminuria — Large  excava- 
tion in  left  lung — Cicatrices  and  induration  of  right  lung — 

Waxy  liver  and  kidneys — Tubercular  ulceration  of  intestines  . 731 

64 


iOiO 


TABLE  OF  CASES. 


Case  Paqi 

CLXII.  Advanced  phthisis — Restoration  to  health — Death  many  years 
afterwards  from  delirium  tremens — On  dissection,  a cicatrix, 
three  inches  long,  in  apex  of  right  lung,  and  cretaceous  con- 
cretions, with  puckering  at  the  summit  of  left  lung  . . 7S9 

CLXIII.  Cancer  of  the  lung,  thyroid  body,  and  lymphatic  glands  of  the 

neck — Bronchitis — Leucocythemia  ....  754 

CLXIV.  Carbonaceous  lungs  with  black  expectoration  . . .756 

C LX V.  Carbonaceous  lungs  with  black  expectoration  in  a female  . . 757 


DISEASES  OF  THE  GENITO-URINARY  SYSTEM. 

CLXVI.  Ovarian  dropsy — Frequent  paracentesis— Excision  of  both  ovaries 
— Strangulation  of  the  intestine — Phlebitis — Death  from  ileus 
the  seventieth  day  after  the  operation  ....  763 

CLXVII.  Ovarian  dropsy — Spontaneous  ulcerative  opening  of  the  cyst  into 

the  bladder,  and  evacuation  of  its  contents — Recovery  . . 770 

CLXYIII.  Ovarian  dropsy  which  gradually  emptied  itself  spontaneously  by 
opening  through  the  Fallopian  tube — Singular  attempt  at  im- 
position of  pigs'  bladders,  for  cystic  formations  in  the  uterus  . 772 

CLXIX.  Ovarian  dropsy — Perforation  of  the  descending  colon  from  without 

inwards — Death  from  ichorhaemia  and  persistent  diarrhoea  . 774 

CLXX.  Acute  nephro  pyelitis — Recovery  .....  782 

CLXXI.  Subacute  nephritis,  with  great  anasarca — Recovery — Acute  nephri- 
tis of  left  kidney — Recovery  .....  784 

CLXXII.  Acute  desquamative  nephritis,  proving  rapidly  fatal  from  diminish- 
ed flow  of  urine,  general  anasarca,  and  oedema  of  the  lungs  . 785 

CLXXIII.  Acute  desquamative  and  hemorrhagic  nephritis — Hydrothorax — 
Collapse  of  the  right  lung — Pulmonary  oedema  and  bronchitis, 
with  symptoms  of  pneumonia  .....  787 

CLXXIV.  Acute  nephritis — Chronic  pneumonia— (Edema  of  the  lung  and 
anasarca  proving  fatal — Perforating  ulcer  of  the  duodenum, 
without  symptoms  .......  7’89 

CLXXV.  Nephritis  follow'ed  by  the  formation  of  a large  abscess  in  the  right 
kidney,  opening  into  the  lumbar  cellular  tissue— Ulceration  of 
ureter  and  bladder — Thickening  of  mitral  and  tricuspid  valves 
— Partial  atrophy  of  lungs,  with  and  without  induration — Par- 
tial oedema  .......  791 

CLXXVI.  Scrofulous  nephritis  and  abscesses  in  the  kidneys — Extensive 

deposition  of  tubercle  in  the  lungs  and  intestines  . . 793 

CLXXVII.  Calculous  nephritis  and  gangrenous  abscess  of  the  right  kidney 

— Waxy  liver — Recto-vesical  fistula  ....  795 

CLXXVIII.  Chronic  pyelitis,  and  cystic  kidneys — Dilatation  of  ureters — Fun- 
goid ulceration  of  urinary  bladder  . . . ,797 

CLXXIX.  Albuminuria — General  anasarca — (Edema  of  lung — Recovery  . 801 

CLXXX.  Albuminuria — (Edema  of  both  feet  and  legs,  left  arm  and  hand — 

Recovery  ........  802 

CLXXXI.  Albuminuria — (Edema — Ascites  and  general  anasarca— Coma  and 

convulsions — Recovery  ......  804 

CLXXXII.  Third  attack  of  general  anasarca  with  albuminuria — Enormous 
dropsical  distention  of  the  abdomen,  scrotum,  and  inferior  ex- 
tremities— Complete  recovery  under  the  action  of  supertartrate 
of  potash  . . . . . . . . 805 

CLXXXIII.  Second  attack  of  albuminuria  with  anasarca — Dismissed  relieved  . 807 

CLXXXIV.  Second  attack  of  albuminuria  after  an  interval  of  tw^enty-nine 

years,  with  anasarca — Bronchitis — Dismissed  relieved  . . 808 

CLXXXV.  Third  attack  of  albuminuria  with  anasarca— Dismissed  relieved  . t09 

CLXXXVI.  Albuminuria,  with  general  anasarca,  terminating  fatally — Waxy 

kidneys,  spleen,  and  liver,  with  extensive  deposition  of  tubercle  8x0 

CLXXXVIl.  Albuminuria— Excessive  amount  of  urine — Phthisis  pulmonalis — 

Waxy  liver,  kidneys,  and  spleen  .....  811 

'LXXXVIII.  Albuminuria  with  great  increase  of  urine — Waxy  kidneys,  spleen, 

and  liver  . . . . . . . . 813 

CLXXXIX.  Albuminuria— Syphilitic  ulcerations  of  throat— Enlarged  spleen 
and  liver  — Leucocythemia  — Waxy  degeneration  of  kidneys, 
liver,  and  spleen  . . . . . . . 814 

CXC.  En  aiged  liver  and  spleen — Leucocythemia,  and  fibrinosis  of  the 

_luod — Albuminuria — Waxy  kidneys  ....  815 


TABLE  OF  CASES. 


1011 


Cask 

CXCI.  Albuminuria,  with  phthisis  pulmonalis,  terminating  fatally — Ex- 
tensive deposition  of  tubercle  and  colliquative  diarrhoea — Atro- 
phied fatty  kidney — Ulcerated  intestines  .... 


DISEASES  OF  THE  INTEGUMENTARY  SYSTEM. 

CXCII.  Favus  of  the  scalp  in  an  adult— Incurable  . . , . 

CXCIII.  Favus  of  the  scalp  of  three  years’ standing — Cured. 

CXCIV.  Favus  caught  in  the  ward  from  Case  CXCII. — Cured 
CXCV.  Favus  of  the  scalp  of  four  years’  standing,  cured  by  a sulphurous 
acid  lotion  ........ 

CXCVI.  Limited  favus  of  the  cheek,  cured  by  cauterisation;  with  nitrate  of 
silver  ........ 

CXCVII.  Parasitic  pityriasis — Incurable  ..... 

CXCVIII.  Pityriasis  versicolor — with  the  microsporon  furfur  of  Eichstadt — 
Cured  by  pitch  ointment  ...... 


DISEASES  OF  THE  BLOOD. 

CXCIX.  Leucocythemia  discovered  after  death — Hypertrophy  of  the  spleen, 
liver,  and  lymphatic  glands— Absence  of  phlebitis  and  of  puru- 
lent collections  in  any  part  of  the  body  .... 

CC.  Leucocythemia  detected  during  life — Hypertrophy  of  the  spleen — 
Ascites  ......•• 

CCI.  Commencing  leucocythemia  determined  during  life  — Enlarged 
spleen  and  liver — Ascites  . . . - • 

CCII.  Eczema  of  the  trunk  and  limbs — Enlarged  lymphatic  glands — 
Leucocythemia,  which  sensibly  diminished 
CCIII.  Chlorosis  and  anaemia — Cured  . . . • . 

CCIV.  Acute  articular  rheumatism — Multiple  abscesses  in  the  joints,  in 
the  muscles,  within  the  cranium,  &c.  .... 

CCV.  Diabetes  mellitus  ....... 

CCVI.  Diabetes  mellitus— Phthisis  pulmonalis — Death 
CC  VII.  Diabetes  mellitus — Improvement  from  the  use  of  sugar 
CCVIII.  Diabetes  mellitus,  treated  with  sugar — Great  improvement  for  a 
time,  followed  by  cataract,  phthisis,  and  death 
CCIX.  Diabetes — Treatment  by  sugar — Phthisis  .... 

CCX.  Diabetes — Treated  in  various  ways  ..... 

CCXI.  to  CCXIII.  Cases  of  diabetes  tabulated  .... 

CCXIV.  to  CCXVJI.  Cases  of  febricula 

CCXVIII.  Relapsing  fever  ....... 

CCXIX.  Typhoid  fever — Convalescence  on  the  forty-second  day 
eeXX.  Typhoid  fever — Fatal  on  the  twenty-fifth  day 
CCXXI.  Typhoid  fever — Fatal  from  perforating  ulcer  of  the  intestine 
CCXXII.  Typhus  fever,  with  cerebral  complication — Fatal 
CCXXIII.  Typhus  fever — Terminating  on  the  fourteenth  day  . 

CCXXIV.  Typhus  fever — Terminating  on  the  twenty -third  day  . 

CCXXV.  Typhus  fever,  with  petechise — Convalescent  sixteenth  day  . 
CCXXVI.  Typhus  fever — Convalescent  the  twenty-fourth  day  . 

CCXXVII.  Typhus  fever — Convalescent  the  fourteenth  day 
CCXXVIII.  Typhus  fever — Convalescent  the  fourteenth  day 
CCXXIX.  Typhus  fever,  complicated  with  bronchitis  and  collapsed  lung — 
Fatal  on  the  twelfth  day  ...... 

CCXXX.  Typhus  fever — Convalescent  on  the  twelfth  day 
CCXXXI.  Typhus  fever — Convalescent  on  the  twenty-first  day 
CCXXXII.  Typhus  fever — Convalescent  on  the  twenty-second  day 
CCXXXIII.  Typhoid  succeeded  by  typhus  fever  ..... 

CCXXXIV.  Typhoid  fever — Convalescent  on  the  twenty-first  day 
CCXXXV.  to  CCL.  Typhoid  and  typhus  fevers,  1862-63 

CCLI.  Infantile  remittent  fever  ...... 

CCLII.  Tertian  intermittent  cured  by  quinine  .... 

CCLIII.  Scarlatina  with  angina  ...... 

CCLIV.  Scarlatina  with  violent  delirium  . . . . . 

CCL V.  Scarlatina  treated  with  moist  warmth  . . . . 

CCLVI.  and  CCLVII.  Scarlatina — The  skin  kept  cool  and  dry  . . 

CCLVIII,  Scarlatina  with  diminished  urine  and  coma  .... 


Faob 


817 


847 

848 

848 

849 

849 

864. 

865 


868 

873 

878 

879 
900 

902 

907 

908 
912 

912 

913 

914 

915 
921 

923 

924 

925 

926 

927 

928 

928 

929 

929 
980 

930 

930 

931 
931 
931 

937 

938 
940 
949 
951 
954 
954 
956 

958 

959 


1012 


TABLE  OF  CASES. 


Case  Page 

CCLIX.  to  CCLXI.  Scarlatina  treated  with  the  wet  sheet  . , • 960 

CCLXII.  Erysipelas — Recovery  on  the  eleventh  day  . • ^ 961 

CCLXIII.  Erysipelas  in  an  intemperate  man — Slow  recovery  , , 961 

CCLXI V.  Variola — Severe  confluent  case  .....  692 

CCLXV.  Variola  discreta  .......  963 

CCLXVI.  Variola — Ectrotic  treatment ......  965 

CCLXVII.  Diphtheria— Recovery  ......  968 

CCLXVIII.  Diphtheria  complicated  with  small-pox — Death — Diphtheritic' 
membrane  covering  the  mucous  membrane  of  the  pharynx, 
epiglottis,  larynx,  trachea,  and  right  bronchus — pulmonary 
apoplexy  ........  969 

CCLXIX.  Syphilitic  ulceration  of  the  face  .....  971 

CCLXX.  Syphilitic  laryngitis  .......  972 

CCLXXI.  Syphilitic  rupia,  followed  by  keloid  growths  on  the  cicatrices — 

S^hilitic  psoriasis  ......  973 

CCLXXII.  to  (jCLXXV.  Treatment  of  acute  rheumatism  by  nitrate  of  potash  981 

CCLXXVI.  to  CCLXXIX.  Treatment  of  rheumatism  by  lemon-juice  . . 988 

CCLXXX.  Diaphragmatic  rheumatism  ......  989 

CCLXXXI.  Rheumatic  iritis,  following  acute  rheumatism — Recovery.  . 990 

CCLXXXII.  Chronic  gout  with  tophaceous  deposits  in  all  the  joints  . . 991 

CCLXXXIII.  and  CCLXXXIV.  Scorbutus 993 

CCLXXXV.  Sudden  polydipsia — Incurable  .....  995 

CCLXXXVI.  Polydipsia  the  last  two  months  of  pregnancy— disappearing  after 

delivery  ........  996 

IICLXXXVII.  Great  obesity — Fatty  degeneration  of  heart  and  muscular  system 
generally— Of  liver  and  kidneys — Hypertrophy  and  dilatation 
of  heart  ••••••..  99T 


IITDEX 


Abdomen,  auscultation  of,  73  ; inspection  of,  37  ; 
post-mortem  examination  of,  32 ; view  of  the 
viscera  in,  34 

Abscess,  pathology  of,  166 ; resolution  of,  173 ; in 
the  brain,  cases  of,  376  ; in  the  abdomen,  483  ; 
in  the  liver,  cases  of,  501,  618 ; in  the  lung, 
cases  of,  713 ; in  the  kidney,  cases  of,  791,  793, 
795 

Acarus  scabiei,  description  and  treatment  of,  842 
Achorion  Schoenleinii,  history  of  the,  850.  See 
Favus 

Acne,  diagnosis  of,  832 ; treatment  of,  839 
Aconite,  case  of  poisoning  by,  620,  628 ; symp- 
toms of,  629  ; influence  of  on  the  heart,  338, 
453 

Address  to  graduates  in  medicine  in  1849,  999 
Adenoma,  206 

Adhesions  between  serous  surfaces,  pathology  of, 
165  ; of  arachnoid,  case  of,  374 ; of  peritoneum, 
case  of,  549 ; of  pericardium,  566 ; of  pleura, 
665 

Albumen  and  oil  considered  as  types  of  nutritive 
substances,  126 

Albumen,  detection  of  in  urine,  110  ; in  solution, 
246  ; membranous,  247  ; fibroid,  247  ; celloid, 
248  ; molecular,  249 

Albuminous  degeneration,  246  ; concretions,  273 
Albuminuria,  persistent,  cases  of,  801 ; pathology 
of,  819  ; diagnosis  of,  823  ; treatment  of,  825 
Aliment,  125 ; conditions  regulating,  125.  See 
Food. 

Alison,  Dr.,  his  views  as  to  blood-letting  in  in- 
flammations, 302  ; Dr.  Scott,  his  stetho-gonio- 
meter,  48  ; his  differential  stethoscope,  64  ; his 
hydrophone,  65 

Alkaline  lotions  in  skin  diseases,  837 
Amaurosis,  case  of  partial,  445 
Ammonia,  urate  of,  microscopic  appearance  of, 
104 

Amphoric  resonance  in  cases,  669,  671 
Amyloid  and  amylaceous  concretions,  282  ; in  the 
auditory  nerve,  283  ; in  the  pancreas,  283  ; in 
the  brain,  380 
Amyloid  degeneration,  250 
Andral’s  opinion  of  the  expression  “ inflamma- 
tion,” 160 

Anaemia,  case  of,  900  ; pathology  and  treatment 
of,  901 

Aneurism,  nature  and  varieties  of,  216  ; cases  of 
in  aortic  valve,  601 ; in  arch  of  aorta,  601 ; 
varicose,  communicating  with  pulmonary  ar- 
tery, 603  ; of  arteria  innominata,  613  ; of  tho- 
racic aorta,  618  ; of  superior  mesenteric  artery, 
620 ; general  diagnosis  of,  630 ; pathology  of, 
633 ; treatment  of,  633 ; Valsalva’s  treatment 
of,  662 

Angina  pectoris,  600 ; case  of,  581 
Angionoma,  216 
Angio-leucitis,  635 
Animal  heat,  135 

Anorexia  in  phthisis,  treatment  of,  750 
Antimonials,  treatment  of  pneumonia  by  large 
doses  of,  694,  695 

Anxiety  and  despondency  in  phthisis,  treatment 
of,  753 


Aorta,  disease  of,  584 ; cases  of  aneurism  of,  602, 
See  Aneurism 

Aortic  valves,  disease  of,  583 ; aneurism  of,  601 ; 
rupture  of,  576 

Apoplexy,  definition  of,  353,  448  ; cases  of,  390  ; 
predisposing  cause  of,  416  ; histology  of,  417  ; 
diagnosis  of,  418 ; pathology  of,  397 ; treatment 
of,  420 

Appetite,  treatment  for  loss  of  in  phthisis,  750 
Arteries,  cerebral  disease  from  obstruction  of, 
390 ; pathology  of,  397  ; fatty  degeneration  of, 
256 ; mineral  degeneration  of,  269 
Arteritis,  chronic,  case  of,  577 
Ascites,  microscopic  appearances  in  fluid  of,  103  ; 
from  enlargement  of  liver,  510,  566 ; from 
peritonitis,  550 ; from  abdominal  cancer,  553 ; 
from  cirrhosis,  527  ; from  ovarian  disease,  776  ; 
treatment  of,  517 

Asthma,  causes  of,  655 ; treatment  of,  657  ; injec- 
tions of  the  bronchi  in,  697 
Assimilation  of  the  food,  128;  effects  of  bad 
assimilation,  136 
Atelectasis,  654 

Atheroma,  cystic,  199  ; of  blood-vessels,  256 
Atrophy  of  face,  remarkable  case  of,  155 
Auscultation,  general  rules  for  practice  of,  63  ; 
of  abdomen,  73 ; of  circulatory  organs,  special 
rules  for,  70 ; sounds  elicited  in  health  and 
disease,  7 1 ; modifications  of  healthy  sounds, 
72  ; new  or  abnormal  sounds,  73  ; of  pulmon- 
ary organs,  special  rules  for,  66  ; sounds  elici- 
ted by,  66  ; altei’ations  of  natural  sounds,  67  ; 
new  or  abnormal  sounds,  68 ; of  the  large 
vessels,  74;  relative  value  of  sounds  iu,  66  ; of 
aneurisms,  631 ; rules  derived  from  in  diseases 
of  the  circulatory  system,  557  ; rules  derived 
from  in  diseases  of  the  respiratory  system,  636 

Bael,  Indian,  use  of  in  dysentery,  529 
Bathing,  therapeutic  uses  of,  328 
Bile,  detection  of,  in  urine,  110;  bile  acids.  111 
Biliary  calculi,  274 

Bladder,  percussion  of,  62  ; urinary  calculi  in^ 
276 ; opening  of  ovarian  cyst  into,  770  ; fun- 
goid ulceration  of,  797 

Blood,  appearance  of,  under  the  microscope,  91  ; 
in  thickened  blood,  92  ; in  haematocele,  92  ; in 
leucocythemia,  93,  882,  887  ; appearance  of, 
in  a case  of  cholera,  92 ; formation  of,  from 
alimentary  matters,  and  the  changes  it  under- 
goes in  the  lungs,  128  ; determination  of,  130 ; 
chemical  alterations  in  disease  of  the,  133  ; 
formation  of,  128  ; reabsorption  of  transformed 
tissues  into  the,  131  ; circulation  of,  130  ; pas- 
sage of  fluid  from,  to  be  transformed  into  the 
tissues,  130 ; chemical  constitution  of  healthy, 

132  ; function  of  the,  132  ; morbid  conditions 
of  the,  132  ; chemical  alterations  of,  in  disease, 

133  ; diseases  of  the,  136,  882,  887  ; causes  of 
disease  in  the,  136 ; principle  of  treatment  of, 
137  ; post-mortem  examination  of,  32  ; micro- 
scopic examination  of,  91 ; mixture  of  pus  with, 
896 

Blood  corpuscles,  relation  between  the  colorless 
and  colored,  882 ; origin  of  the,  884 ; ultimate 


1014 


mDEX. 


destination  of  the,  890 ; structural  alterations 
in,  93 

Blood-forming  glands,  structure  of,  128,  881; 
functions  of,  128 

Blood-letting,  diminished  employment  of  in 
treatment  of  acute  inflammations,  302  ; former 
reasons  for,  erroneous,  306 ; local,  observations 
of.  Dr.  John  Struthers  on,  310;  can  the  ma- 
teries  morbi  in  the  blood  be  diminished 
by  ? 306  ; can  it  diminish  the  flow  of  blood 
to  the  inflamed  part  ? 308  ; can  it  diminisli  the 
amount  of  blood  in  an  inflamed  part  ? 309 ; 
should  it  be  indicated  by  the  character  of  the 
pulse?  312;  in  acute  pneumonia,  316,  692; 
useful  as  a palliative,  313  ; and  in  over-disten- 
siou  of  the  right  side  of  the  heart,  venous 
congestion,  engorgement,  etc.,  317 ; in  func- 
tional nervous  disorders,  454 
Blood-vessels,  changes  in  previous  to  inflamma- 
tion, 156 ; new  formation  of,  219  ; fatty  degen- 
eration of,  256 ; mineral  degeneration  of,  269 
Bone,  fatty  degeneration  of,  259 ; formation  of 
new,  227  ; morbid  growths  of,  225 
Eorborygmi,  73 

Bowditch,  Dr.  H.,  on  thoracentesis,  675 
Brain,  distinction  between  pressure  on  and  com- 
pression of,  149  ; proper  functions  of  the,  139  ; 
effects  of  removal  of,  140;  amyloid  concre- 
tions in  the,  282,  381  ; softenings  of  the,  353 ; 
abscess  in  the,  376 ; chronic  inflammation  of 
the,  380  ; obstruction  of  arteries  in  the,  390  ; 
hemorrhage  in  the,  400  ; cases  of  tubercle  in 
the,  369,  373 ; cancer  of  the,  421 ; dropsy  of 
the,  424 ; acute  inflammation  of  the,  376  ; 
functional  disorders  of  the,  447 
Breathing,  bronchial  or  tubular,  68 
Bright’s  disease,  801;  casts  of  uriniferous  tubes  in, 
105,  824 ; cases  of,  801 ; pathology  of,  819  ; forms 
of,  819  ; diagnosis  of,  823  ; treatment  of,  825 
Bronchi,  injections  of  the,  in  pulmonary  diseases, 
658 

Bronchitis,  acute  cases  of,  651 ; nature  and 
ti’eatinent  of,  652  ; chronic,  cases  of,  653  ; 
causes  of,  655 ; treatment  of,  656 
Bronchophony,  67 

Bronzing  of  the  skin.  Dr.  Addison  on,  264 
Bruit  de  diable,  601 
Bulla,  definition  of,  828 

Calculi,  biliary,  274  ; urinary,  275  ; renal,  275  ; 

vesical,  276  ; prostatic,  278 ; intestinal,  280 
Callosities,  210  ; cause  of,  210 
Cancer,  general  description  of,  229  ; scirrhous, 
229 ; encephalomatous,  230 ; cells  in  simple 
and  compound,  230  ; reticulare  of  Muller,  230  ; 
colloid,  232 ; chimney-sweeps’,  213 ; villous, 
215;  of  the  brain,  421;  of  the  liver,  518;  of 
the  lung,  754  ; of  the  skin,  109  ; of  the  oesopha- 
gus, 470  ; of  the  stomach,  489,  534  ; of  mesen- 
teric glands,  534  ; of  abdominal  organs  simu- 
lating peritonitis,  551  ; of  the  peritoneum,  554  ; 
of  vei’tebral  bones,  437  ; of  cranial  bones,  441 
Cancerous,  growths,  229 — (see  Cancer) ; cyst  of 
the  liver,  522  ; peritonitis,  554 
Cancrum  oris,  171 
Canman’s  stethoscope,  64 
Cantharides,  action  of,  453 
Capillaries,  changes  which  take  place  in,  pre- 
ceding-inflammation, 156;  contraction  of  the, 
note,  156  ; new  foimation  of,  219 
Carbonaceous  lungs,  756;  morbid  anatomy  and 
pathology  of,  759;  treatment  of,  762 
Carcinoma,  229.  See  Cancer 
Cardiac  sounds,  70 ; diseases,  rules  for  the  diag- 
nosis of,  557 

Caries,  scrofulous,  436  ; cancerous,  437  ; from 
pressure  of  aneurism,  620 
Cartilage,  morbid  growths  of,  220  ; ulceration  of, 
223  ; fatty  degeneration  of,  259 
Cartilages,  loose,  194 

Cartilaginous  growths,  220  ; forms  and  structmn 
of,  221 ; in  articulations,  223 


Cases,  method  of  taking,  30 
Casts  of  the  tubuh  uriniferi,  varieties  of  in 
Bright’s  disease,  105,  824 
Catalepsy,  definition  of,  449 
Cell  therapeutics,  307  ; theories  of  organisation, 
115;  theory  of  Schleiden  and  Schwann,  161; 
of  Goodsir,  117  ; of  Huxley,  117  ; of  the  author, 
118  ; change  of  type  theory,  fallacy  of,  299 
Cells,  importance  of  in  practice,  20  ; fatty  dege- 
neration of,  253 ; cell  fibres,  189 ; fusiform,  189  ; 
plastic  or  pyoid,  165  ; gi-anule,  167  ; fibre,  168, 
189  ; of  cancer,  229  ; development  of  morbid 
growths  by,  235  ; pigment,  266,  267  ; transfor- 
mation of  exudation  by,  in  pneumonia,  690 ; 
in  pericarditis,  175;  in  pleurisy,  165;  on 
mucous  membranes,  166 ; in  the  brain,  167 ; 
in  healing  granulations,  168 ; enlargement  of, 
in  pregnant  uterus,  189 ; atrophy  of,  after 
delivery,  256  ; in  malacosteon,  259 
Cephalalgia,  treatment  of,  453 
Cerebellum,  structure  and  functions  of,  142 ; 

effects  of  removal  of,  143;  disease  of,  373 
Cerebral  and  spinal  softenings,  pathology  of, 
353  ; origins  and  varieties  of,  354 ; necessity 
for  microscopic  examination  of,  358 ; cases  of, 
359,  380 

Cerebral  disease  from  obstruction  of  arteries, 
cases  of,  390  ; pathology  Of,  397 
Cerebral  disorders,  classification  of  functional, 
447 

Cerebral  hemorrhage,  cases  of,  400 ; predisposing 
cause  of,  416  ; microscopic  appearances  of,  417; 
diagnosis  of,  418  ; treatment  of,  420 
Cerebral  meningilis,  cases  of,  367  ; seat  of,  370  ; 
microscopic  appearances,  371 ; diagnosis  of, 
371  ; treatment  uf,  371 ; pathology  of,  372 
Ccrebritis,  acute,  cases  of,  376  ; chronic,  cases 
of,  380  ; pathology  of,  387 
Ccrebro-spinal  disorders,  classification  of  func- 
tional, 449 

Cerebrum,  structure  and  functions  of,  139; 

olfects  of  removal  of,  140 
Chest,  inspection  of,  36  ; mensuration  of,  45  ; 
motions  of  during  respiration,  37  ; post-mor- 
tem examination  of,  31  ; view  of  viscera  in,  34; 
percussion  of,  54 ; auscultation  of,  66 
Chicken-pox,  identical  with  small-pox,  967 
Chlorides  in  urine,  detection  of,  112  ; absence  of 
in  pneumonia,  686 

Chloroform  not  an  anaesthetic,  452  ; inferior  to 
cold  as  a true  anaesthetic,  454 
Chlorosis  anaemia,  cases  of,  900 
Cholera,  microscopic  appearance  of  blood  in  a 
ca  se  of,  92 
Cholesteatoma,  202 
Chorea,  definition  of,  448 

Chyle,  formation  of,  128  ; of  a dog,  743 ; of  a cat, 
885 

Chylification,  128 
Cicatrisation,  process  of,  190 
Cicatrix,  structure  of,  190 

Circulation,  129 ; static  force  of  the  heart  and 
arteries  in,  130 

Circulatoi’y  system,  examination  of,  26  ; action 
of  medicine's  on  the,  339 ; diseasee  of  the,  557  ; 
rules  for  diagnosis  of,  557 
Circulatory  organs,  auscultation  of,  70  ; sounds 
elicited  by,  in  health  and  disease,  71 ; modifi- 
cations of  healthy  sounds  of,  72  ; new  or  abnor- 
mal sounds  in,  73 

Cirrhosis  of  liver,  cases  of,  514 ; pathology  of, 
516  ; treatment  of,  517 

Clinical  course,  mode  of  conducting,  6 ; micro- 
scope of  Dr.  Beale,  80 

Climate,  therapeutic  uses  of,  325  ; influenc  of  in 
phthisis,  746  ; in  producing  fatty  liver,  512 
Clothing,  therapeutic  uses  of,  327 
Cod-liver  oil  in  tuberculosis,  184 ; as  a nutrient, 
321 ; as  increasing  molecular  elements,  336 ; 
introduced  as  a remedy  for  phthisis  by  the 
author,  744 ; mode  of  action,  745  ; in  favus, 
864 


INDEX. 


1015 


Colchicum  in  scarlatina,  959 
Cold,  therapeutic  uses  of,  326  ; action  of  en  the 
nervous  system,  454  ; in  inflammation,  176; 
in  cephalalgia,  327  ; in  fever,  946 
Collapse  of  lung,  653 

College  of  Physicians  of  Edinburgh,  its  sale  of 
licenses,  17 

Collier’s  lung,  756  ; pathology  and  treatment  of, 
758 

Colloid  cancer,  232 
Colostrum  of  human  female,  90 
Complemental  nutrition,  135 
Compression  and  pressure,  distinction  between, 
149 

Concretions,  272  ; albuminous,  273  ; fatty,  273  ; 
biliary,  274  ; pigmentary,  274  ; mineral,  275  ; 
urinary,  275  ; renal,  276  ; vesical,  276  ; prosta- 
tic, 278  ; hairy,  279  ; vegetable  fibrous,  280  ; 
intestinal,  280  ; amyloid  and  amylaceous,  282 
Condylomata,  212 
Congelation  a true  ansesthetic,  454 
Congestion  preceding  inflammation,  155  ; of  the 
right  side  of  .the  heart,  bleeding  useful  in,  317, 
711 

Congestive  disorders  of  the  nervous  system,  450 
Conium.  See  Hemlock 
Constipation,  causes  and  treatment  of,  525 
Contagion,  defini*tion  of,  953 
Contractility  defined,  148 
Convulsion,  definition  of,  353,  448 
Cord,  spinal,  cases  of  structural  diseases  of  the, 
427  ; pathology  of,  438 ; functions  of  the,  144 ; 
functional  disorders  of  the,  448 
Corns,  210;  causes  of,  210 

Corpuscles  of  the  blood,  91 ; in  thickened  blood, 
haematocele,  and  cholera,  92;  in  leucocythemia, 
93,  871  ; relation  between  the  colored  and 
colorless,  882 ; origin  of  the,  884 ; ultimate 
destination  of  the,  890 

Corpuscles,  pus,  appearance  of  in  healthy  pus, 
94  ; in  scrofulous  pus,  94 
Corpuscles,  salivary,  88  ; tubercle,  95,  179 
Corrosive  sublimate,  poisoning  by,  496 
Coryza,  nature  and  treatment  of,  652 
Cough  and  expectoration  in  phthisis,  treatment 
of,  749 

Countenance,  inspection  of  the,  36 
Cracked-pot  sound,  56 

Cranium,  amount  of  fluids  within  the,  148 ; 
views  of  Drs.  Munro,  Abercrombie,  and  Wat- 
son, 148 ; experiments  of  Bonders  and  Kellie, 
149 ; observations  of  Dr.  Burrows,  150 ; obser- 
vations of  Dr.  John  Peid,  151 
Curative  action  of  remedies,  335 
Cutaneous  eruptions,  microscopic  examination 
of,  107  ; classification  of,  828  ; diagnosis  of, 
831 ; treatment  of,  836  ; on  the  scalp,  835 
Cystic  duct,  occlusion  of,  506 
Cystic  growths,  199  ; simple,  199 ; compound, 
200  ; contents  of,  200  ; hygromatous,  200  ; col- 
loid, 201 ; melicerous,  202  ; cholesteatomatous, 
202 ; atheromatous,  203  ; hairy,  203  ; with 
teeth,  203  ; osseous,  204 ; cancerous,  remark- 
able case  of,  518 

Cystine,  microscopic  appearance  of,  105 
Cystoma,  199 

Debility  in  phthisis,  treatment  of,  753 
Degeneration,  albuminous,  246  ; general  patho- 
logy find  treatment  of  the,  252  ; colloid,  251 ; 
fibroid,  of  Handfield  Jones,  247 
Degeneration,  fatty,  252  ; of  cells,  253 ; of  mus- 
cle, 254 : of  blood-vessels,  256 ; of  the  placenta, 
258  ; of  Cartilage,  259 ; of  bone,  259 ; of  the 
exudations,  260  ; of  morbid  growths,  261  ; of 
the  heart,  598 ; general  pathology  and  treat- 
ment of,  261 

Degeneration,  mineral,  269 ; of  blood-vessels, 
269  ; of  the  exudations,  271 ; of  nervous  text- 
ure, 2”  ) ; of  morbid  growths,  272 
Degeneration,  pigmentary,  262  : general  patho- 
logy and  treatment  of,  2 J7 


Degeneration,  waxy,  249 
Degenerations  of  texture,  morbid,  24  i 
Deln’ium  tremens,  cases  of,  455  ; pathology  and 
treatment  of,  457 

Dermatophyta,  diagnosis  of,  833,  335.  Sea 
Favus 

Dermatozoa,  853 

Despondency  and  anxiety  in  phthisis,  treatment 
of,  703 

Determination  of  blood,  theory  refuted,  308 
Diabetes  Mellitus,  cases  of,  907  ; theories  regard- 
ing the  nature  and  treatment  of,  909 
Diagnosis,  eftects  of  advanced  knowledge  o^ 
287 

Diagnosis,  microscopic,  of  saliva,  88 ; ndlk,  90  ; 
blood,  92  ; pus,  93  ; sputum,  94  ; vomited  mat- 
ters, 97  ; faeces,  99 ; uterine  and  vaginal  dis- 
charges, 100 ; mucus,  102  ; dropsical  fluids, 
103 ; urine,  103 ; cutaneous  eruptions  and 
ulcers,  107  ; the  knowledge  derived  from  an 
improved,  297 

Diagnosis,  general,  of  cardiac  diseases,  rules  for 
the,  557  ; of  thoracic  aneurisms,  630 ; ol 
abdominal  aneurisms,  633 ; of  pulmonary 
diseases,  rules  for,  637  ; of  skin  diseases,  831 ; 
of  continued  fevers,  931 

Diarrhoea,  cases  of,  524;  varieties  and  causes 
of,  525  ; pathology;  of,  530  ; treatment  of,  525  ; 
treatment  of  in  children,  533 ; treatment  of  in 
phthisis,  751 

Diastaltic  or  reflex  movements,  147  ; classifica- 
tion of  disorders,  451 

Diet,  irregularity  in,  the  most  common  cause  of 
disease,  126  ; causing  scui’vy,  993 
Dietetica,  320 

Digestion,  in  the  stomach  and  intestines,  127  ; 
kinds  of,  131  ; disorders  of,  472  ; pathology  and 
treatment  of  derangements  of,  475 
Digestive  system,  examination  of,  26 ; action  ol 
medicines  on  the,  341 ; diseases  of  the,  466 
Diphtheria,  968 

Discharges,  uterine  and  vaginal,  microscopic 
examination  of,  100 

Disease,  definition  of,  114  ; natural  progress  of, 
295  ; Bright’s,  cases  of,  801  ; cerebral,  from 
obstruction  of  arteries,  390 ; general  laws  of 
nutrition  in,  124 ; general  law's  of  innervation 
in,  137  ; irregularity  in  diet  the  most  common 
cause  of,  126  ; importance  of  a knowledge  of 
the  causes  of,  284  ; cause  of  recent  changes  in 
the  treatment  of,  284  ; of  nutrition,  136 
Diseases  of  the  nervous  system,  352 ; of  the  diges- 
tive system,  466  ; of  the  circulatory  system, 
547  ; of  the  respiratory  system,  637  ; of  the 
genito-urinary  system,  763;  of  the  integumen- 
tary system,  827  ; of  the  blood,  867 
Drainage,  as  a cause  of  fevers,  943 
Drinks,  therapeutic  uses  of,  322 
Dropsical  fluids,  microscopic  examination  of,  103 
Dropsy,  246  ; general,  566,  784,  805  ; of  the  brain, 
case  of,  424  ; of  the  pericardium,  560  ; of  the 
chest,  579,  587  ; of  the  abdomen,  510,  514 
Dropsy,  ovarian,  cases  of,  763  ; pathology  of, 
775  ; diagnosis  of,  779  ; treatment  of,  780  ; pro- 
ducts found  in  fluid  of,  103 
Duodenum,  perforating  ulcer  of,  789 
Dyspepsia,  cases  of,  472  ; pathology,  treatment 
and  causes  of,  475 

Dysentery',  cases  of  acute,  526  ; case  of  chronic, 
527  ; pathology  of,  530  ; treatment  of,  533 

Eclampsia,  definition  of,  449 
Ecthyma,  diagnosis  of,  832  ; treatment  of,  833 
Eczema,  diagnosis  of,  832  ; treatment  of,  837 
Electricity,  therapeutic  uses  of,  Mi) 

Embolismus,  399 

Emboli,  in  the  brain,  pathology  of,  397  ; in  the 
lung,  721 

Emphysema,  pathology  of,  655  ; cases  of,  654, 
657  ; treatment  of,  658 
Emprosthotonos,  definition  of,  448 
Empyema,  cases  of,  667  ; paracentesis  for,  675 


1016 


INDEX. 


Encephaloma,  230 

Enchondroma,  220 ; structure  of,  221 ; diagnosis 
of,  222 

Endocarditis,  575 

Engorgement,  bleeding  useful  in,  317,  711 
Entozoon  folliculorum,  description  of  the,  845 
Ephelis,  diagnosis  of,  833  ; treatment  of,  840 
Epilepsy,  definition  of,  353,  449  ; case  of  relieved 
by  galvanism,  452  ; case  of,  from  chronic  cere- 
britis,  376 

Epithelial  growths,  210.  See  Epithelioma 
Epithelial,  scales  in  saliva,  88 ; ulcer,  109 ; 
growths,  210 

Epithelioma,  210  ; principal  forms  of,  210  ; struc- 
ture of,  213  ; of  the  lip  and  tongue,  213  ; of 
the  lymphatic  glands^  214 ; of  the  urinary 
bladder,  215  ; pathology  of,  236 
Epithelium,  fringe-like,  89 
Epulis,  226 
Eremacausis,  171 
Ergot  of  rye  in  paraplegia,  434 
Eruptions,  cutaneous,  microscopic  examination 
of,  107 

Erysipelas,  cases,  diagnosis,  and  treatment  of, 
961 

Erythema,  diagnosis  of,  832  ; treatment  of,  837 
Ethics  of  medicine,  999 

Examination  of  patient,  24;  by  interrogation, 
24  ; by  inspection,  36 ; by  palpation,  43  ; by 
mensuration,  45  ; by  succussion,  44 ; by  per- 
cussion, 48  ; by  auscultation,  63 
Examination,  post-mortem,  30 ; method  and 
order  of,  30  ; object  of,  30  ; of  external  appear- 
ances, 31  ; of  head,  31 ; of  spinal  column,  31  ; 
of  neck,  31 ; of  chest,  31 1 of  abdomen,  32  ; of 
blood,  32  ; by  microscopic  examination,  32  ; 
hints  for  carrj  ing  out  post-mortem  examina- 
tion, 32  ; knowledge  required  for  correct  ex- 
amination, 33 ; necessary  to  determine  the 
value  of  remedies,  627  ; Dr.  Sibson’s  “ Medi- 
cal Anatomjr,”  34 

Exanthemata,  definition  of,  828 ; diagnosis  of, 
832  ; treatment  of,  837 
Excrescence,  cauliflower,  213 
Excretion  of  matters  from  the  body,  133  ; amount 
of,  134 

Exercise,  therapeutic  uses  of,  323 
Exophthalmia,  case  of,  384 
Exostosis,  225  ; from  poisoning  with  mercury, 
978 

Expectoration  and  cough  in  phthisis,  treatment 
of,  749 

Experience,  past  and  present,  in  the  treatment 
of  inflammation,  304 

Exudation,  definition  of  the  term,  162,  note.; 
production  of,  158  ; theory  of,  159  ; cancerous, 
235  ; tubercular,  181  ; death  of  the,  169  ; gen- 
eral treatment  of,  176,  184  ; fatty  degenera- 
tion of  the,  260  ; mineral  degeneration  of  the, 
271 ; essential  to  inflammation,  303,  304 ; 
transformation  of,  in  pneumonia,  689 ; in 
cerebritis,  387  ; in  pericarditis,  174  ; in  pleuri- 
tis,  665 ; seat  of  in  dysentery,  532 

Face,  remarkable  case  of  atrophy  of,  155 
Fatty  concretions,  273 

Fatty  degeneration,  252 ; of  cells,  253 ; of  muscle, 
25.4 ; of  blood-vessels,  256 ; of  the  placenta, 
258  ; of  cartilage,  259  ; of  bone,  259  ; of  the 
exudations,  260 ; of  morbid  gi'owtbs,  261  ; of 
the  brain,  354  ; of  the  liver,  512  ; of  the  cardiac 
valves,  597  ; of  the  heart,  598  ; of  the  kidney, 
821 

Fatty  growths,  196  ; steatomatous  and  lipoma- 
tous,  197  ; fibro-lipomatous,  197 
Favus  crust,  composition  of,  108 
Favus  of  the  scalp,  diagnosis  of,  834 ; cases  of, 
847  ; history  of  favus  as  a vegetable  parasite, 
850  ; mode  of  development  and  sj-mptoms  of, 
850  ; causes  of,  853  ; pathology  of,  855  ; treat- 
ment of,  862;  on  the  face  of  a mouse,  853, 
note 


Febricula,  characters  o£i  920  ; cases  of,  92* 
Febrile  symptoms  in  phthisis,  treatment  of,  732 
Fern,  male  shield,  as  a vermifuge,  542 
Fever,  continued,  changes  of  type  in,  305, 
symptoms  of,  918;  forms  and  characters  of, 
920 ; diagnosis  of,  931  ; morbid  anatomy  of  the 
Edinburgh  epidemic  of,  during  1816-7,  934; 
causes  of,  942  ; treatment  of,  945 
Fever,  intermittent,  case  of,  951 ; nature  of,  952; 
treatment  of,  952 

Fever,  relapsing,  character  of,  920 ; case  of,  923  ; 

identical  with  the  synocha  of  Cullen,  924 
Fever,  remittent,  case  of,  949  ; nature  and  treat- 
ment of,  950 

Fever,  therapeutic  action  of  quinine  in,  948 
Fever,  typhoid,  character  of,  920 ; cases  ofi 
treated  by  quinine,  924 ; diagnosis  of,  931  ; 
nature  of,  937  ; morbid  anatomy  of,  934 
etiology  of,  937 

Fever,  typhus,  character  of,  920  ; case  of,  treat^J* 
by  quinine,  927  ; cases  of,  treated  withoirt 
quinine,  930  ; diagnosis  of,  931 ; treatment  ofj 
945 

Fevers,  eruptive,  953 

Fibres,  molecular,  189  ; nuclear,  189  ; cell,  189 
Fibrin,  in  the  blood,  92 ; not  altered  by  vene- 
section, 133 
Fibroma,  188 

Fibrous  growths,  188 ; molecular,  nuclear,  and 
cell,  189 ; fibro-nucleated  and  fibro-cellular, 
190 ; sarcomatous  or  soft,  191 ; dermoid  or 
hard,  193  ; neuromatous,  195 
Fistula,  recto-vesical,  795 
Fluctuation,  examination  of  patient  by,  44 
Faeces,  microscopic  examination  of,  99  ; in  diar- 
rhoea, 525  ; in  constipation,  526  ; characters  of 
in  disease,  530 

Food,  various  kinds  of,  125  ; circumstances  regu- 
lating, 125  ; assimilation  of  the,  128  ; effects 
of  bad  assimilation,  136;  effects  of  improper 
quantity  or  quality  of,  154 ; therapeutic  uses 
of,  320  ; in  scorbutus,  993 
Foramen  ovale,  enlarged,  case  of,  592 
Force,  attractive  and  selective,  131 
Freckle,  diagnosis  of,  833  ; treatment  of,  840 
Functions,  influence  of  derangement  of  one  over 
another  order  of,  154 

Functions  of  the  body,  influence  of  predominant 
ideas  on  the,  285 
Fungus  haematodes,  230 

Fungus  from  a favus  crust,  108  ; in  the  ear,  108 

Gangrene,  moist,  169  ; dry,  171 ; of  the  intes- 
tine, 535  ; of  the  lungs,  716  ; from  obstruction 
of  pulmonary  artery,  721  ; of  the  kidney,  795 
Gall-bladder,  with  gall-stones  in,  504,  509  ; en- 
largement of,  506 

Gall-stone,  273  ; case  of  impaction  of,  in  com- 
mon bile-duct,  504  ; passage  of  into  the  gall- 
bladder, 506 

Gastric  glands,  organic  changes  in,  493 
Genito-urinary  system,  examination  of,  27 ; 
action  of  medicines  on  the,  342  ; diseases  of 
the,  762 

Gland,  thyroid,  liability  of  to  new  formation  of 
tissue,  208 ; enlargement  of,  in  bronchocele, 
251 

Glands,  mesenteric,  liability  of,  to  increased 
growth,  208 

Gland,  prostate,  calculi  found  in  the,  278 
Glands,  structure  of  blood-foiming,  886 
Glandular  grovdhs,  206  ; forms  of,  207  ; structure 
of,  207  ; of  the  thyroid  gland,  208 ; of  the 
lymphatic  glands,  208  ; causes  of.  209 
Glottis,  cases  of  acute  oedema  of  the,  642 
Glycohaemia,  cases  of,  907  ; theories  regarding 
the  nature  and  treatment  of,  909  ; treatment 
of  by  sugar,  912  ; tabulated  cases  of,  with 
analysis,  etc.,  914 

Gout,  general  pathology  and  treatment  of,  982 
case  of  chronic,  991 

Granulations,  formation  and  structure  of,  168 


INDEX. 


1017 


Granule  cells,  167,  253 

Granules  and  molecules,  deposition  of  fatty,  253 
Growths,  morbid,  185 ; classification  of,  187  ; 
ultimate  elements  of,  186  ; general  pathology 
of,  233  ; origin  of,  233  ; development  of,  234  ; 
propagation  of,  237  ; malignancy  and  non- 
malignancy of,  238;  curability  of,  239;  Van 
der  Kolk’s  views  of  causes  of  propagation  of, 
241 ; decline  or  degeneration  of,  242  ; general 
treatment  of,  242  ; means  of  retardation  and 
resolution  of,  243 ; means  of  extirpation  of, 
243  ; necessity  for  microscopic  examination  of, 
243 ; constitutional  treatment  of,  244 ; M. 
Velpeau  on  the  permanent  removal  of,  245  ; 
fatty  degeneration  of,  261 ; mineral  degenera- 
tion of,  271 

Growths,  morbid,  of  texture,  185  ; fibrous,  188  ; 
fatty,  196  ; cystic,  199  ; melicerous,  199 ; cho- 
lesteatomatous,  202  ; atheromatous,  203  ; glan- 
dular, 206  ; cartilaginous',  220  ; erectile,  218  ; 
steatomatous  encysted,  202 ; epithelial,  210 ; 
vascular,  216 ; osseous,  225 ; myeloid,  226  ; 
cancerous,  229  ; distinction  of  cancerous  from 
other,  229 

Gruby’s  pocket  microscope,  79 

Haematocele,  appearance  of  altered  blood  cor- 
puscles in  the  fluid  of  an,  92 
Haemoptysis  in  phthisis,  treatment  of,  751 
Hairy,  formations,  215  ; concretions,  279 
Hammer,  Dr.  Winterich’s,  49 
Head,  post-mortem  examination  of,  31 
Headache,  definition  of,  447  ; treatment  of,  453 
Headland,  on  the  actions  of  medicines,  reviewed, 
333 

Healing  process,  results  of  the,  185 
Health  and  disease,  general  laws  of  nutrition  in, 
124  ; general  laws  of  innervation  in,  137 
Heart,  functional  disorders  of  the,  600 ; treat- 
ment of,  601 

Heart,  rules  for  the  diagnosis  of  diseases  of  the, 
557 

Heart,  sounds  of  the,  71 ; percussion  of  the,  56  ; 
mechanical  injuries  of  the  valves  of,  594 ; exu- 
dation into  or  on  the  surface  of  the  valves  of, 
595  ; deposition  of  fibrin  on  the  valves  of, 
597  ; degeneration  of  the  valves  of  the,  597  ; 
fatty  degeneration  of  the,  598;  hypertrophy 
ot  the,  598  ; inflammation  of  the  substance  of 
the,  599 

Heart,  valvular  diseases  of  the,  575  ; cases  of, 
576 ; causes  of,  594 ; pathology  of,  594 ; treat- 
ment of,  599  ; dislocation  of  the,  677 
Heat,  source  of  animal,  35 ; therapeutic  uses  of, 
326 

Hemiplegia,  definition  of,  448 ; cases  of,  392 ; 

pathology  of,  418  ; treatment  of,  420 
Hemlock,  case  of  poisoning  by,  459 ; sjTnptoms 
of,  462  ; physiological  action  of,  463  ; death  of 
Socrates  by,  464 ; identity  of  ancient  with 
modern,  464 

Hemorrhage,  cerebral,  cases  of,  400  ; predispos- 
ing cause  of,  417  ; microscopic  appearances  of, 
417  ; diagnosis  of,  418  ; treatment  of,  420 
Hepatitis,  case  of,  497 

Herpes,  diagnosis  of,  832  ; treatment  of,  838 
Hooping  cough,  649 
Homy  productions,  216 

Husband,  Dr.,  his  mode  of  preserving  vaccine 
lymph,  966 

Hutchinson’s  spirometer,  48 
Hydatid  cyst  of  the  liver  cured,  522 
Hydrocele,  200 

Hydrocephalus,  acute,  cases  of,  360  ; nature  of, 
364  ; treatment  of,  365 
Hydrocephalus,  chronic,  case  of,  424 
Hydro-pericardium,  560 ; pathology  of,  570  ; 

treatment  of,  573 
Hydrophobia,  definition  of,  448 
Hydrophone,  65 
Hydro-thorax,  579,  587 
Hygienica,  323 


Hypertrophy,  186 ; of  the  liver,  510 ; of  th« 
heart,  598 
Hypnotism,  290 

Hysteria,  definition  of,  448 ; treatment  of,  454 

Ichorhaemia,  case  of,  902  ; theories  regarding  the 
nature  of,  904 

Ichthyosis,  diagnosis  of,  833  ; treatment  of,  840 
Ideas,  predominant,  influence  of,  on  the  func- 
tions of  the  body,  284 

Ileus,  case  of,  535 ; following  ovariotomy,  case 
of,  763  ; pathology  of,  537  ; treatment  of,  538 
Illusions,  spectral,  cases  of,  445,  455  ; theory  o^ 
290 

Impetigo,  diagnosis  of,  832 ; treatment  of,  838 
Incompetency  of  aortic  valves,  cases  of,  577  ; ol 
mitral  valve,  cases  of,  579 ; of  tricuspid  valve, 
cases  of,  587 
Induration,  186 

Infection,  definition  of,  953 ; purulent,  886 
Inflammation,  Andral’s  opinion  of  the  expres- 
sion, 160 

Inflammation,  155  ; phenomena  of,  155  ; theory 
of,  158 ; definitions  of,  160  ; terminations  of, 
164 ; general  treatment  of,  176 ; fallacious 
character  of  past  experience  in  the  nature  and 
diagnosis  of,  303 ; unchangeable  nature  of, 
305 ; natural  progress  of,  313 ; diminished 
employment  of  blood-letting  in  acute,  302  ; 
former  reasons  for  bleeding  erroneous,  306 ; 
cannot  be  cut  short,  313  ; value  of  bleeding  in, 
315  ; effects  of  general  and  local  blood-letting 
in,  309 ; character  of  the  pulse  as  an  indica- 
tion for  blood-letting  in,  312 ; real  use  of 
blood-letting  in,  317  ; effects  of  mercurials  in, 
318  ; antiphlogistic  practice  injurious  in,  318  ; 
blood-letting  controversy  in,  319.  See  also 
Exudation 

Influenza,  nature  and  treatment  of,  652 
Innervation,  general  laws  of,  in  health  and  dis- 
ease, 137 

Innervation,  function  of,  137  ; influence  of  dis- 
ordered nutrition  on,  154 
Inoma,  187,  188 
Insalivation,  126 
Insanity,  definition  of,  447 
Inspection,  examination  of  patient  by,  36 ; of 
the  general  posture,  36 ; of  the  countenance, 
36  ; of  the  chest,  36  ; of  the  abdomen,  37  ; of 
the  pharynx,  38  ; of  the  larynx,  39 ; of  the 
posterior  nares,  42 

Integumentary  system,  action  of  medicines  on 
the,  343  ; diseases  of  the,  872 
Integumentary  system,  examination  of,  27 
Intestinal  concretions,  280 
Intestine,  case  of  obstruction  of  the  large,  534 
Intestines,  percussion  of,  60 ; diseases  of  the, 
524  ; condition  of,  in  typhoid  fever,  935 
Intestine,  small,  case  of  strangulation  and  per- 
foration of,  from  inguinal  hernia,  535 
Iritis,  case  of  rheumatic,  990 
Irritation,  spinal,  definition  of,  448 
Itch,  insect,  description  and  treatment  of  the, 
842 

Jaundice,  cases  of,  498,  504,  506,  509 

Kamala,  as  a vermifuge,  545 
Keloid  growths,  case  cf,  973 
Kidney,  perenssion  of  the,  61 ; waxy  degenera- 
tion of  the,  249  ; calculi  in  the,  275  ; inflam- 
mation of  the,  782  ; abscess  in  the,  791  ; scrof- 
ulous abscesses  in,  793  ; calculous  inflamma- 
tion and  gangrene  of,  795  ; chronic  inflamma- 
tion of,  and  cystic,  797  ; origins  of  cystic  dis- 
ease of  the,  799  ; Bright’s  disease  of  the,  801  ; 
remarkable  case  of  Bright’s  disease  of  the, 
recovering  under  the  influence  of  super-tait- 
rate  of  potash,  805 ; atrophied,  817.  See 
Bright’s  disease,  also  Nephritis 

Laryngismus  stridulus,  651 


1018 


INDEX. 


Laryngitis,  cases  of,  638  ; method  of  applying 
topical  remedies  in,  640  ; symptoms  of,  642 ; 
diagnosis  of,  647  ; treatment  of,  648 
Laryngitis,  syphilitic,  case  of,  972 
Laryngoscope,  39 

Larynx,  inspection  of  the,  39  ; appearance  of  in 
health,  40  ; in  disease,  41 
Lead,  case  of  poisoning  with,  464  ; treatment  of, 
465 

Lenses,  objective,  of  microscopic,  81 
Lentigo,  diagnosis  of,  833 ; treatment  of,  840 
Lepra  tuberculosa,  diagnosis  of,  833  ; vulgaris, 
diagnosis  of,  833  ; treatment  of,  839 
Leucocythemia,  867  ; definition  of,  868 ; cases 
of,  868  ; pathology  and  treatment  of,  880 ; dis- 
covery of,  892  ; appearance  of  blood  in,  93 
Lichen,  diagnosis  of,  833  ; treatment  of,  839 
Life,  Bedard’s  definition  of,  114 
Light,  therapeutic  uses  of,  329 
Lime,  oxalate  of,  microscopic  appearance  of,  104 
Lipoma,  197 
Lithic  acid  calculi,  276 

Liver,  percussion  of,  57  ; waxy  degeneration  of 
the,  240,  514 ; diseases  of  the,  497  ; case  of 
acute  congestion  of  the,  497  ; abscess  of  the, 
501,  618  ; cases  of  enlargement  of  the,  510  ; 
fatty  enlargement  of  the,  511 ; cirrhosis  of  the, 
514  ; cancer  of  the,  518  ; nutmeg,  517  ; hyda- 
tid cyst  of  the,  cured,  522  ; syphilitic  deposits 
in,  503 

Lungs,  percussion  of,  53  ; abscess  of  the,  713, 
718  ; case  of  gangrene  of  the,  716 ; condition 
of,  in  typhus  fever,  934  ; fistulous  openings  in, 
667  ; partial  atrophy  of  the,  791  ; compression 
of  the,  in  empyema,  674  ; collapse  of  the,  653  ; 
oedema  of  the,  785  ; hgemorrhage  into  the,  579, 
583  ; infiammation  of  the.  See  Pneumonia, 
and  names  of  special  diseases  of  the 
Lungs,  cancer  of  the,  case  of,  754  ; foims,  diag- 
nosis, and  treatment  of,  755 
Lungs,  carbonaceous,  cases  of,  756  ; nature  and 
causes  of,  758  ; treatment  of,  762 
Lupus,  diagnosis  of,  833  ; treatment  of,  840 
Lymph,  plastic  formation  and  structure  of,  165 
Lymphatics,  inflammation  of,  635 

Maculae,  definition  of,  829 ; diagnosis  of,  833  ; 
treatment  of,  840 

Magnesia,  triple  phosphate  or  ammonio-phos- 
phate  of,  microscopic  appearance  of,  104 
Magnetism,  animal,  287 

Malignancy,  in  morbid  growths,  discussed,  237 
Mamma,  compound  cystic  sarcoma  of,  200  ; 

cause  of  increased  growth  in,  209 
Mastication,  126 
Materia  medica,  331 

Medical  bill  which  passed  the  legislature  in 
1858,  14 

Medicine,  relation  of  the  science  to  the  art  of, 
2 ; present  state  of  practical,  20 ; principles  of, 
114  ; ethics  of,  999 

Medicines,  curative  actions  of,  335  ; action  of  on 
the  ultimate  elements  of  the  tissues,  336 ; 
action  of,  on  the  nervous  system,  337  ; action 
of,  on  the  respiratory  system,  339 ; action  of, 
on  the  circulatory  system,  339  ; action  of,  on 
the  digestive  system,  341 ; action  of,  on  the 
genito-ui  inary  system,  342  ; action  of,  on  the 
integumentary  system,  343 ; general  theory  of 
the  action  of,  344 
Melanin,  267 
Melanoma,  265 

Meningitis,  cerebral,  cases  of,  367  ; seat  of,  370  ; 
microscopic  examination  of,  371  ; diagnosis  of, 
371  ; treatment  of,  371 ; pathology  of,  372 
Meningitis,  spinal,  case  of,  427 
Menstrual  discharge,  microscopic  appearance  of, 
100 

Mensuration,  examination  of  patient  by,  45 
Mentagia,  diagnosis,  of,  834  ; treatment  of,  838 
Mercurial  poisoning,  971  ; of  neuro-spinal  func- 
tions, 453  ; in  a dog,  978 


Mercury,  inutility  of,  in  inflammations,  177, 
318 ; in  acute  hydrocephalus,  366  ; in  jaundice, 
505  ; in  pericarditis,  574  ; Graves’  extravagant 
praises  of,  opposed  by  facts,  575  ; injurious  in 
syphilis,  cases  of,  971,  973 ; treatment  of  syphi- 
lis by,  980  ; not  necessary  in  iritis,  991 
Mesenteric  artery,  aneurism  of,  620 
Mesenteric  glands,  in  typhoid  fever,  936,  209 ; 

hypertrophy  of,  in  leucocythemia,  868 
Mesmeric  mania  of  1851,  294 
Mesmerism,  285 

Metallic  tinkling,  69;  in  pneumo-thorax,  669, 
671 ; cause  of,  675 
Micrometer,  84 

Microscope,  use  of  the,  in  examination  of  pati- 
ent, 75;  Oberhaeuser’s,  77  ; Gruby’s  compound 
pocket,  79 ; Beale’s  clinical,  80 ; objective 
lenses  of,  81 ; eye-piece,  82  ; methods  of  illu- 
mination, 82  ; test  objects  for  the,  83  ; methods 
of  mensuration  and  demonstration,  83  ; how  to 
observe  with  a,  85  ; principal  ap))lications  of, 
to  diagnosis,  87  ; necessity  of  employing,  to 
determine  the  nature  of  cerebral  and  spinal 
softenings,  352  ; examination  of  the  saliva,  88  ; 
milk,  89  ; blood,  91 ; pus,  93  ; sputum,  94  ; 
vomited  matters,  97  ; faeces,  99  ; uterine  and 
vaginal  discharges,  100  ; mucus,  102  ; dropsical 
fluids,  103  ; urine,  103 ; cutaneous  eruptions 
and  ulcers,  107 

Microscopic  objects,  physical  characters  which 
distinguish,  85 

Milk,  microscopic  examination  of,  89 
Mind,  evolution  of  the  power  of,  dependent  on 
the  hemispherical  ganglion,  facts  in  proof  of, 
139 

Mineral  substances  essential  to  nutrition,  125 
Mineral  degeneration,  269  ; of  blood-vessels,  269 
of  nervous  texture,  270  ; of  the  exudations, 
271  ; of  morbid  growths,  272 
Mineral  concretions,  275 
Mitral  valve,  cases  of  disease  of,  579 
Molecules  and  granules,  deposition  of  fatty,  253  ; 
basis  of  the  tissues,  119  ; agency  of,  in  genera- 
tion, 120  ; in  nutrition,  121 
Molecular  theory,  of  organisation,  115  ; of  the 
author,  118  ; opposed  to  that  of  the  cell  patho- 
logists, 121 ; the  basis  of  the  arts  of  horticul- 
ture, agi’icultiu’c,  and  medicine,  123  ; well  il- 
lustrated, 135  ; importance  in  therapeutics,  351 
Moles,  diagnosis  of,  833 

Molluscum  contagiosum,  201 ; diagnosis  of,  833 
Mono-ideism,  note,  292 
Moore’s  test  for  sugar  in  urine.  111 
Morbid  growths,  185.  See  Growths 
Mortification,  or  moist  gangrene,  169 
Motion,  contractile,  diastaltic,  and  voluntary, 
147 

Motions,  irregnlar,  definition  of,  448 
Mouth,  diseases  of  the,  466 
Movements,  contractile,  diastaltic  or  reflex,  and 
voluntary,  147 

Mucus,  gelatinous,  structure  of,  from  os  uteri, 
100  ; microscopic  examination  of,  101 
Muscle,  fatty  degeneration  of,  254 
Mugnet,  minute  structure  of  exudation  in,  89 
Murmurs,  laryngeal  and  tracheal,  67;  bronchial, 
67  ; vesicular  respiratory,  67  ; cavernous,  68  ; 
amphoric,  68  ; sonorous,  69  ; dry  vibrating,  69  ; 
sibilous,  69  ; bellows,  73  ; exocardial  and  endo- 
cardial, 73  ; pericardial  or  friction,  73  ; val- 
vular or  vibrating,  73  ; musical,  in  heart,  73, 
583 

Muscular  sense,  143 

Myelitis,  acute  case  of,  428  ; chronic  cases  of,  432 
Myocarditis,  599 

Nsert,  diagnosis  of,  833  ; treatment  of,  840 
Nares,  posterior,  inspection  of,  42 
Nausea  and  vomiting,  treatment  of  in  phthisis, 
750 

Neck,  post-mortem  examination  of,  31 
^ Nephritis,  acute,  cases  of,  782  ; desquamative, 


INDEX. 


1019 


785  ; haemorrhagic,  787  ; scrofulous,  793  ; cal- 
culous, 795  ; chronic,  797 
Nerves  of  special  sense,  definitions  of  irritation 
of,  449 

Nerves,  structure  and  fxinctions  of,  145 ; gan- 
glionic system  of,  146 

Nervous  system,  examination  of,  26;  general 
anatomy  and  physiology  of  the,  138  ; structure 
and  arrangement  of  the,  138 ; reflex  and  dias- 
taltic  actions  of,  139  ; functions  of  the  brain, 
139 ; functions  of  spinal  cord,  144 ; general 
pathology  of,  148  ; eftects  of  stimuli  or  disease 
on  the  functions  of  the,  152  ; influence  of  rapid 
and  slow  lesions  of,  on  symptoms,  153  ; in- 
fluence of  seat  of  disease  on  nature  of  pheno- 
mena, 152  ; production  of  similar  phenomena 
in  various  lesions  and  injuries  of  the,  153  ; in- 
fluence of,  on  nutrition,  154 
Nervous  system,  diseases  of  the,  352 
Nervous  system,  functions  of  the,  139  ; action  of 
mediciues  on  the,  337  ; functional  disorders  of 
the,  445  ; classification  of,  447  ; pathology  of, 
449 ; causes  of,  450  ; treatment  of,  453  ; case 
of,  445  ; congestive  disorders  of  the,  450  ; dia- 
staltic  or  reflex  disorders  of  the,  451 ; toxic  dis- 
orders of  the,  452 

Nervous  texture,  mineral  degeneration  of,  370 
Nervous  trunks,  effects  of  direct  mechanical  in- 
jury on,  154 

Neuralgia,  deflnition  of,  449 ; from  cancer  of 
cranial  bones,  441  ; treatment  of,  445 
Neural  disorders,  classification  of,  449 
Neuroma,  191,  195 

Neuro-spinal  disorders,  classification  of,  449 
Nihilismus,  23 
Noli  me  tangere,  213 
Noma,  171 

Nutrition,  complemental,  307 
Nutrition,  general  laws  of,  in  health  and  disease, 
124 

Nutrition,  function  of,  124  ; division  of  process 
into  five  stages,  125  ; introduction  of  appro- 
priate alimentary  matters,  125 ; formation  from 
these  of  a nutritive  fluid,  the  blood,  and  the 
changes  it  undergoes  in  the  lungs,  128  ; pas- 
sage of  fluid  from  the  blood  to  be  transformed 
into  tissues,  130  ; disappearance  of  transformed 
tissues,  and  their  re-absorption  into  the  blood, 
131 ; excretion  of  these  effete  matters  from  the 
body,  133 

Nutrition,  importance  of  albumen,  oil,  and 
mineral  substances  in  the  process  of,  125 
Nutrition,  diseases  of,  136  ; causes  of,  137  ; prin- 
ciple of  treatment  of,  137 
Nutrition,  disordered,  influence  of,  on  innerva- 
tion, 154 

Oberhaeuser’s  microscope  for  medical  men,  77 
Obesity,  196  ; case  of,  907 

Oidema,  of  the  brain,  356  ; of  subarachnoid  cel- 
lular tissue,  case  of,  380 ; of  the  legs,  from 
cirrhosis,  527  ; from  cardiac  disease,  587  ; of 
the  glottis,  642  ; of  the  lungs,  785  ; from  albu- 
minuria, 802 
G£gophony,  69 

(Esophagus,  case  of  stricture  of  from  epithelioma, 
467  ; cancer  of,  384,  470,  518 
Oil  and  albumen,  importance  of  in  the  process 
of  nutrition,  125 
Oligocythemia,  902 
Opisthotonos,  definition  of,  448 
Opium,  case  of  poisoning  by,  458 
Organs,  circulatory,  auscultation  of,  70 ; sounds 
elicited  by,  iu  health  and  disease,  71  ; modifi- 
cations of  healthy,  sounds,  72  ; new  or  abnor- 
mal sounds,  73 

Organs,  natural  position  of,  33  ; displacement 
of,  remarkable  cases  of,  35,  674 
Organs,  pulmonary,  auscultation,  66 ; sounds 
produced  by,  66  ; circulatory,  auscultation  of, 
70  ; sounds  produce'd  by,  71  ; abdominal,  aus- 
cultation of,  73 


Osseous  growths,  225  ; seats  of,  225  ; myeloid, 

226  ; new,  227  ; in  the  eye  and  other  textures, 

227 

Osteochondrophytes  of  Cruveilhier,  221 
Osteoma,  225 

Osteoma,  cystic,  of  femur  and  tibia,  204 
Osteo-sarcoma,  191,  222  ; observations  of  Goodsir 
and  Eedfem  on,  223 
Otorrhcea,  427 

Ovarian  dropsy,  cases  of,  763  ; pathology  of,  775  ; 

diagnosis  of,  779  ; treatment  of,  780 
Ovariotomy,  case,  763 
Oxalic  acid,  poisoning  by,  495 
Oxalui’ia,  cases  of,  473 

Painters’  colic,  case  of,  464 
Palpation,  examination  of  patient  by,  43 ; of 
aneurisms,  630 

Palpitations  of  the  heart,  causes  and  treatment 
of,  600 

Pancreas,  cases  of  cancer  of,  489,  509  ; Bernard’s 
views  of  the  functions  of,  510 
Papilloma,  211 

Papulae,  definition  of,  829  ; diagnosis  of,  833  ; 
treatment  of,  839 

Paracentesis  capitis,  425;  thoracis,  671;  abdo- 
minis, 764 

Paralysis,  definition  of,  353  ; cases  of,  386,  428  ; 
definition  of  local,  449  ; of  abducens  oculi  and 
auditory  nerves,  386 

Paraplegia,  definition  of,  448 ; cases  of,  430 ; 

cause  and  treatment  of,  436 
Parasites,  animal,  842  ; vegetable,  847 
Pathology,  effects  of  advanced  knowledge  of,  297 
Patient,  method  of  examination  of,  25  ; circula- 
tory system,  26  ; respiratory  system,  26  ; ner- 
vous system,  26  ; digestive  system,  26  ; genito- 
urinary system,  27  ; integumentary  system, 
27  ; antecedent  history,  27  ; hints  for  carrying 
out  examination,  28 

Patient,  examination  of  by  inspection,  36 ; by 
mensuration,  45  ; by  fluctuation,  44  ; by  pal- 
pation, 43  ; by  percussion,  48  ; by  auscultation, 
63  ; use  of  microscope  in  examination  of,  75  ; 
use  of  chemical  tests  in  examination  of.  111 
Pectoriloquy,  67 

Pemphigus,  diagnosis  of,  832  ; treatment  of,  838 
Percussion,  examination  of  patient  by,  48  ; dif- 
ferent sounds  produced  by,  50  ; sense  of  resist- 
ance produced  by,  51 ; general  rules  for  prac- 
tice of  mediate,  51 

Percussion  of  particular  organs,  special  rules 
for,  53  ; of  lungs,  53  ; of  heart,  56  ; of  liver, 
57  ; of  spleen,  59  ; of  stomach  and  intestines, 
60  ; of  kidneys,  61 ; of  bladder,  62  ; of  aneur- 
isms, 630 

Percussion  hammer,  utility  of,  49 
Perforation  of  the  stomach,  cases  of,  483  ; of  the 
duodenum,  789  ; of  the  intestine,  from  hernia, 
535 

Pericarditis,  changes  which  take  place  in  the 
exudation  of,  174  ; cases  of,  559  ; pathology  of, 
570;  diagnosis  of,  571;  complication  of,  573  ; 
treatment  of,  573 

Peritonitis,  cases  of,  545  ; acute,  545  ; tubercular, 
549  ; cancer  of  abdominal  organs,  resembling, 
551 ; cancerous,  554 
Pertussis,  649 

Pharyngitis,  case  of  follicular,  467 
Pharynx,  diseases  of  the,  466 ; inspection  of  the,  38 
Phlebitis  of  left  iliac  vein,  634 
Phlcbolites,  194 

Phosphorus,  in  spinal  diseases,  433 
Phthisis  of  colliers,  appearance  of  sputum  in, 
97,  266  ; cases  of,  756  ; nature  and  causes  of, 
758  ; treatment  of,  762 

Phthisis  pulmonalis,  cases  of,  722  ; natural  pro- 
gress of,  tendency  to  ulceration,  and  modes  of 
arrestment  of,  733  ; pathology  and  general 
treatment  of,  741 ; indications  for  the  treat- 
ment of,  742  ; cod-liver  oil  as  a remedy  for, 
744  ; value  of  microscopic  examination  of 


1020 


INDEX. 


sputum  in,  95  ; special  treatment  of,  749 ; cough 
and  expectoration,  749  ; loss  of  appetite,  750  ; 
nausea  and  vomiting,  750  ; diarrhoea,  751; 
haemoptysis,  751  ; sweating,  751 ; febrile  sjanp- 
toms,  752  ; debility,  753;  despondency  and 
anxiety,  753 

Picrotoxine,  effects  of,  453 

Pigmentary  degeneration,  262  ; general  patho- 
logy and  treatment  of  267  ; concretions,  274 
Pigment,  formation  and  varieties  of,  262  ; causes 
of,  267 

Pityriasis,  diagnosis  of,  833  ; treatment  of,  840  ; 

parasitic,  cases  of,  864 
Piorry’s  pleximeter,  49 
Placenta,  fatty  degeneration  of  the,  258 
Pleuritis,  cases  of,  660;  pathology,  diagnosis, 
and  treatment  of,  664  ; cluonic  cases  of,  663 
Pleurosthotonos,  definition  of,  448 
Pleximeter  of  M . Piorry,  49 
Pneumonia,  acute,  microscopic  appearance  of 
sputmn  in,  96,  changes  which  take  place  in, 
173  ; natural  progress  of  a,  316  ; treatment  by 
bleeding,  692  ; results  of  antiphlogistic  treat- 
ment of,  693  ; results  of  dietetic  ti-eatment  of, 
694 ; results  of  treatment  by  large  doses  of 
tartar  emetic,  694 ; results  of  mixed  treatment, 
695  ; results  of  restorative  treatment  directed 
to  further  the  natui'al  progress  of  the  disease, 
696;  bleeding,  a palliative  m,  711;  cases  of, 
678  ; a table  of  129  cases  of,  698  ; diagnostic 
value  of  the  absence  of  chlorides  from  the 
urine  in,  686  ; general  pathology  and  treat- 
ment of  acute,  692  ; chronic  cases  of,  713 
Pneumo-thorax,  cases  of,  669  ; remarkable  death 
in  a case  of,  671  ; metallic  tinkling  in,  675 
Poisoning  by  alcohol,  455 ; by  opium,  458  ; by 
hemlock,  459  ; by  lead,  464  ; by  oxalic  acid, 
495  ; by  sulphuric  acid,  496  ; by  corrosive  sub- 
limate, 496  ; by  aconite,  628 ; by  meremy,  971. 
Polycythcemia,  902 
Polydipsia,  cases  of,  995 

Polypus,  soft,  193  ; hard,  194  ; in  the  heart,  590 
Polysarcia,  997 

Porrigo,  definition  and  varieties  of,  835 
Post-mortem  examination,30  ; method  and  order 
of,  30  ; hints  for  carrying  out,  32  ; knowledge 
required  for,  33 

Posture  of  patient,  inspection  of,  36 
Pisesystolic  murmur,  585,  586 
Pressure  and  compression,  distinction  between, 
149 

Probang,  method  of  using,  in  laryngitis,  640 
Prostatic  concretions,  278 
Prurigo,  diagnosis  of,  833  ; treatment  of,  839 
Psoriasis,  diagnosis  of,  833  ; treatment  of,  839 
Psychologists,  their  mode  of  studying  insanity, 
142 

Pulmonary  organs,  special  rules  for  auscultation 
of,  66  ; sounds  produced  by,  66 
Pulmonary  diseases,  injections  of  the  bronchi 
in,  658  ; case  of,  657 

Pulmonary  artery,  varicose  aneurism  of,  608 
Pulse,  characters  of,  26 ; as  an  indication  for 
bleeding,  312 

Purgatives,  use  of,  in  intestinal  disease,  526 
Purpura,  diagnosis  of,  833  ; treatment  of,  840 
Pus,  microscopic  examination  of,  93,  166  ; forma- 
tion of,  in  pneumonia,  173  ; scrofulous,  micro- 
scopic appearance  of,  94,  166 ; efi'ects  of  mix- 
ture, with  the  blood,  904  ; injection  of,  into 
the  blood,  906 

Pustulae,  definition  of,  828  ; diagnosis  of,  832 ; 
treatment  of,  838 

Pyaemia,  case  of,  902 ; theories  regarding  the 
nature  of,  904 
Pyelitis,  cases  of,  782 
Pyi’osis,  479 

Quain’s  stethometer,  45 

Quinine  in  continued  fever,  therapeutic  action 
of,  948 ; in  intermittent  fever,  952  ; in  hectic 
fever,  753 


Rammollissement.  See  Softening 
Battles,  moist,  68 
Recto-vesical  fistula,  case  of,  79 
Remedies,  indications  for  the  use  of,  297.  Se# 
Medicines 
Renal  calculi,  257 
Resolution,  173 
Resonance,  vocal,  66 
Respiration,  motions  of  chest  during,  36 
Respiration  natural  and  exaggerated,  66;  puerile, 
67  ; alterations  of,  67  ; function  of,  129  ; Dr. 
E.  Smith’s  experiments  in,  129 ; effects  of,  on 
the  blood,  129 

Respiratory  sounds,  66  ; alterations  in  natural, 
67  ; new  or  abnormal  sounds  of,  68 
Respiratory  system,  examination  of,  26  ; action 
of  medicines  on  the,  339  ; diseases  of  the,  637  ; 
rules  for  the  diagnosis  of,  637 
Rest,  therapeutic  uses  of,  324 
Reticulum  of  cancer,  260 

Rheumatism,  general  pathology  and  treatment 
of,  982 ; treatment  of,  by  nitrate  of  potash, 
984 ; treatment  of,  by  lemon-juice,  988 ; dia- 
phragmatic case  of,  989 
Rhinoscope,  42 
Ringworm,  841 

Roseola,  diagnosis  of,  832  ; treatment  of,  837 
Rupia,  diagnosis  of,  832  ; treatment  of,  839 

Saliva,  microscopic  examination  of,  88  ; function 
of,  126 

Sanguification,  128 
Sarcina  ventriculi,  98 

Sarcoma,  191 ; cystic,  205  : compound  cystic,  of 
the  mamma,  200  ; osteo,  191,  222 
Scabies,  diagnosis  of,  832 ; treatment  of,  838 
Scalp  diseases,  treatment  of,  840 
Scarlatina,  cases  of,  954  ; diagnosis  and  treat- 
ment of,  955  ; colchicum  in,  959  ; bodies  found 
in  urine  in  a case  of,  108 
Scirrhus,  229 

Scorbutus,  cases  of,  993  ; epidemic  of,  in  Edin- 
burgh, 993  ; observations  of  Dr.  Christison  and 
Dr.  Lonsdale  on,  994  ; Dr.  Garrod  on,  995 
Scrofula.  See  Tuberculosis 
Scrofulous  pus-cells,  94,  166 
Sectio  cadaveris,  method  and  order  of,  30  ; object 
of,  31 ; external  appearances,  31  ; head,  31 ; 
spinal  column,  31 ; neck,  31 ; chest,  31  ; abdo- 
men, 32  ; blood,  32  ; hints  fc».-  canying  out 
post-mortem  examination,  32  ; knowledge  re- 
quired for  correct  examination,  33 
Sensation,  definition  of,  147 
Sensibility,  definition  of,  148 
Sibson,  Dr.,  his  “ Medical  Anatomy,”  34 ; his 
chest-measurer,  46 

Silver-,  nitrate  of,  action  and  use  of,  in  laryngitis, 
639 

Skin  diseases,  classification  of,  828  ; definitions 
of,  828  ; diagnosis,  831  ; varieties  of,  834 ; 
treatment  of,  836  ; scaly  diseases  of,  211  ; treat- 
ment of,  839  ; treatment  of  syphilitic  diseases 
of  the,  841 

Small-pox,  cases  of,  962  ; general  treatment  of, 
963  ; cctrotic  treatment  of,  963  ; greater  fre- 
quency of,  965  ; relation  of,  to  varicella,  968  ; 
identical  with  cow-pox,  968 
Socrates,  his  death  by  taking  hemlock,  463 
Softening,  cerebral  and  spinal,  pathology  of,  353 ; 
exudative  or  inflammatoiy,  354  ; hemorrhagic, 
355  ; fatty,  355  ; serous  or  dropsical,  356  ; 
mechanical,  356  ; putrefactive,  357  ; necessity 
for  microscopic  examination  of,  359  ; cases  of, 
359  ; cerebral  cases  of,  380  ; spinal  cases  of,  434 
Solanoma,  222 

Sounds  produced  by  percussion,  50  ; elicited  over 
lungs,  53  ; produced  by  pulmonary  organs,  66  ; 
cracked-pot,  56  ; alterations  of  natural,  67  ; 
abnoi-mal,  68  ; rubbing  or  friction,  68  ; relative 
value  of  in  auscultation,  70  ; of  the  circulatory 
organs,  71  ; diagnostic  of  diseases  of  the  cir- 
1 culatory  system,  557  ; of  aneurisms,  631 ; diag- 


INDEX. 


1021 


nostic  of  diseases  of  the  respiratory  system, 
637 

Spasm,  definition  of,  353,  448  ; of  the  jaw,  case 
of,  408 

Spermatocele,  appearance  of  spermatozoids  in 
fluid  of,  103 

Spinal  column,  post-mortem  examination  of,  31 
Spinal  cord,  structure  and  functions  of,  144 
Spinal  softening,  pathology  of,  353  ; origins  and 
varieties  of,  354  ; necessity  for  microscopic 
examination  of,  359  ; cases  of,  434 
Spinal  irritation,  definition  of,  448 
Spinal  disorders,  classification  of  functional,  448 
Spirometer  of  Mr.  Hutchinson,  48 
Spleen,  percussion  of,  59  ; waxy  degeneration  of 
the,  249 ; hypertrophy  of,  in  leucocythemia, 
868,  881 ; morbid  anatomy  of,  in  fever,  934 
Sputum,  microscopic  examination  of,  94  ; value 
of  microscopic  examination  of,  95;  microscopic 
appearance  of  in  acute  pneumonia,  102 ; ap- 
pearance of  in  black  phthisis  of  colliers,  97, 
267  ; elastic  tissue  in,  96 
Squamae,  definition  of,  829  ; diagnosis  of,  823  ; 

treatment  of,  839 
Starvation,  symptoms  of,  154 
Steatoma,  197,  203 

Stetho-goniometer,  of  Dr.  Scott  Alison,  48 
Stethometer  of  Dr.  Quain,  45 
Stethoscope,  63  ; hints  for  choice  of,  64  ; Can- 
man’s,  64  ; diJfferential,  of  Dr.  Scott  Alison,  64; 
flexible,  64 

Stomach,  percussion  of,  60  ; hairy  concretions  in 
the,  279  ; functional  disorders  of  the,  472  ; or- 
ganic diseases  of  the,  481 ; ulceration  of  the, 
cases  of,  481  ; perforation,  cases  of,  483  ; fre- 
quency of  ulceration  in,  488  ; symptoms  and 
treatment  of  ulcers  in,  489  ; cases  of  cancer  of 
the,  489  ; structural  changes  in  glands  of,  493  ; 
remarkable  cases  of  emphysema  of  the  co^s  of, 
671 

Stramonium,  action  of,  453 
Stricture,  186  ; of  intestine,  534,  535,  763 
Strychnine,  action  of,  453 
Succussion,  examination  of  patient  by,  44 
Sugar  in  urine,  detection  of.  111  ; trial  of  in  the 
treatment  of  diabetes,  913 
Sulphuric  acid,  poisoning  by,  496 
Supra-renal  capsules,  Dr.  Addison’s  views  of, 
264 ; case  of  disease  of,  without  bronzing  of 
skin,  714 

Sweating  in  phthisis,  treatment  of,  751 
Syphilis,  cases  of,  971;  observations  on,  974 ; 
symptoms  of,  974 ; diagnosis  of,  975  ; propaga- 
tion of,  976  ; pathology  of,  977  ; treatment  of, 
980 

Syphilitic  diseases  of  the  skin,  treatment  of,  841; 

deposits  in  the  liver,  503 
System,  nervous,  general  anatomy  and  physio- 
logy of,  138  ; general  pathology  of,  148 

Taenia  solium,  origin  and  development  of  the, 
539  ; cases  of,  542  ; treatment  of,  544 
Tape-worm.  See  Taenia  solium 
Temperature  of  fevers,  933 
Tests,  chemical,  use  of  in  examination  of  pa- 
tient, 110 

Tetanus,  definition  of,  448 
Therapeutics,  general,  284  ; recent  changes  in, 
12  ; as  aft'ected  by  the  influence  of  the  mind, 
284  ; by  the  natural  progress  of  disease,  295  ; 
by  an  improved  diagnosis  and  pathology,  297  ; 
by  the  diminished  employment  of  bloodletting 
and  antiphlogistics,  302 ; of  the  dietetica,  320 ; 
of  the  hygienica,  323  ; of  the  materia  medica, 
331 

Thermometric  observations  in  fevers,  933 
Thoracentesis,  675 

Thorax,  inspection  of,  36  ; mensuration  of,  45  ; 
motions  of  during  respiration,  36  ; post-mor- 
tem examination  of,  31 ; view  of  viscera  in,  34 
Thrombosis,  399 

Tissues,  structural  relations  of,  119 ; formation 


and  sustentatlon  of,  by  the  blood,  130 ; attrac- 
tive and  selective  property  of  the,  131  ; re- 
absorption  of  transformed  tissues  into  the 
blood,  131 ; action  of  remedies  on  the  ultimate, 
336 

Texture,  morbid  degenerations  of,  245  ; morbid 
growths  of,  185 
Tonsillitis,  466 

Toxic  disorders  of  the  nervous  system,  452  ; 

treatment  of,  455 
Trance,  definition  of,  448 
Tracheotomy,  in  laryngitis,  643 
Treatment,  an  inquiry  into  our  present  means 
of,  320.  See  Therapeutics 
Tricuspid  valve,  cases  of  disease  of,  587 
Trismus,  definition  of,  448 
Trommer’s  test  for  sugar  in  urine,  111 
Tubercle,  definition  of,  179 ; forms  of,  179 ; mi- 
nute structure  of,  179  ; corpuscles,  95,  179 ; 
chemical  composition  of,  181 ; pathology  of,  181 
Tubercula,  definition  of,  829  ; diagnosis  of,  833  ; 
treatment  of,  840 

Tuberculosis,  179;  general  pathology  of,  181, 
741  ; natural  progress  of,  182  ; general  treat- 
ment of,  183,  741.  See  Phthisis 
Tumeur  h6teradenique  of  M.  Robin,  208 
Tumors,  classification  of,  187  ; fibrous,  188 ; sar- 
comatous or  soft  fibrous,  191  ; dermoid  or  hard 
fibrous,  193  ; neuromatous  fibrous,  195  ; fatty, 
196  ; fibro-lipomatous,  197  ; cystic,  1'99  ; simple 
cystic,  199 ; compound  cystic,  200 ; osseo-cystic, 
204  ; glandular,  206  ; epithelial,  210  ; horny, 
216  ; aneurismal,  217  ; cases  of,  601  ; erectile, 
218;  varicose,  218;  enchondromatous,  220; 
osseous,  225  ; myeloid,  226  ; cancerous,  229 
Typhus  and  typhcdd  fevers.  See  Fever. 

Ulcer,  cancerous,  of  skin,  microscopic  appear- 
ance of,  109  ; cutaneous,  microscopic  examina- 
tion of,  108  ; of  tonsil,  case  of,  466  ; of  oesopha- 
gus, 468  ; of  stomach,  481 ; of  duodenum,  789  ; 
of  intestine,  535  ; typhoid,  935 
Ulceration,  172 
University  (Scotland)  Bill,  15 
Uric  acid,  microscopic  appearance  of,  105 
Urinary  concretions,  275 

Urine,  microscopic  examination  of,  103  ; specific 
gravity  of,  110;  detection  of  albumen  in,  110; 
detection  of  bile  in,  110 ; detection  of  bile 
acids  in.  111;  of  leucin  andtyrozin  in,  111; 
detection  of  sugar  in.  111 ; detection  of  chlo- 
rides in,  112  ; diagnostic  value  of  the  absence 
of  chlorides  from  the,  in  pneumonia,  686  ; exa- 
mination of  in  Bright’s  disease,  823 ; various 
kinds  of  casts  in,  824 

Urticaria,  diagnosis  of,  832  ; treatment  of,  837 
Uterine  discharges,  microscopic  examination  of, 
100 

Uterus,  appearance  of  cancerous  juice  from  the, 
101 ; fibrous  structure  of  the,  189  ; fatty  degen- 
eration of,  after  delivery,  256 

Yaccination,  mode  of,  966  ; Dr.  "Wier’s  scarifica- 
tor  for,  966 

Yaginal  discharges,  microscopic  examination 
100 

Valsalva’s  treatment  of  aneurism,  626 
Valves  of  the  heart,  diseases  of,  575 
Van  der  Kolk’s  observations  on  phthisical  spu- 
tum, 95 ; views  as  to  the  propagation  of  cancer, 
241 

Varicella  identical  with  small-pox,  968 
Varicose  aneurism,  between  vena  cava  and 
aorta,  217  ; case  of  communicating  with  the 
pulmonary  artery,  608  ; signs  of,  610  ; patho- 
logy and  treatment  of,  511 
Variola,  cases  of,  962  ; treatment  of,  963  ; obser- 
vations upon,  965.  See  Small-pox 
Varix,  218 

Vascular  growths,  216 ; aneurismal,  217  ; erec- 
tile, 218  ; varicose,  218  ; of  new  vessels,  218 
Vegetation,  dendritic,  215 


1022 


INDEX. 


Velpeau  on  the  propagation  of  cancer,  239,  242  ; 
his  letter  on  the  results  ef  excision  of  cancers, 
245 

V enesection.  See  hloo  d-letting 
Ventilation,  326 

Vermifuge  remedies,  542  ; male  shield  fern,  544 ; 
kamala,  544 

Verruca  achrocordon,  107,  212 
Vesical  calculi,  276 

V" esiculse,  definition  of,  828  ; diagnosis  of,  832  ; 
treatment  of,  837 

Vessels,  auscultation  of  the  large,  74 
■V  illi,  formation  of,  in  pericarditis,  175 

V ocal  resonance,  67 


Voluntary  motion,  148 

Vomited  matters,  microscopic  examination  ol; 
9 / 

Vomiting  and  nausea  in  phthisis,  treatment  oJ^ 
750 

> 

"Warts,  211 

Waxy  degeneration,  249 

Weir’s  vaccinating  instrument,  966 

Winterich’s  percussion  hammer,  49 

Woorari,  effects  of,  453 

Worms,  intestinal,  539  ; varieties  in  man,  543 

Zymosis,  definition  of  the  term,  953 


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